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.