The Social Medicine Portal

“The People’s Misery: Mother of Diseases”: Johann Peter Frank (1790)

With the publication last week of the final report of the WHO Commission on the Social Determinants of Health (see our posting), it may be pertinent to recall a bit of history. The concern over social determinants of health - and what to do about them - has a very long and rich tradition from which we might profitably learn.

Johann Peter Frank (1745-1821) was one of the leading German physicians of his time and a founding figure in social medicine and public health. He is best known for his System einer vollständigen medicinischen Polizey (A complete system of medical police), a multi-volume work published throughout his lifetime. The term “medical police” is bit off-putting to modern ears. Essentially Frank set out an extraordinarily detailed system for regulating and promoting hygiene throughout Germany.

In 1790 Frank gave a graduation lecture at Pavia entitled De populorum miseria: morborum genitrice (The People’s Misery: Mother of Diseases). This talk was translated from the original Latin by Henry Sigerist and published in the Bulletin of the History of Medicine in 1941. Sigerist was a leading figure in the American health left of the mid-20^th century, a group that was severely hit by the post-WWII red witch hunt. (The Sigerist Circle was formed in 1990 by a group of critical medical historians.)

Sigerist notes that Frank “approached the problem [of poverty] as a physician.” But what is striking about his approach is that (again quoting Sigerist): “As a public health officer of vision, he was a statesman also and saw very clearly that the health problem was merely one aspect of a much broader social and economic problem.”

Frank’s lecture is devoted to a discussion of how poverty causes ill health. He attributes poverty to social conditions, noting that:

“Every social group has its own type of health and diseases, determined by mode of living. They are different for the courtiers and nobleman, for the soldiers and scholars. The artisans have various diseases peculiar to them, some of which have been specially investigated by physicians. The diseases caused by the poverty of the people and by lack of all the goods of life, however, are so exceedingly numerous that in a brief address they can be discussed only in outline.”

Frank organizes this outline by tracing the human lifecycle:

• We begin with the embryo: “Sewn in exhausted soil, the fetus has hardly drawn the first juices through the animal roots of the placenta when, without resistance, it already is shaken and torn as a result of the awful physical labor imposed upon the ill-nourished mother.”
• The birth: “Exhausted from lack of food and hard work, wearily [the mother] gets ready for the great task. In the hands of a drunken or ignorant midwife she has no advice, no assistance, no sympathy.”
• The infant: “If the mother does not sell her breasts to foreign mouths, the scarcity of milk - consumed by excessive labor - or her own frequent separation from the child will force her after a few months to prepare coarser food for the babe.”
• The adolescent: “The sons of destitution have hardly reached boyhood when they are compelled by their parent’s poverty to get ready for too hard labors. They are forced to lose in perspiration the nutritional juices destined for the future development of the body. Hence the lack of slenderness, symmetry and natural perfection.”
• The workers: “Everybody must admit from his own experience that the human machine must break down in a very short time if food of the right kind and quantity does not replace what labor has used up every day and sweats have consumed. Slave people are cachectic people.“
• The dying man: “He enters a hospital if there is one, but he is hardly there before the funeral separates him from his family. He may possibly seek this refuge sooner, but in most hospitals you find so much danger of contagion and such a cruel neglect of the poor that the hospital mortality rate is considerably higher than the general rate.”

The essay offers an interesting early example of using statistical data to explore the social origins of disease:

“For many years the midwives of the Principality of Spires submitted to me accurate reports on abortions and premature births. In comparing figures I was struck by the fact that in certain districts their incidence every year was much higher than in other localities of the same jurisdiction. Investigating the cause of such an unfortunate condition I soon found that it lay in servitude. The husbands are very often kept busy with statute labor and are thus forced to leave not only their household duties but also the agricultural work in the fields and meadows - rather difficult and abundant in those districts - to their wives until the last months of pregnancy.”

Frank also notes the protective effect of social class:

“Physicians, surgeons, military commanders, or priests may be living in the corrupt atmosphere of the sick, coming in close touch with them, and yet they are less frequently affected by contagion than the poor, emaciated and depressed citizens and soldiers.”

