Archive for the 'History of Social Medicine' Category

Health/PAC Bulletin Archives available online: A new resource for health activists

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www.healthpacbulletin.org_wp-content_uploads_2013_03_1988-Vol-18-2-Summer_Corrected-page-001

Health/PAC (the Health Policy Advisory Center) has recently posted PDF versions of all their Bulletins at: http://www.healthpacbulletin.org/.  The Bulletin was published from 1968 to 1994 and documented the work and analysis of progressive health activists from around the country.  The introduction to the collection provides a history of the organization and the Bulletin. Health/PAC’s organizational archives are housed at the Temple University Library: http://library.temple.edu/collections/scrc/healthpac-policy-advising.

Health/PAC was also responsible for the publication of three books:

  • The American Health Empire (1971): Chapter 1 is available at this link.
  • Prognosis Negative (1976): You can read a review from Science and Society
  • Beyond Crisis: Confronting Health Care in the United States (1994)

Health/PAC developed the concepts of “medical empire” and “medical-industrial complex.”  With time we have seen the increasing relevance of these terms for the analysis of a economic sector that makes up nearly 1/5 of our economy.  This is an invaluable collection for the critical analysis of health and health activism.

Can we eliminate health disparities without addressing wealth disparities?

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Our colleague, Claudio Schuftan passed along a link to the video below regarding wealth inequality in the US, a topic that has been re-introduced into the national debate by the Occupy Movement.

The issue of wealth inequality has enormous implications for health disparities.  Johann Peter Frank’s classic paper , The People’s Misery: Mother of Diseases, (now available online) shows that physicians even in 1790 understood the connections between poverty and ill-health. Indeed, the statistical evidence linking poverty and disease (or health and wealth) was so strong that William Farr, considered by some as the father of medical statistics, remarked in 1839 that “diseases are the iron index of misery.

The data on wealth disparities presented in this video poses a question:  is it is possible to meaningfully address health disparities in the US without addressing these massive transfer of wealth from the rich to the poor that has taken place since the Reagan Revolution in the 1980’s? If we attend to the bulk of the evidence, the answer is probably no. But this leaves us with the question, how do we reduce wealth disparities when the Congress has become a club of millionaires?

Any thoughts?

New issue of Social Medicine (V4N3) Just Published

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Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).

Children in post-Civil War Nepal singing revoutionary songs

Children in post-Civil War Nepal singing revoutionary songs

Special Theme: Social Medicine & War

For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.

Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write:  “Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”

Closing the Gap: Where are we one year later

a87ad0d1a8In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.

The Peckham Experiment

peckhamhealthcentreWe are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!

Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.

posted by Matt Anderson, MD

Social Medicine V4N1: Health Activism from Philadelphia to India

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We have just published the 12th edition of Social Medicine/Medicina Social, our bilingual, online journal.  It is available in both English and Spanish.  Our 12th issue captures the stories and struggles of diverse health activists, among them Dr. Walter Lear (shown below):

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US Health Activism Collection

Last summer we had an opportunity to interview Dr. Lear (now 85 years old), founder of the US Health Activism Collection.   In a wide-ranging interview in his home Dr. Lear discussed his personal background, the origins and purpose of the collection, the impact of the McCarthy period on the US health left, as well as his vision for the future (available at this link).  Dr. Lear later added copious footnotes to his interview creating a virtual “Who’s Who” of the mid-20th century US health left.

Dr. Lear also allowed us to make PDF copies of two of the pamphlets in his collection. These are Autopsy on the AMA: An Analysis of Healthcare Delivery Systems in America [1970] published by the Student Research Facility and Your Health Care in Crisis: A HEALTH/PAC Special Report [1972] [Both documents are a bit long and may take some time to download.]  Although HEALTH/PAC no longer exists as an organization, there is a HEALTH/PAC website.

Seize the Hospital to Serve the People

We are also publishing a video of Cleo Silvers, a remarkable Bronx health activist who was involved in the takeover of Lincoln Hospital.  (For more on this take over see our spring 2007 journal)  The video of Ms. Silvers can be seen at our Audio/Visual tab.

Should India Use Commercial Ready To Use Therapeutic Foods (RUTF) For Severe Acute Malnutrition (SAM) ?

Indian Activists associated with Jan Swasthya Abhiyan (People’s Health Movement – India) and the Right to Food Campaign question the value of Plumpy Nut, an Ready to Use Therapeutic Food (RUTF).  They argue that locally produced alternatives are cheaper, more acceptable, and serve to strengthen communities.  At the very least Plumpy Nut should have been compared to local supplements before being adopted by the government.  Available at this link.

