file: hph_lec1d.mp3
A History of Modern Public Health: Introduction (continued)
So continuing on with his book "Mirage of Health," Rene Dubos had
created an intellectual climate that facilitated an attack on
medicine. And two people took up the challenge: Thomas McEwen and
Ivan Ilich.
First of all, let us look at the role of Thomas McEwen. He was a
professor of social medicine, and that is crucial, a professor of
SOCIAL medicine, at Birmingham University in the United Kingdom,
and he wrote two very important books, first of all "The Modern
Rise of Population" in 1976, and secondly "The role of Medicine."
The two books examined changes in mortality rates from specific
causes in England and Wales from the mid 19th century. This
rather detailed look at mortality rates and at the published data
provided an empirical verification of Dubos's work in the
late1950s and early 1960s.
So what were MacEwen's conclusions when he analyzed the evidence?
First of all, he suggested that the cause of death information
that he looked at led him to believe that medical intervention
played little or no role in the control of acute d infectious
diseases. He argued that the most important factor in the decline
of mortality was improved living standards and nutritional levels
whilst other influences included sanitation and a decline in the
virulence of some diseases.
Here is a graph that McEwen used in his 1976 publication that
basically in a very simple form illustrated the role of medical
intervention on the decline of respiratory tuberculosis. You have
death rates from respiratory TB from 1838, and you can see that
there is a steady picture of decline throughout the whole period.
However, this decline had commenced well before the tubercular
bacillus was identified by Robert Cock in the 1880s, who you can
see here, and the decline progressed and was well underway and
almost achieved very low levels even before chemotherapy and BCG
vaccination were introduced in the 1940s and 1950s. And what you
got to understand here is that in a medical climate that believed
that chemotherapies and vaccinations had actually secured most of
the decline of tuberculosis, the impression that these long-term
rates gave was something of a revelation to the medical
profession.
Just to emphasize this point, here you have death rates from
respiratory conditions from the mid 19th century onwards.
Chemotherapy was introduced in the late 1930s, early 1940s, yet
the decline of mortality from these diseases had begun well
before that and dates back to the beginning of the 20th century.
Again, measles, death rates of children under the age of 15 in
England and Wales: McEwen used these rates to show how
immunization had actually provided very little of the
contribution to the decline of measles over this period. You can
see a precipitous decline from the early 20th century that took
place, and we achieved very low levels in the mortality of the
under-5 well before immunization was introduced.
Whooping cough: causal organisms identified in the early 1900s;
immunization generally available in the 1950s; but again, this
picture of constant decline before a therapy even became
available. So effectively, MacEwen is arguing that medical care
and medical interventions played little or no part in the decline
of mortality in the second half of the 19th century or even the
first half of the 20th.
Here you have a flow diagram showing a representation of
MacEwen's arguments for that second half of the 19th century. And
so he suggested that because there was no intervention available
for tuberculosis when it contributed to 38 percent of the
mortality decline, he argued that there was no medical
intervention over this period for cholera and typhus and typhoid,
which contributed 29 percent of the decline, and there was no
medical intervention to cure or prevent scarlet fever which
contributed to 12 percent of the mortality decline, then we need
to look at other explanations for why life expectancy improved.
Linking tuberculosis to improvements in the standard of living
and diets, linking cholera and typhus and typhoid to sanitary
reforms
and public and personal hygiene, and linking scarlet fever to
changes in virulence in the disease microorganism itself,
effectively MacEwen marginalized -- if not obliterated -- the
role of medicine in declining mortality over the second half of
the 19th century.
What is crucial to MacEwen's argument is the role of
industrialization. Industrialization, the introduction of
mechanization into production processes, effectively created
cities. And so in this way industrial technology redefined social
organization from predominantly a farming society
to a predominantly urban industrial one.