Frank was not a revolutionary. Rather he was a believer in an enlightened despotism as exemplified by Emperor Joseph II. Frank supported Joseph’s reforms, including the abolition of serfdom. Joseph II had died shortly before this speech was given and his reforms were under attack. This, then, was the political context for Frank’s conclusion:

“This is the influence of extreme misery on the people. This is the influence of luxury collected from everywhere, of officials who do not care enough for the welfare of the most useful citizens. If the government really wishes an increase in population, it must see to it that parents and children feel secure of their subsistence. It must not let the prices of vital commodities rise beyond what labor and sweat can pay. It must abolish servitude which is a disgrace to mankind…”

Posted by Matt Anderson

Community Health Workers & Promotoras: An Introduction

During the Industrial Revolution various initiatives were developed to bring health into the community. In 1859 William Rathbone used nurses accompanied by “lady visitors” to go into the homes of Liverpool; this became the model for British district nurses. In 1862 the Ladies Section of the Manchester and Salford Sanitary Association used a “working class woman” to visit homes and provide educational materials and sanitary advice; this program led to the adoption of home visits as a way to promote health.

Contemporary Community Health Workers fulfill a number of roles in health care systems. There is, however, a debate regarding the degree to which CHW should be “professionals” or remain lay workers. In 1999 Texas became the first state to offer a certification program for CHW, recognition of the important role that promotoras play in health care in immigrant communities; they are essentially the modern version of the Manchester “working class woman.” For current information on training of CHW, visit the Community Health Worker National Education Collaborative.

Perhaps the most comprehensive current site on CHW is the Community Health Worker Program Resource from the South Texas Health Research Center and the University of Texas Health Sciences Center at San Antonio. This site has information on training and certification, technical assistance, examples of CHW projects in the US, a bibliography, and a discussion of contemporary issues relating to CHW.

Community Health Workers and Community Voices: Promoting Good Health, is a 64-page document (PDF) that provides an overview of Community Health Workers. It was produced by the Community Voices initiative of the National Center for Primary Care at Morehouse School of Medicine. Their publications page has other documents on CHW.

Health Wrights has made available for free a number of books regarding community health and CHW on its website. Among these are the incomparable Where There Is No Doctor.

Latino Health Access works in Orange County, California to promote community health using promotoras (community health workers) and principles of community diagnosis. Watch a video of their work.

Class and Health

Social Medicine had its birth during the Industrial Revolution in Europe as health statistics (a relatively new tool) made clear that disease and death were linked to poverty and exploitation.

One of the first empiric studies examining this question was done in the 1820’s by the French physician Louis Rene Villerme. Villerme looked at mortality statistics in Paris and noted marked differences in death rates between one section of the city and another. After considering several possible explanations, he concluded that poverty was the main determinant of differentials in death rates. We are fortunate that his original publication from 1830 is available online at the French National Library. We have discussed Villerme’s paper in greater detail in an article entitled “Social Medicine 101.”

Twenty years later Friederich Engel’s impassioned The Condition of the Working Class in England, described in detail the devastating health impact of the Industrial Revolution on workers and their families.

Two centuries later these problems are very much with us. As Vicente Navarro pointed out in a 2004 Monthly Review article entitled “Inequality is Unhealthy“, a member of the corporate class in Europe lives some 7 years longer than an unskilled worker who is chronically unemployed; in the US, the gap is 14 years.

The debate over health inequalities in the English-speaking world was revitalized by Sir Douglas Black’s 1980 report on inequalities and health (most of which is available on the website of the Socialist Health Association). The Black Report is a very rich document born out of the flowering of Social Medicine in England after World War II. Later Allison Quick and Richard Wilkinson introduced the idea that mortality depends upon the degree of inequality in a society, irrespective of the absolute wealth of the country.

In the United States we are told there is no social class and the Federal government does not routinely collect statistics on class and health. Class issues are often discussed in racial terms or in terms of “inequality”. Inequality.org provides an introduction from a US perspective. The New York City-based Russell Sage Foundation has published a number of interesting social critiques, which are available on their website. There are several papers on the topic of inequality and health. See The Social Dimensions of Inequality, a literature review of the Foundation.

Matt Anderson

Lear Fellowships for Medical History Students

As noted in an earlier posting, this year Walter Lear turned 85. He used his birthday party (in part) to fundraise for a medical history fellowship. Here is the description of the fellowship:

“The U.S. Health Left History Center is pleased to announce the availability of the Lear Fellowships to further the investigation of the history of U.S. health activism using the U.S. Health Activism History Collection at the University of Pennsylvania Rare Book and Manuscript Library as well as other relevant resources. Two fellowships of $1000 will be awarded annually. If the fellow is not in commuting distance of Philadelphia the documented costs of travel and two weeks residence will also be defrayed (maximum $2,000).In addition to conducting research, fellows will submit a report of the research completed no later than one year after receipt of the fellowship (this may be posted on the website of the History Center or published in its newsletter).

