SOCIAL MEDICINE 1998 7

Introduction:

\Xlhere Medicine and Society Meet

HIS REPORT MARKS the completion of our sec- ond decade as a faculty of Social Medicine. In that time we have T heard the question "What is it?" countless times. To the uninitiated, "social medicine" will surely sound less familiar than "family," "internal," or even "nuclear" medicine. Yet, our name is neither a new term nor a recent calling- which is why the editorial introductions to both and each has had moments in the spotlight- of the department's earlier reports sought tore- social medicine's central focus is always on the mind the reader of social medicine's heritage. relation of medicine to the broader society. This The first report 10 years ago contained a brief connection more than anything defines both account of social medicine activity at the Uni- where and what social medicine is. Its history, versity of North Carolina since 1952. And in therefore, is of the understanding between medi- Social Medicine 1993, I recounted several of the cine and the body politic, and of the gradual connotations (and aliases) that the terJ!l "social emergence of a "wider" medical profession in medicine" has carried since Jules Guerin, response to technological change and human Rudolph Virchow and other physician partici- society's shifting configuration and values. pants in the political revolutions of 1848 first This essay is more ambitious than the intro- used it to underscore their conviction that medi- ductions to the two earlier reports. My aim is cine should address the human misery brought to trace the antecedents of some of the interests by industrialization. I pointed out that every and areas of scholarship represented by our fac- use of the term-from 1848 to the present- ulty. How and when, I've wondered, did medi- has embraced the same set of core ideas: inves- cine come to incorporate social and individual tigation of the causes and distribution of dis- ethics, become interested in the power of cul- ease, prevention, the organization and delivery ture, or the "science" of preventive medicine, of medical care, a focus on "community," and or epidemiology, and especially, how did the the importance of political action and public doctor's work become an issue of social policy? policy in matters of health. In preparing my thoughts on these questions Regardless of which of these ideas received I've looked at many sources. But one in par- greatest emphasis at any particular moment- ticular got me started. 8 SOCIAL MEDICINE 1998

N THE SPRING OF 1947 the New irs strategy for securing the welfare of workers; I York Academy of Medicine celebrated fearing that a national social insurance program its centennial with an "Institute on Social Medi- for health care was now unlikely, unions began cine." The introduction to the published vol- demanding private benefit;; from private ume of papers was written by the Academy's employers. Already, the number of workers direcror, Howard Reid Craig, who commented: covered for health insurance had doubled since the end of the war. Mrer 1947 the growth of "To introduce a book on social medicine employment-linked private insurance would is a high adventure in the realm of the phi- sharply accelerate because of collective losophy of modern medicine and its rela- bargaining. Two non-profit "prepaid group tionships to man and the world in which practice plans" (the term "HMO" would not he lives. Economists, sociologists, even be heard for another 23 years) began operation statesmen and governments, are thinking in 1947. One, the Health Insurance Plan of in terms of people as humans and of the Greater New York, was an initiative of the world as an integrated association; but former New York City Mayor, Fiorello medical men (sic) as a group have been LaGuardia; the other, the Group Health more than slow in initiating this type of Cooperative of Puget Sound, had roots in the thinking in their own particular Beld of cooperative and labor movements of the Pacific endeavor. This lag is understandable, for Northwest. A year earlier, Henry ]. Kaiser's the average physician is very close to the group practice program for his wartime shipyard sickbed; it is only the exception who can workers had opened to the public. raise his head skyward for a broader view Implementation of the Hill-Burton program (of and a better understanding of what is go- federally-assisted hospital construction) was just ing on about him .... it would be well for underway. And American medical schools were medicine as a whole to become acutely beginning to feel the effects of a major metabolic aware of the tidal movements in the affairs change, brought on by a flood of new specialty of man, for medicine to recognize that, al- training programs, full-time faculty members, though it is an important constituent, it is and an unheard of federal largesse in the form only one element in the whole so1=ial or- of new research grants. Bur despite these shifts ganism. It is perhaps more important still and the social forces behind them, Craig's for medicine to fully realize that it is an assessment was probably correct: by all accounts integral, interrelated, and interdependent "medicine as a whole" had not yet recognized part of a functioning social and economic that the profession's seemingly insular work was system which to be viable must exist in a in reality "an integral, interrelated, and continuing state of flux." I interdependent part" of the larger social fabric. Social medicine was surely in a state of flux One further event worth our remembering in 1947. It had been less than two years since occurred in the Spring of 1947. A young World War II's end. The British National Health Manitoba physician, who had helped plan Service and the World Health Organization Saskatchewan's social insurance program, found were preparing to commence the following year. a summer job teaching biostatistics at the Uni- And 1947 was also the year when the Canadian versity of North Carolina. Cecil Sheps had just Province of Saskatchewan enacted the first so- co~pl~ted a Rockefeller Foundation Fellowship, cial health insurance program in North America. usmg It to study medical care under Franz In Washington, the disinclination of the new ~oldmann at Yale. On his way south he stopped Republican Congress to act on national health Ill New York to pay a call on his Foundation insurance prompted organized labor ro revise patron, Dr. John Grant, who noted in his diary:

1}t:;ar! Reid Craig: ·:Introduction," in lago Galdsron (ediror), Social Medicine: Its Derivatiom and Objectives: The New or ca emy oflvfedzczne lnstztute on Sacral Medzcme, 1947. New York: Commonwealth Fun d , !949 , p. v11.·· SOCIAL MEDICINE 1998

history of the medical profession's response to the larger society. In his review of the medical work of the ancients, Temkin mentioned that the contemporary medical literature "deals al- most exclusively with such medical problems as are encountered in private practice, especially among well-to-do citizens."4 He said that the Greek and Roman physicians had felt bound to society only by the intrinsic values of medi- cine and that the emperors and communities who gave certain privileges and immunities to the better doctors and provided them with of- fices, even lecture rooms. and pupils, could not count on a code of social responsibility from those they had favored. This state. of affairs began to change in the Middle Ages, when two new social elements were superimposed on medicine: the town and the idea of a Christian commonwealth of na- tions. The medieval town brought a new cor- porate life, which included self-regulating guilds Dr. Cecil G. Sheps in 1948 complete with rules governing admission, train- "S. is certainly bright, and one judges (he) will ing, intercourse among members, and elimina- make an excellent and enthusiastic teacher."2 tion of competition from outsiders. The medi- At summer's end, Sheps was asked t~ stay on as cal guilds also took on supervision of quality a member of the School of Public Health fac- and assumed responsibility for preventing or ulty. Three years later, he received a Rockefeller punishing malpractice. Such intramural activ- grant (via Dr. Grant) that allowed him to lead ism also extended at times to the broader com- munity; doctors were expected to cooperate the planning of a teaching and research pro- when asked by the authorities in matters of gram in social medicine that would focus on the strategic mission of the new clinical faculty public health and safety. Surgeons from the 14th and hospital (scheduled to open in 1952): To century on were required to report all injuries serve the people ofNorth Carolina. that came to their attention; and by law physi- cians reported all cases of leprosy and syphilis. HILE THE YOUNG Dr. Sheps When plague threatened, doctors helped plan W made his way to Chapel Hill, bring- how the town would combat the disease. ing his vision of social medicine, the New York These questions of supply, education, distri- Academy's Institute on Social Medicine opened bution and quality of doctors, and their respon- with papers by the four leading historians of sibility for the public health, are still with us. medicine in the United States-George Rosen, At times the larger community has trusted the Richard Shryock, Henry Sigerist, and Owsei profession to decide these things on its own; at Temkin) Together, they traced some of the other times, society has expressed its concern 2 John Grant, "New York, June 6, 1947, Dr. C. G. Sheps" in the guise oflegislation and new institutions. (Rockefeller Foundation Archive, Record Group 12, Box But issues of professional control continue 21, John Grant 1947 diary). prominently on today's social policy agenda. 3 Owsei Temkin, "Changing Concepts of the Relation of Medicine to Society: In Early History"; George Rosen, "In The social responsibility that the medical pro- the Age of Enlightenment"; Richard H. Shryock, "In the fession took on in order to accommodate the 1840's"; Henry E. Sigerist, "From Bismarck to Beveridge"; all in Galdston, Op Cit. 4 Temkin, Op. Cit. p 4 SOCIAL MEDICINE 1228 10