Combatting Organ Tafficking

Activists Debra A. Budiani and Kabir Karim of the  Coalition for Organ-Failure Solutions discuss the social roots of organ trafficking and consider the implications of  a 2008 WHO resolution and the Istanbul Declaration.  Available at this link.

posted by Matt Anderson, MD

Peckham Experiment (1926-1950): Turning the conventional Medical view inside out

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peckhamhealthcentreThe Peckham Experiment (1926-1950) was a remarkable English attempt to rethink the role of health and medicine, an attempt that greatly influenced subsequent thinking about community health.  We recently learned the the Pioneer Health Foundation, which was set up to finance the Experiment, is still in existence and has a very informative website. The wealth of pictures and documents on the site really brings this piece of history alive.

The story of the Experiment begins in 1926 when two English physicans  Scott Williamson, a pathologist, and his (future) wife Innis Pearse set up a small health center in Peckham, a working class neighborhood of southeast London.  Located within a small house, the first Pioneer Health Center was a social club which also provided physical examinations (“overhauls”), day-care, social services, and orthopedic consultation.

Williamson and Pearse were struck by the degree of disease they found among the attendees at the Center.  Quoting from Pearse (see link):

“Suffice it to say that of all those overhauled, only 10 per cent were found to be without any clinically discoverable disorders. There were some 25 – 30 per cent who knew they had some disease; less than one half of these were under medical treatment at the time of examination. The remaining examinees (some 65 to 70 per cent) all had some pathological disorder of which they were unaware, or which they ignored.” (J Roy.Coll. Gen. Pract., 1970, 20, 147)

Findings like these spurred a rethinking of the role of the center. In the words of Mary Langman, the Center’s Founder Secretary:

“Within a few years Scott Williamson shut this venture down; it had become apparent that whatever abnormalities they found were returning in some form even where they had been successfully treated, on return to the same environment as had caused them in the first place.

Something had to be done about that; but what? The doctors could have no control over the working environment, not over the facilities at home. They had little influence over conditions is schools. Their only point of leverage was small – the limited leisure time available to everyone at various time of their day.”

The logical conclusion was to build a new Pioneer Health Center, this in the form a recreation center. The beautiful new center (shown in the image) was opened in 1935 and included a gymnasium, theater,  swimming pool, and school. Nursery facilities were available and a cafeteria served organic food grown at the Center’s farm.  [The PHC website has beautiful pictures of these facilities.]  To join the center one had live nearby (“within easy pram pushing distance”), pay a small fee, and agree to a yearly, family physical examination.

The  Center was seen as a vast experiment to understand what promotes health.  Quoting from the website, it sought “to turn the conventional medical viewpoint inside out – to look at what is biologically right whereas pathology and therapeutics look at what is biologically wrong.”  Its results profoundly influenced thinking about community health.  Here is a brief summary prepared in 1986 of the major findings:

“Basic Concepts and Processes derived from the work of Dr George Scott Williamson and Dr Innes Pearse

1. Health is a positive process and not merely the absence of disease.
2. Health has action patterns and behaviour of its own, and its own laws.
3. The basic unity is the parents and their children.
4. Health is to be seen in the excellent of structure and function – in their individual actions and behaviour of this unity, and in their relationship to each other and the environment.
5. This excellence is established mainly during certain key phases of growth and development, from birth (or before) through infancy, childhood, puberty, adolescence, courtship, mating, parenthood.
6. Each phase has its own developments characteristic of that phase which are integrated into the whole person and the quality and direction of all future action.
7. The potential for this growth and development is inherent in the family and its individual members, and is entirely self-announcing and self-directing.
8. It announces itself in each phase through feelings, appetite, and interest in things pertinent to that particular development, and is characterised by the spontaneous nature of the behaviour.
9. It directs itself through the dedication of the individual or individuals in all the appetitive phases, e.g., in physical achievement or in courtship and marriage.
10. Its completion is accompanied by feelings of satisfaction and fulfilment.
11. The successful completion of such cycles is not only necessary for the acquisition of important skills/capabilities, but also provides a foundation of emotional health and contributes to such qualities as contentment, judgment and courage.
12. Throughout each phase there is a high degree of energy – vitality and drive manifested within the dedication.
13. The emerging skill can only grow and develop if the environment contains the appropriate opportunity/stimulus for exercise and practice.
14. The environment must contain sufficient families to cover the whole spectrum of interests, actions and growth and development, so that each family and its members may find opportunities for its own specific action and development.
15. This population must be one in action, through the full range of phases and interests, and visible and accessible to each member in continuity.
16. This population will develop and exhibit community integration, purpose and achievement in its major and minor actions. What is being manifested is the growth and development of the whole. It is a biological entity in its own right, as well as being the nurtural environment for each individual and family.
17. The growth and development of each family in mutuality with the social whole constitutes biological order.
18. Such a community is cultivable, and is self-sustaining. As was demonstrated by the Peckham Experiment, this is achieved by cultivation of the environment and not by direct cultivation of the individual and family.”
(Compiled by Douglas Trotter and Allan Pepper, November 1986)