And Ivan Ilich, who is the third of our major protagonists in
this debate, argued that this industrial technology and the way
in which define social organization is achieved by an increase in
the level of bureaucracy and administration. This leads to a
conflict between the managers, the health professionals, and
consumers, the patients. This is because medicine exists and
attempts to ensure the healthiness of the population. Workers
have to remain healthy to contribute to national economic growth,
and medicine is part of making sure that those healthy workers
continue to thrive. Ilich took this argument and said that
actually what happens under industrial conditions is that
physicians and doctors themselves create illness, and he termed
this iatrogenesis, from the Greek term "iatros," physician, and
"genesis," origin. So he has taken McEwen's arguments one step
further, the idea not only that medicine did not contribute to
improved health and reduced mortality but in fact that medicine
was actually adversely affecting the health of the population.
He suggested there were three forms of the iatrogenesis,
clinical, social, and structural. In clinical iatrogenesis, he
argues that damage is caused by doctors and the providers of
health services. The high status of the medical profession and
the faith that is invested in its members' ability has resulted
in other social problems being defined as illness, such as
stress, drug dependency, and even pregnancy. And this is partly
caused by a mechanistic approach to health that privileges
therapeutic interventions.
What you see here on the right-hand side is a mechanistic
representation of the human body drawn by Giovanni Alfonso
Borelli in his "De Motu Animalium" from 1680-81. You can see here
that the body is represented as a machine. It is represented as a
system of levers and pulleys, effectively if the machines goes
wrong, it can be fixed. And it is this notion that Ilich
challenged. He suggested that the idea that physicians could fix
a broken body resulted in problems that were compounded by both
professional arrogance and incompetence.
Another form of iatrogenesis that Ilich identified was social
iatrogeneis, and this very much reflects Dubos's arguments about
drug dependency and the idea that Western health in the mid 20th
century was not at its most optimal. Ilich identified and argued
that society was addicted to medical care. He suggested that
overmedicalization alters the adaptive ability into a passive
medical consumer discipline. So human beings who at one point had
been used to drawing on their environmental resources and kinship
systems and families and charities to adapt and to cure
themselves had now become medical consumers in a passive way,
basically taking whatever it was that the doctor had prescribed
for them. Ilich argued this was partly caused by the manipulative
behavior of medical bureaucracies and also that medicine men
monopolized definitions of health and modes of care. He suggested
that such medicine is better devised to convince those who are
sick and tired of society that it is they who are ill, impotent,
and in need of technical repair.
And the third form of iatrogenesis is structural iatrogenesis. In
some senses, this is linked to the social iatrogenesis that I
just described. He argued that patients lost their autonomy as
medical progress took hold. Individuals had their health and
their notions of health taken away from them by the medical
industry. Health and illness came to be defined not by people's
own experience but by what medicine said health and illness was.
Here you have a picture of Laneque of the Necker hospital in
Paris in the early 19th century. Laneque introduced the
stethoscope and diagnosed a multiplicity of pulmonary conditions
with its help: bronchitis, pneumonia, and pulmonary tuberculosis.
From this point on, physicians could listen directly to the body
and bypass the story that was told by the patient. Doctors no
longer needed to have a patient history in order to diagnose a
disease. And so what this does is it breaks with traditional
beliefs in society, the idea that death, that disease, pain and
suffering were part and parcel of life. It brings a more
rational, a more scientific approach to disease. And this is part
of what Ilich called structural iatrogenesis.
So in conclusion, the three protagonists argued that
industrialization and the changing nature of the environments in
which humans lived brought about different sets of diseases and
different sets of infections. However, as MacEwen argued, and
also Dubos, as these infections and diseases began to decline,
certainly throughout the second half of the 19th century and
during the 20th century, medicine could claim no success and no
part in that improvement in life expectancy. Ilich himself argued
that medicine had reached a point by the 1960s and 70s that made
it harmful to society. And it is in this context of the critique
of medicine that we have the new public health emerging: the idea
that we need to shift away from medicine in terms of therapeutics
and cure which is highly expensive and technocratic and
technological and move back towards ideas and ideologies about
prevention.