institutions of medieval life was a narrow one that rarely extended beyond the immediate con- cerns of guild and town. A much wider and more decisive force came from the establishment of an official and comprehensive religion, one that emphasized charity and brotherly love as high moral virtues. Although charity as an individual ethic had existed in antiquity, the medieval concept of charity based on Christianity transformed it into a social ethic that bound every member of the community. Wherever Christianity dominated, the treatment of the sick poor soon became a social priority-leading, for example, to the in- stitution of hospitals. Yet, for the medical pro- fession charity as universal imperative could cause problems. As Temkin explained, "It was not a question of whether the individual physi- cian wanted to be charitable; society had a right ro expect charity from him.''5 And what if the doctor didn't wish to care for the poor? The town (or the state) might devise regulations designed Theophrastus Bombastus von Hohenheim, to assure that he would perform his Christian known as Paracelsus (1490-1541) duty: fees fixed by ordinance, physicians as- signed to charitable duty on a fixed schedule, and thus display their manifest shame be- or laws guaranteeing the poor free care. fore all the world, which they deem an If regulation weren't enough, public criticism honour and well suited to a physician. To of doctors for their avarice and love of riches walk around thus decked out like a picture was also common. A Strasbourg preacher named is an abomination before God."7 Geiler von Keisersberg advised physicians where Society's expectation of medicine, whether they should place their priority and from whom voiced as regulation, exhortation from the pul- they should seek their remuneration: pit, or in literature, has always commanded a ''A physician should ... not only help (the response from the profession. And so we have poor person) from compassion and for come to appreciate the importance of this par- God's sake, but he should also be at his ticular social nexus-of ethics, cultural norms, service every day. Afterwards he may take and medical behavior-so much that it now im- all the more from the rich who can afford bues our social medicine teaching. to pay."6 ROFESSIONAL SELF-INTEREST Paracelsus' criticisms were harsher. The "doc- Pand civic duty together with religion- toral custom," he declared, had failed to fulfill based morality were the bases of medieval so- "the commandment of love." Physicians were cial medicine. Science played little part. But instead following the law of social medicine's foundations began to shift in " ... grab, grab, whether it makes sense or the Age of Enlightenment. One of the main not. Thus they receive golden chains and movers was William Petty, an English army golden rings, thus they go in silk raiment physician, anatomist, professor of music,

5 Ibid, p 9. 7 Paracelsus, "Seven Defensiones," in Henry E. Sigerist (edi- 6 L. Kotelmann, Gesundheitspflege im Mitte!alter. Hamburg tor), Four Treatises ofTheophrastus von Hohenheim. Balti- and Leipzig: Voss, 1890 (quoted in Ibid, p 10). more: Johns Hopkins Press, 1941, p. 31. SOCIAL MEDICINE 1998 11

statistician, member of Parliament, and founder of the discipline of political economy. One of Petty's fascinations was with the concept ofvalue TWO 11 and how to conserve it, an understandable in- terest given the momentous changes that were E s s A y s occuring in European commerce during the IN 17th century. ~olitiral ~ritbmetitli, Industrial capitalism was then displacing me- Concerning the dieval commercial capitalism and production overtaking exchange as the chief economic con- People, Houfing, Hofpitals, &c. cern. The new importance of production meant OF that labor-in Petty's words the "value of the Lo·NooN PARIS-. people"-would henceforth have a much higher and worth, higher even, thought Petty, than capital and land combined. Human illness and prema- By Sir WILLIAM PE1'1'-T, ture death, therefore, brought major economic Fellow of the Royal Society. consequences for both private producers and the - -~·-ilf'i foiret Rtgibm 111i state. Clearly, having the largest possible num- F11j1idirtt •lm--- ber of healthy productive workers would bring the greatest return to the state. It followed, there- LONDON, fore, that records, reliable public statistics and Printed for 1· Lloyd in the Middle Exchange next S4/iJ6HrJ-Houfein theSrr•nd. t6S7• government expenditure on health measures could be seen as economic investments. Cen- trally important to Petty were the most produc- The tide page of Petty's Two Essays (1687), a tive groups in society-farmers, manufacture, volume owned and often cited by another merchants, seamen and'~oldiers-while "all influential economist, Karl Marx other great professions do arise out of the infir- mities and miscarriages of these."8 Petty's economic calculation, which he called "political arithmetick," was a new feature of"so- cial medicine." It showed the practical wisdom of protecting the people's health, something that an enlightened ruler could accomplish readily (in an age of absolute monarchy) by appoint- ing public officials who would be guided by "policy." In Germany, this doctrine, called Medizinalpolizei (medical policy or police) was carried out by physician administrators, who became the first public health officers and pro- fessional medical regulators. The social medi- cine pioneer Johann Peter Frank explained the purpose of medical police: "(It) is an art of defense, a model of pro- tection of people ... against the deleterious consequences of dwelling together in large