The Center was closed during World War II and turned into a munitions factory.  It reopened in 1945 but then closed permanently in 1950 due to lack of funding. The Center apparently did not find favor in the new formed British National Health Service.  The building is now an apartment house.  The Pioneer Health Foundation has remained in business, publicizing the work of the Experiment.  For a fuller overview of the Experiment see the 1985 paper by Allan Pepper at this link.

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The Peckham Experiment is one of the most influential of many attempts to reconceptualize the role of clinical medicine by integrating it with the life of the community and focusing on health promotion by various means rather than simply the cure of disease using medicines.  One is struck by the bold vision represented by the project.  Also in this tradition is the work of Sidney and Emily Kark on Community Oriented Primary Care (originally, A Practice of Social Medicine).

posted by Matt Anderson

Lincoln Hospital: The Decline of Health Care, A 1971 Radio Documentary

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The old Lincoln Hospital

The old Lincoln Hospital

In April of 2007, our journal Social Medicine, published the audio tapes of a 1971 Pacifica Radio documentary about the conditions at Lincoln Hospital, one of the largest public hospitals in the Bronx.  Lincoln had been briefly occupied by the community in 1970 and this takeover was the subject of several articles in the journal.

Unfortunately, technical problems broke the link to this audio. Thanks to help from Sebastian Pais Iriart this has now been corrected and the audio file is available at this link in mp3 format.

The audio tape was accompanied by an article.  Here are the first few paragraphs:

“Lincoln Hospital: the decline of health care” was broadcast on WBAI radio in New York City on April 22, 1971, roughly a year after the community takeover of Lincoln Hospital (see Fitzhugh Mullan’s article “Seize the Hospital to Serve the People” on page 98 of this journal).  The documentary provides an opportunity to
hear the voices of some of the people at the center of the struggle to reform – or revolutionize – one of New York City’s most dysfunctional hospitals.

These voices include physicians (Drs. Martin Stein, Helen Rodriguez-Trias, Lewis Fraad, Arnold Einhorn, and Fitzhugh Mullan), a community activist (Cleo Silvers), administrators (Antero Lacot, Edmund Rothschild, Stanley Bergin) and several patients.

Much of the documentary focuses on the health issues of the Bronx and the inadequacies of the hospital. Dr. Lewis Fraad notes, for example: “Lincoln Hospital is full of lead poisoning. And until recently, we have seen children get lead poisoning while hospitalized at Lincoln Hospital.” Patients recount long waits in the Emergency Room. […to read the rest of the article, click here]

What makes this documentary particularly interesting is the extensive discussion/debate regarding woker and community control of the hospital. This topic is essentially absent from the current corporate-dominated discussion of hospital management.

We hope in January 2009 to publish a video interview with Cleo Silvers, one of the key activists at Lincoln.

posted by Matt Anderson

Spirit of 1848 Presentations at the American Public Health Association 2008

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Berlin Revolution, March 1848

Berlin Revolution, March 1848

The Spirit of 1848 (www.Spiritof1848.org) is a network of progressives dedicated to “politics, passion and public health.” They are perhaps best known for their very active listserve and their well-attended sessions at the American Public Health Association.  They recently circulated a report about the Spirit of 1848 sessions at the October 2008  APHA conference in San Diego.  The report offers an exciting picture of critical and activist scholarship in public health.

If you are curious where the name “Spirit of 1848” comes from, see the explanation on their website.  It’s probably worth noting that the term “social medicine” was coined in the year 1848 independently by Rudolf Virchow in Berlin and Jules Guerin in Paris.

What follows is taken from their report.  It will shortly be available on their website.

The Spirit of 1848 at APHA 2008

In brief, we grew out of the work in the late 1980s of the National Health Commission of the National Rainbow Coalition, we cohered as the Spirit of 1848 network in 1994 and began organizing APHA sessions as an affiliate group to APHA that year. In 1997 we were approved as an official Caucus of APHA, enabling us to sponsor our own sessions during the annual APHA meetings.