The U.S. Health Activism History Collection gives priority attention to classism, racism and sexism in the health field and major reform of the health care delivery system including national legislation, as well as to the health and medical aspects of poverty, labor unions, civil and human rights, women’s movements, Left political parties, grass-roots human services, red witch hunts, L/G/B/T issues, and international peace and progressive people’s solidarity campaigns.

Eligibility: Applicants must have been or be enrolled in a college/university degree program.

Time schedule: The deadline for the receipt of applications is July 1. Awards will be announced September 1 and will apply for the subsequent twelve months.

Applications (both PDF and hard copy) must include:

1. a project description of no more than 3 double-spaced pages in 12-point font indicating the purpose and methodology of the research and the historical materials to be consulted; preference will be given to projects that are likely to be useful to current and future U.S. health activists;

2. a curriculum vitae of no more than 2 pages;

3. a proposed budget for travel and residence (two weeks maximum) for applicants not in commuting distance of Philadelphia;

4. the name of one reference who has agreed to send a supporting letter directly to the History Center by July 1.

Submissions may be made either by mail or email to:

The U.S. Health Left History Center
206 N. 35th St.
Philadelphia, PA 19104-2429
Email: wjlear@critpath.org

For more information please contact:
Walter J. Lear, M.D., Director
U.S. Health Left History Center
215-386-5327

Salvador Allende: Chilean President, Advocate of Social Medicine

In the 1930’s Salvador Allende, a public health physician, served as Chilean Minister of Health. He produced an analysis of the social origins of disease and suffering in Chile, La Realidad Medico-Social Chileña, arguing that the solution to health problems lay not simply in improved medical care but also in better sanitation, housing, nutrition and working conditions. Echoing Virchow, Allende wrote: “[I]t is not possible to provide health and knowledge to a malnourished people, dressed in rags and working under merciless exploitation.”

These ideas were eventually embodied in the political program of the democratically-elected Unidad Popular government in Chile. Allende served as President of the Unidad Popular government from 1971 until his government was overthrown in a US-sponsored military coup on September 11, 197. Allende died in the coup which broke Chile’s long tradition of democratic government and initiated a long period of military dictatorship under General Augosto Pinochet.

Allende’s most famous document on Social Medicine is La Realidad Médico-Social Chilena (Chile’s Medical Social Reality which was published in 1939. Selections of this document were in 2006 in Volume 2, No 3 of of Social Medicine (English) and Medicina Social (Spanish) along with an introduction by Claudio Schuftan; the Spanish site also contains the original health platform from one of Allende’s presidential campaigns. The original version of La Realidad Medico-Social Chileña can be found (with a bit of searching) at the very rich Archivo-Chile.

For more information on Allende in Spanish consult the Salvador Allende archives run by the Partido Socialista. Salvador Allende: Chile’s Voice of Democracy offers English translation of some of Allende’s writiings and speeches.

To read documents related to US involvement in the 1973 coup (”the Latin American 9/11″) visit the National Security Archive website. Wikipedia offers a more general view of this “watershed event in the history of Chile and the Cold War.”

A visit with Dr. Walter Lear

[Originally Posted in January of 2007.  For information on Dr. Lear's 85th birthday party -  May 4th 2008 - click here. ]

In late November 2006 the editors of the Social Medicine Portal visited the US Health Left History Center and its Health Activism History Collection in West Philadelphia. Here is a report on what we learned:

The Health Left History Center and its Collection were created by Dr. Walter J. Lear who in 1970 switched his professional work from public health to medical history, with the mission of “bringing out of the closet the history of the US health left and related activism.” Dr. Lear has also been a tireless and distinguished activist, recently receiving the American Public Health Associations Helen Rodriguez-Trias Award for Social Justice. Although “uncomfortable in the world of academia” by self-report, he is one of the founders and an officer of the Sigerist Society, an organization of critical and radical medical history scholars. Most of the materials in the unique and extensive Health Activism History Collection might have been lost but for the efforts of Dr. Lear. For example when describing his discovery of the complete organizational records of the American Soviet Medical Society (formed by Henry E. Sigerist), Dr. Lear explained how they had been stored in cartons in a Brooklyn basement, forgotten and untouched since the Society’s demise fifty years earlier. He subsequently used these records to write a chapter about the Society which was published in Elizabeth Fee and Theodore Brown’s Making Medical History: The Life and Times of Henry E. Sigerist. The Health Activism History Collection has seven divisions:

1. Archives of Organizations, Campaigns and Movements: These include the Medical Committee for Human Rights, the Physicians’ Forum, the Philadelphia women’s health movement of the 1970’s and 1980’s, American medical support for Spanish democracy, the American Soviet Medical Society and the various campaigns for national health insurance and a national health service.