8 William Perry, (C. H. Hull, editor), The Economic Writings of Sir William Petty. Cambridge: 1899, volume 1, p. xiii Dr. William Petty (1623-1687) (quoted in Rosen, Op Cit, p. 14). SOCIAL MEDICINE 15J5J8 12

numbers, but especially of promoting their pre-paid surgical attention for "every ... sub- physical well-being so that (they) will scriber ifby any casualty (drunkenness and quar- succumb as late as possible to their even- rels excepted) they break their limbs, dislocate tual fate from the many physical illnesses joints, or are dangerously maimed or to which they are subject."9 bruised ... "; visitation by physicians and pre- scriptions "if [the subscribers] are at any time Petty, Frank and others of their late 17th and dangerously sick"; and hospitalization "if they early 18th century contemporaries contributed become lame, aged, bedrid, or by real infirmity an effective rationale and the necessary statisti- of body (the pox excepted) are unable to work, cal tools and administrative methods for an or- and otherwise incapable to provide for them- ganized preventive medicine. The application selves .... "10 Other early 18th century of statistics to clinical medicine came later. It visionaries proposed public hospitals open to developed largely in France, possibly beginning all citizens and government programs of health with Diderot's Encyclopedia, which contained insurance. But the time for such projects was an influential article on probability that not yet, and none of these proposals was realized. prompted administrators of all kinds to engage in numerical analysis. After the French Revolu- OCIAL MEDICINE HAS LONG tion, the practice of counting events and Sbeen interested in the alleviation of expressing the results in percent spread to the poverty and the welfare of the poor. This, in Paris hospitals, where it was carried on, most fact, was the key concern behind Guerin's in- notably, by Benjamin Franklin's Parisian friend, vention of the term "social medicine," and it Phillippe Pinel. As physician in charge of the was underlined by Virchow's memorable Bicetre hospice, the largest asylum in Europe statement in the very first issue of Medizinische with 8,000 patients, Pinel was uniquely situ- Reform Quly 10, 1848): "Doctors are the natural ated to collect and apply numerical data in pa- advocates of the poor, and social problems are tient care. In the early 19th century Pinel's meth- · very largely within their jurisdiction." It is not odological successor Pierre Louis devised his surprising, therefore, that social medicine should "numerical method" for analyzing outcomes of have often aligned itself with-and considered therapy and set the course for what we now call itself part of-the related field of social welfare, "clinical epidemiology." and that the two fields have asked many of the The value of healthy workers may have been same questions: Must essential human services foremost in the minds of the 17th century po- for the poor always be provided apart from those litical economists, but the question of what to to the rest of the population? What is gained do about the poor continued to stir the con- and lost by segregating recipients according to sciences of Christian moralists, just as it had in their economic status? the Middle Ages. The plight of poor workers Probably the most instructive national ex- also incited the creativity of some early inven- ample in modern history of social welfare policy tors of "projects" (public schemes by which and the poor, including their health care, is that income maintenance and social services, includ- of Great Britain. Partly this is because the in- ing medical care, could be more effectively dis- dustrial revolution, which so exacerbated the tributed and organized). Daniel Defoe, for ex- problem of poverty, began there. In addition, ample, in his Essay upon Projects (1697) imag- while British attitudes on social welfare were ined a social security plan for the laboring class never unanimous, they were usually expressed based on collective self-help. It would include loudly and unambiguously. The great shift in attitude toward the welfare of the working classes from the Elizabethan period to the post-· 9 Johann Peter Frank, "Introduction to Medical Police" in Erna Lesky (editor), A System of Complete Medical Police: World War II years shows well some of the extra- Selections from Johann Peter Frank (translated from the third, revised edition ofVienna, 1786, by E. Vilim). Balti- 10 Daniel Defoe, Essay Upon Projects (1697) quoted in more: Johns Hopkins University Press, 1976, p. 12. Rosen, Op. Cit., p. 16 SOCIAL MEDICINE 1998 13