  • We have 4 sub-committees:
    • politics of public health data,
    • progressive pedagogy & curricula,
    • history (with the sub-committee serving as liaison to the Sigerist Circle, an organization of progressive historians of public health & medicine), and
    • e-networking, which handles our listserve and website.
  • To ensure accountability, all projects carried out in the name of the Spirit of 1848 are approved by the Spirit of 1848 Coordinating Committee. The Coordinating Committee communicates regularly (by email) and its chair (and other members, as necessary) deals with all paperwork related to organizing & sponsoring sessions at APHA and maintaining our Caucus status. The subcommittees also communicate regularly by email in relation to their specific projects (e.g., organizing APHA sessions).

Below is a brief summary of the highlights of each session, in chronological order.

1) SOCIAL HISTORY OF PUBLIC HEALTH
Our provocative session was attended by ≈ 100 people (about the same as the ≈ 120 in both 2006 and 2005 and more than ≈ 70 in 2007 and ≈ 45 in 2004).

HISTORY, BORDERS, IMMIGRATION, AND PUBLIC HEALTH: FROM 1848 TO 2008 – 160 YEARS OF DEBATE
MON, OCT 27 ***10:30 AM-12 NOON (SESSION 3159.0) *** SD CONV. CENTER (SDDC) RM 7A
10:30 AM — Introduction: Border conflicts and negotiations: a hidden history of public health. Luis Alberto Avilés, PhD & Kirby Randolph, PhD, but presented by Anne-Emanuelle Birn, MA, ScD
10:35 AM — Commercial and social disturbance and restrictions at the U.S.-Mexico border (1819-1924): an improvement to the public’s health? Ana Maria Carrillo, PhD
11:00 AM — Medicalizing borders and immigrant bodies: immigration & public health policy in the 20th century. Natalia Molina, PhD
11:25 AM — “Medical Borders”: a historical perspective. Rakefet Zalashik, PhD (discussant)
11:40 AM — Question & answer period

Anne-Emanuelle Birn opened up the session by commenting on how immigration has always been a critical issue in public health and that focusing on issues of US-Mexican politics, immigration, and public health was especially timely, given the theme of the APHA conference (“Public Health Without Borders”) and its location in San Diego, CA.

Ana Maria Carrillo gave a fascinating presentation, focusing on how Mexico actively engaged with the US over sanitary codes and other aspects of public health and immigration policy during the late 19th and early 20th century. Among the many points raised, one was that whereas the US government (at the federal and state level) repeatedly represented Mexico as a threat to the US, many of Mexico’s epidemics in the early 20th century (e.g., typhus, plague) were imported from the US. Additionally, Mexico was not simply reactive to the US, but instead instigated negotiation over sanitary codes, including via its joining of the American Public Health Association in 1892, so as to have a larger say in US public health policies.

Natalia Molina then covered more recent US-Mexican immigration/border public health issues. Building on her central thesis that immigration and public health policies are profoundly intertwined, she discussed the role of public health in medicalizing borders, with regard to both legal and also symbolic citizenship and inclusion. The three examples she focused on pertained to: (1) Railroad workers in Los Angeles in the early 20th c.; (2) the Bracero program (1942-1964), designed to bring in Mexican laborers to work in the US; and (3) contemporary patient deportations by hospitals of undocumented persons unable to pay for long-term care. As per the prior presentation, a common theme was how Mexicans were depicted by US authorities as a threat, with complete disregard for how Mexicans were badly treated in the US. For example, in the case of the railroad workers, when an outbreak of typhus occurred in the highly congested railroad worker camps, built without adequate sanitary facilities and populated by workers receiving less than a living wage, the US public health authorities waged a campaign premised on the idea that Mexican were “dirty” and needed to be taught hygiene; by contrast, as documented by a letter that Molina cited, the Mexicans argued that what they needed was better housing, better sanitation, and better pay.

The discussant, Rakefet Zalashik, reiterated themes pertaining to the medicalizing of borders, as contrasted to the statement that “disease has no borders.” Among the topics addressed during the lively Q&A period included whether it was appropriate to discuss all of the patient transfers as “deportations,” since some involved actions of only private hospitals or even the Mexican consulate, but not the US government, to which Molina replied that she used the term “medical deportation” to make clear that these events occurred in the context of US immigration policy. Another theme concerned the context-specific racializing of immigration and public health threats, with depictions of Mexicans on the West Coast often different from those of the Japanese, and with concerns about immigration of white “ethnic” groups being more of an East Coast phenomenon than one of the West Coast.