2. Personal Papers of Health Activists: These include Dr. Lear’s papers as well as those of Ruth Blier, Carl Dahlgren, JoAnne Fischer, Frank Furstenberg Sr, and Paul Lowinger.

3. Images: The collection contains over a 1000 photographs, cartoons and other images in 22 subject categories.

4. Audio-visual materials: The collection contains some 70 audio-interviews of health activists and a smaller number of videos.

5. Rare and Special Books, Pamphlets and Serials: 200 books, about 1000 pamphlets and twelve serials are located in this division. We had a chance to peruse Iago Galdston’s two books on Social Medicine.

6. Reference Division: This division contains information on over a 1000 individuals associated with the US health left. Dr. Lear is preparing a talk on pediatrician activists and showed us his four inch thick file on Allan Butler, a Chief of Pediatrics at Harvard and the Massachusetts General Hospital who had been persecuted by the House Un-American Affairs Commiteee despite being an anti-communist. This division also has files on over 700 organizations.

7. Epherema: Items such as buttons, banners and T-shirts.

Last year the US Health Activism History Collection was legally donated to the University of Pennsylvania’s Rare Book and Manuscript Library by the Institute of Social Medicine and Community Health. (the History Center’s parent organization). The transfer of the Collection from Dr. Lear’s beautiful pre-Victorian home to the University is being done in stages and will be completed in about a year.

Why is this history important to us today? At a time when the political class in the US has taken the goal of a proper national health care system off the agenda, it is important to remember that the struggle for this has a century long tradition. In addition much still needs to be done to eliminate elitism, racism and sexism in the health field. We can learn many lessons from past health activism and be inspired by those who have gone before us.

Dr. Lear shared with us a favorite quote from Antoinette Konikow, a Boston physician and birth control champion who - in 1943 at age 74 - told her communist party comrades at a rally: “I have always been a rebel and have led a life of struggle. But it has been a thrilling life. I will not see the time when you win. When you do, please lay the red flag on my grave.”

Dr. Lear has developed a list of 50 topics in the history of US health activism which he considers worthy of scholarly attention by students. This list, publications of the History Center and information about the US Health Left are available on request. He can be reached at: wjlear@critpath.org or 215-386-5327.

- Matt Anderson and Carolyn Chu

How to research a question in medical history

General guides to historical research.

You might consider starting with the chapter: “Sleuthing and Science: How to Research a Question in Medical History” from Jacalyn Duffin’s text History of Medicine: A Scandalous Short Introduction. This text is written for medical students.

One accessible introduction to general historical research is Anthony Brundage’s Going to the Sources: A Guide to Historical Research and Writing.

Sources for information on medical history

The History of Medicine Division of the National Library of Medicine has a rich website with many resources for historical research. Their on-line syllabus archive is a good place to start to find a list of readings about specific topics; many - if not most - of these syllabi relate to social issues and medicine. A number are in Spanish.

MedHist: Gateway to Internet Resources on the History of Medicine: This website is run by a consortium of seven universities and is designed to link to high quality internet resources on the history of medicine.

Portail pour l’histoire des sciences et des techniques en France et en Europe A web portal for medical history run by the University of Paris.

Sigerist Circle: The Sigerist Circle (named after Henry E. Sigerist) is “a group of medical historians, scholars in related fields and others interested in the history of health, health care and the biomedical sciences, who give special attention to the issues of class, race and gender and /or use Marxist, feminist and related critical methodologies in the analysis of medical history.” Their website primarily has information about the Circle.

Wellcome Library, The Wellcome Trust An amazing on-line archive from Britian’s largest charity funding biomedical research. It is named after Henry Wellcome, a British “pharmaceutical entrepreneur.”

The Countway Library at Harvard Medical School is one of the major medical libraries in the US and its website has a History of Medicine section.

Funding

The US Health Left History Center offers a Lear Fellowship for Medical History Students. This is an unparalleled collection of 20th century materials on US health activism. See our posting on the Center.