scientific impetus of social medicine. It also the first industrial revolution, which provided shows how the economic, political and moral employment-but the jobs were often ilnstable environment can change, and why medicine with wages insufficient to feed a family. Oliver must constantly gauge its own course to deter- Goldsmith depicted the plight of the unfortu- mine whether it is following, leading or resist- nates in his poem, "Deserted Village" (1770): ing the broader movement of sociery. Where then, ah! where shall poverty reside, In Britain, as in most industrialized nations, To 'scape the pressure of continuous pride? transformations in the lives of the poor, includ- If to some common's fenceless limits strayed ing changes in health, became integral to na- He drives his flock to pick the scanty blade, tional policy, economic growth, and class rela- Those fenceless fields the sons of wealth divide, tions. A summary account of this experience And e'en the bare-worn common is denied. must begin with the Elizabethan Poor Law Act Near the end of the century, the war with of 1601. Behind the Poor Law and the local France combined with a succession of poor har- customs that preceded it lay an assumption: the vests precipitated a rise in prices that resulted poor must be given relief lest they become a in food riots. One response was a new system nuisance. Overseers in each parish would dis- of "outdoor" relief that soon spread through- pense a small allowance to poor families until our England. Local parishes gave workers a the breadwinner could find work. Given relief supplement to their wages, up to the minimum the recipients were more likely to stay in their required for a family to subsist (the amount was homes and not become roving vagabonds or linked to the size of the family and the price of turn to begging. This kind of "outdoor" relief, bread). The wage supplement scheme soon however, co-existed with "indoor" relief (tied failed. Without a minimum wage law, the em- to residence in the workhouse). Since the pre- ployers' incentive was to keep wages low, since vailing belief held that most people's poverry they could be confident that the supplement was caused by their own disinclination to work, would bridge the gap between what they were the able-bodied poor-with their entire fami- paying and subsistence. The new "outdoor" re- lies-were made to live in "workhouses" to re- lief scheme also prompted a more general cri- ceive their subsistence. It soon became clear, tique-that a workman's income shouldn't be however, that poor health accompanied indoor determined solely by the size of his family and relief. A committee appointed by the House of not at all by his skill or diligence. Finally, the Commons in the late 18th century found that parishes' abiliry to pay the supplement usually "only seven in a hundred" infants born in the required a steep increase in local tax rates. workhouse had survived beyond two years. A reaction was inevitable. It came in 1834, Clearly, removal "from more salubrious air to when the Whig government enacted a New Poor such mansions of putridiry" took a severe toll. 11 Law and Britain reverted to a system of strict At about this same time a new group of able- "indoor" relief, designed this time to end once bodied poor were emerging in England-rural and for all what was regarded as the coddling of subsistence workers whose home industries those who wouldn't work. One result of the new couldn't compete with the steam-powered mill. law was a decline in relief expenditures. But the Further, such workers were no longer being al- return to the workhouse also brought other con- lowed to grow vegetables or graze a cow on what sequences. All categories of dependents-the had once been public access lands. If the "en- able-bodied poor, the ill, feeble-minded, insane, closure of the commons" were not by itself a crippled, and blind-were commonly housed sufficiently calamitous economic event for these together in the workhouse; yet members of landless rural poor, it arrived concurrently with families were separated, assigned to different

11 John Scott, Observations on the Present State of the Parochial and Vagrant Poor, 1773. (quoted in Karl de Schweinitz, Englands Road to Social Security: From the Statute of Laborers in 1349 to the Beveridge Report of 1942. Philadelphia: University of Pennsylvania Press, 1943, p. 66. SOCIAL iVIED!CINE 1998 14

sections of the institution. The specter of being alarm, a closer examination ofhealth conditions sent to the workhouse indeed proved to be a among the urban working class gave rise to the most effective deterrent for any member of the sanitary movement. Its leaders were with a few underclass who was tempted to ask for relief. exceptions middle-class humanitarians (many How the poor managed to survive, both in and were physicians) who directed their appeals to out of the workhouse, would be depicted starkly the economic interest of the state.14 What to the world by Charles Dickens and Frederick emerged was greater official attention to envi- Engels.12 ronmental measures. Edwin Chadwick's find- Most members of the dominant middle-class ing that place of residence and t:conomic class approved of the New Poor Law. The punitive were related to mortality (among the Liverpool rationale behind it in fact took on the force of a gentry the average age at death was 35; in fami- moral code, strong enough to guide Britain's lies oflaborers it was 15); William Parr's obser- social welfare policy for the next 75 years. At vation of a positive correlation between popu- the end of the 1860s came a new intellectual lation density and mortality; and John Snow's justification for the harsh treatment of the poor. demonstration that cholera was spread by wa- Social Darwinism applied "the survival of the ter, led to the establishment of official boards fittest" to human society and taught that mate- and offices devoted to public health. rial charity would only perpetuate human weak- None of this early public health activity, how- ness and degeneracy. The conventional wisdom ever, involved medical care. The earlier interest is illi.Jstrated by a Cambridge professor's warn- in seeing that the poor received medical atten- ing that philanthropy was provoking "demands" tion now took a back seat to sanitation. In the from "so many of the working-classes ... that par- mid-19th century this order of priority made ents should not be required to pay for their sense-on two counts: First, in political-eco- children's education, but that all schools should nomic terms, sanitation simply overwhelmed be free .... (Such demands) simply show how medicine in terms of what each could offer in many there are who will always try to escape saving lives of rich and poor alike (although this from the responsibility of their own acts."13 began to change after about 1875, when the Voluntary charity societies saw the poor as sin- development of bacteriology made surgery ners, responsible for their own plight but in need "safe" and direct prevention of certain commu- of physical sustenance and moral uplift. Yet few nicable diseases possible). Second, free medical of the would-be uplifters perceived any social care for the poor was considered another form problem-except pauperism, or any social so- of Poor Law relief, to be limited to the destitute lution-except the workhouse. and doled out meagerly so that there would be Middle class and business interests have also no question that its quality was inferior to that from time to time defined the agenda of social received by persons not on relief. The low sti- welfare (and of social medicine). In fact, by the pends and status of the Poor Law medical offic- middle of the 19th century the increasingly ers confirmed the value that the society placed wealthy and influential business class had dis- on their positions; they shared the scorn directed covered a new motivation to act that was more toward their clients, despite the efforts of pa- powerful than Christian moral uplift-concern thologist Thomas Hodgkin to champion their for one's own personal health and economic self- cause by advocating higher qualifications and a interest. When the teeming industrial slums reorganization ofPoor Law medicine using vol- combined with epidemic disease raised the untary prepaid clinics.

