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