12 Dickens' Oliver Twist appeared during 1837 and 1838 (as a newspaper serial) and Hard Times came out in 1854. Engels published The Condition ofthe Working Class in En­ 14 Prominent among them were William Farrand Edwin gland in 1845. Chadwick in England, Louis-Rem' Villerme in France, 13 Henry Fawcett, Pauperism: Its Causes and Remedies (1871 ), Rudolph Virchow in Prussia, and Lemuel Shattuck and quoted in de Schweinitz. Op. Cit., p. 142. Stephen Smith in the United States. SOCIAL MEDICINE 1998 15

ONTROLLING AS THE POOR Claw philosophy was ofVictorian views on social welfare, at least five contrarian forces also found voice and built momentum through- out the 19th century. All were linked to medi- cine-although if viewed by to day's strict cat- egorical terms, they may not appear so. The first counterforce came on behalf of- and finally from-the working class. It began early in the century as a campaign for worker protection. A law forbidding textile mills from employing apprentices below the age of nine was followed by a second law limiting the work day for women and children to ten hours. Late in the century a second industrial revolution followed the introduction of electricity, and new manufactured products resulted in millions of new wage workers. When the proportion of wage workers increases sharply, as occurred with both industrial revolutions, insecurity grows until the wage-earning class becomes restive enough to protest its powerless condition, Dorothea Dix (1802-1887) whereupon the existing order is apt to make a corrective response. One such response in the should be available to the entire population 19th century was to extend suffrage to urban irrespective of social class or ability to pay. laborers, then to miners and agricultural work- A third counterforce took the form of a se- ers. The first trade unionists entered Parliament ries of reports on the condition of the poor. First in the 1870s. Their ranks grew, until by the end came Edwin Chadwick's 1842 Report upon the of the century the workers themselves had be- Sanitary Condition of the Laboring Population come a formidable political counterforce. ofGreat Britain, 15 followed by Henry Mayhew's A second counterforce was personified by two 1849 articles on "London Labour and the remarkable social medicine crusaders- London Poor," and near the end of the century Dorothea Dix and Florence Nightingale-who by industrialist Charles Booth's social surveys- were similar in their life situations, dominating 17 publications in all-on the life and work of single-minded personal styles, public reputa- Londoners. Each of these influential documen- tions and influence, and in what they accom- taries turned public opinion yet another degree plished. The American Dix, who took her cru- toward the view that the poor should not be sade to the British Parliament and Scotland, ef- held wholly at fault for their destitution and fectively rescued the insane from workhouses, that the state might have a greater role to play. jails and other odious receptacles, and removed them to special asylums. Nightingale resusci- 15 The Chadwick Report more than any other document tated hospitals physically and organizationally, was responsible for launching the public health movemenr. and thereby abetted their growth later in the Its author, ironically, was the same ambitious, single-minded civil servant (and gifted polemicist) who drafted the regres- century when they were becoming essential to sive 1834 Poor Law. After concluding that an unsanitary healing. One consequence of a science-based environment was the major cause of excessive sickness, medicine centered at hospitals was that its costs which not only reduced the available labor but increased increased beyond the purchasing power of the the expense of the Poor Law, Chadwick persuaded the En- glish ruling class that removing the cause of disease would population, which in turn prompted a widely be cheaper than paying the relief that inevitably accompa- shared conviction that medicine's benefits nied so much individual illness and premature death. SOCIAL MEDICINE 1998 16

VER THE COURSE of the late 0 19th and early 20th centuries these counterforces in combination proved more du- rable than the Poor Law morality. Unemploy- ment, poverty, and health and illness became more significant matters of national policy; and discussion of these issues uncovered class ten- sion, prompted moral inquiry and ethical de- bate, and pointed social reform in a different direction. The first cracks in the workhouse foundation appeared in 1885, when the city of Bi.rming- ham instituted a program of public works for the unemployed. Eleven years later the Local Government Board recommended that those aged poor who had "habitually led decent and deserving lives" not be required to enter the Florence Nightingale (1820-1910) workhouse in order to receive relief, and that workhouse inmates of good moral character be allowed separate sleeping cubicles. In another Yet a fourth counterforce was British social- thirteen years the Royal Commission on the ism, which although it could claim powerful Poor Laws and Relief of Distress would find the intellectual antecedents like Robert Owen, the "effect of a sojourn in the workhouse ... wholly Rochdale cooperators, Karl Marx and Frederick bad" and acknowledge, finally, the part played Engels, had only minor political importance- by "our industrial system" in creating unemploy- until the founding of the Fabian Society in ment and distress. That Commission also rec- 1883. A remarkable group of thinkers and ac- ommended certain corrective measures-child tivists, the Fabians set an ambitious course for labor laws, reduction in the length of the work- themselves, aiming to accomplish a series of ma- day, a national labor exchange, unemployment jor political, industrial and social reforms- insurance, and sickness insurance.16 founding of a Labor Party, the eight-hour day, public water, public education, women's In 1908, Board of Trade President Winston suffrage, a minimum wage, abolition of the Poor Churchill demonstrated the pragmatism in the Law, and social insurance. new thinking: Finally, one counterforce came from abroad. "I do not agree with those who say that In 1883 German Chancellor Bismarck prevailed every man must look after himself, and that over the conservatives of the Liberal Party and the intervention by the State in such the radical Social Democrats and enacted the matters ... will be fatal to his self-reliance, world's first social insurance law, thus setting in his foresight, and his thrift .... The mass of place an example for other nations to copy- the laboring poor have known that unless directly or eventually. Since Bismarck's goal was they made provision for their old age to reduce the social insecurity of the German betimes they would perish miserably in the worker, which he believed imperiled the state, workhouse. Yet they have made no provi- his program was primarily designed to mollify sion; ... for they have never been able to low-wage industrial laborers and win their loy- make such provision .... It is a great mistake alty. After Bismarck's rule ended, the program to suppose that thrift is caused only by fear;

was expanded gradually, mostly by the Social 16 Report ofthe Poor Commission on the Poor Laws and Relief Democrats, until it covered not only low-in- ofDistress, 1909 (The Majority Report), quored and sum- come workers, but all workers. marized in de Schweinitz, Op. Cit., pp. 189, 190, 198. SOCIAL MEDICINE 1998 17

it springs from hope as well as from fear; ·agreed-upon contingency arose. In this respect, where there is no hope, be sure there will social insurance was the opposite of Poor Law be no thrift." 17 relief. Finally, in 1918 Britain made suffrage And Chancellor of the Exchequer David universal by extending it not only to women, Lloyd George declared (also in 1908) his but also to people on relief, an action that fur- government's philosophy on social welfare: ther eroded the Poor Law legacy. "There is plenry of wealth in this country All of these steps were leading up to the ma- to provide for all and to spare. What is jor turning point in Britain's shift from Poor wanted is fairer distribution .... [in order Law to welfare state. It came in 1941, at a time that] those whose labor alone produces that when the nation faced imminent invasion. The wealth are amply protected with their fami- appointment of an Interdepartmental Commit- lies from actual need ... owing to circum- tee to study social insurance resulted in publi- stances over which they have no control. cation of the Beveridge Report the following By that I mean ... that the spare wealth of year. Sir William Beveridge was an internation- the country should, as a condition of its ally renowned educator, economist and insur- enjoyment by its possessors, be forced to ance expert. His report was built upon two un- contribute first towards the honorable derlying concepts-Comprehensiveness and maintenance of those who have ceased to Equaliry-and it embodied well the war-born be able to maintain themselves."18 social sentiment of Britain in the 1940s. He proposed that the nation attack the "five Giant Riding on the wave of interest in improving Evils (of) Want, Disease, Ignorance, Squalor and the welfare of workers, a spate of social legisla- Idleness" with a complete system of social in- tion emerged from Parliament after 1905. All surance for all citizens as of right.19 As a later of it pointed away from the Poor Law. The single report amplified, the equaliry motif was basic: most important of these initiatives followed a "In a matter so fundamental, it is right for all visit by Lloyd George to Germany. He imme- citizens to stand in together without exclusions diately launched a two-year campaign for so- based on differences of status, function or cial health and unemployment insurance, which wealth."20 Parliament enacted in 1911. Unlike German sickness insurance, however, the British version Beveridge made three fundamental social of health insurance was never extended beyond policy assumptions: there would be guaranteed its original target-low income workers. full employment, a system of child allowances, and a comprehensive national health service that In 1925, Great Britain added yet another so- would assure every citizen "whatever medical cial insurance program-old age and survivors' treatment he requires, in whatever form he re- benefits-thereby setting an example that the quires it, domiciliary or institutional, general, United States would copy ten years later (with specialist or consultant, and also ... dental, oph- the Social Securiry Act ofl935). Unlike the 19th thalmic and surgical appliances, nursing and century programs of relief for the poor, few of midwifery and rehabilitation after accidents."21 these new programs required a demonstration of financial need or someone to vouch for the recipient's worthiness. The services and pay- ments were simply delivered to the insured person as promised, when and if the previously- !9 Social Insurance and Allied Services: Report by Sir William Beveridge, Presented to Parliament by Command ofHis Maj­ 17 Winston Spencer Churchill, Liberalism and the Social esty, November, 1942. New York: Macmillan, 1942. para- Problem. London: Hodder and Stoughton, 1909. pp 208- graph 456. 210. 20 White Paper on Sociallnsurance, 1945. Quoted in Harry 18 David Lloyd George, Slings and Arrows; Sayings Chosen Hopkins, The New Look: A Social History ofthe Forties and from the Speeches ofthe Rt. Hon. David Lloyd George. Fifties in Britain. Boston: Houghton Mifflin, 1964, p. 126. London: Cassell and Co., 1929. p. 8. 21 Social Insurance and Allied Services, p. 158. SOCIAL MEDICINE 1998 18

ideals of its medical practitioners, questioning the goals of the new "health care industry," and continuing to examine the ethical values that underlie healing. As we respond to these con- temporary concerns, we should keep in mind that our disciplines and areas of interest-pub- lic health and preventive medicine; epidemiol- ogy; medical care financing, organization and policy; biomedical ethics; and the sociology, an- thropology, and political economy of health- all began at the same juncture where we experi- ence them now. They represented areas of in- quiry, methods, and actions at the interface of medicine and society, attempts by the social medicine pioneers to understand, in some cases measure, but always respond to shifts in the social environment on the-one hand and in the profession of medicine on the other. As both medicine and society have enlarged, William Beveridge in 1942 so has their area of convergence-to the point where a Department of Social Medicine can- The importance of the Beveridge Report to not begin to cover it all; nor should it try. the National Health Service, which went into Howard Reid Craig was correct when he said: "It operation six years later, was not in the specifics would be well for medicine as a whole to of the author's proposal; others worked out the become acutely aware of the tidal movements in the affairs of man." Yet, medicine as a whole political strategy and the details of how the NHS has a more elusive identity now tha..r1 it did in would operate. What makes William Beveridge 1947; and it would not be wise, nor possible, a major figure in the history of social medicine for its heterogeneous membership to rely on a is that he placed medical care policy in the con- single antenna-a popular leader or even a single text of a more general social policy. He saw the organization-to detect new signals in the air NHS as a practical expression of the ethic of and respond for all. Every sector of medicine, solidarity, born of the war, but chosen by the from each clinical specialty to the drug trial British people in the post-war years to replace judges and genome mappers-and every indi- an older social morality that they realized was vidual professional-should be aware of the outmoded. "tidal movements," attempt to understand them, and participate actively at the social in- O DAY'S SOCIAL MEDICINE still terface of the profession. This is what the So- T refers to all of these antecedent prob- cial Medicine faculty tries to represent, and it is lems, visions and solutions. At the end of the this understanding and behavior that we hope 20th century society is concerned with the social to instill in our students. DLM