During the Q&A period, questions focused on the use of the language of “medical deportations” (which Molina argued was appropriate, so as to situate health policies in context, especially in relation to immigration policies) and also how issues of “race” and immigration played out differently for diverse groups in the US, e.g., the emphasis in California on persons of Mexican, Japanese, and Chinese origins, with all “whites” lumped into one group, whereas on the US East Coast during this same time period, different “white ethnic” groups were considered separately.

2) POLITICS OF PUBLIC HEALTH DATA
Our thought-provoking session was attended by ≈ 250 people (up from the ≈ 220 in 2007 and 2005, all better than the ≈ 140 in 2006).

ANALYZING HEALTH INEQUITIES: WHAT’S NEW IN THE 160 YEARS SINCE 1848? – APPLYING NEW METHODS TO LONGSTANDING PROBLEMS OF SOCIAL INJUSTICE
MON, OCT 27 ***2:30 PM-4:00 PM (SESSION 3359.0) *** SD CONV. CENTER (SDCC) RM 2
2:30 PM — Introduction to the Politics of Public Health Data session. Catherine Cubbin, PhD
2:35 PM — Using 21st c technologies to analyze the impact of racism on health: the implicit association test (IAT), web-based surveys, and explicit measures of racial discrimination. Nancy Krieger, PhD, Dana Carney PhD, and Mahzarin Banaji, PhD
2:55 PM — Utilizing the CT Health Equity Index, GIS, and community engagement to address health inequities. Baker Salsbury, MPH, MSW, MHSA
3:15 PM — Biological embedding of social factors: epigenetic processes and health inequalities. Darlene Francis, PhD
3:35 PM — Discussant. Vickie Mays, PhD, MSPH
3:45 PM — Question & answer period

Catherine Cubbin opened up the session, introducing the speakers and also the theme of the session – our need to use whatever are the best available methodologies to move forward the work on social justice & public health.

Nancy Krieger presented preliminary research results on novel use of the implicit association test (IAT) to measure experiences of racial discrimination (noting that the IAT has previously been used mainly to study prejudice). In both a community-based sample and a web-based sample of US-born black American adults, the explicit measure of racial discrimination revealed the usual person/group discrimination discrepancy phenomenon (higher reports of discrimination against group than against self), but no such discrepancy was evident using the IAT. Noting that the web-based sample had a much higher education level and better health status than the US black population on average, preliminary findings indicated that among those with less than a college education, both the explicit and implicit measures were significantly associated with hypertension. The implication is that use of both types of measures can advance understanding of how racial discrimination harms health, a hypothe
sis that is now being tested in a large-scale community-based study that Krieger and colleagues currently have underway.

Baker Salsbury presented on the Connecticut Health Equity Index, a public health tool meant to raise accountability at the neighborhood and local level regarding the monitoring of health inequities and efforts to address them, especially by state and local health departments. Developed by the Connecticut Association of Directors of Health, Inc. (CADH), which consists of health directors who represent Connecticut’s 169 towns, including both health departments and districts, the tool draws on public health surveillance data, census data, and myriad other sources of data providing information on social and economic conditions at the census tract level. Using GIS to help map the results, it employs data on a core set of social determinants of health, organized into 9 domains, with 27 components and 71 core indicators, as well as data on diverse health outcomes. Preliminary work conducted in 20 census tracts in two cities in Connecticut has shown expected associations with diverse health outcomes, spanning from mental health emergency room treatment and Hepatitis C infection to cancer incidence rates and age-adjusted mortality rates. Next steps are to test the tool in 800 Connecticut census tracts, with a goal of developing a tool that can be used nationally by communities and local health departments. For more information about the tool, contact Sharon Mierzwa, at CADH (email: smierzwa@cadh.org; phone: 860-727-0974). And see also: http://www.cadh.org/AboutCADH/CurrentProjectsOverview/HealthEquityIndex/tabid/79/Default.aspx

Darlene Francis spoke about why epigenetic processes – that is, processes that regulate gene expression – matter for understanding health inequities. Noting that her work explicitly challenges the dogma that always places genes first, and context second, in shaping phenotype, she offered instead empirical evidence, based on elegant studies of mice, that vulnerable experiences can affect gene expression, thereby affecting phenotype – with the implication being that social and developmental experiences can affect biological vulnerability. As one of the several examples she presented, she discussed one experiment with two different strains of mice – in shorthand, one bred to be “cool, calm, collected” and “smart,” the other much more “anxious” and “less smart.” Noting that fetuses in each breed of mouse would be differently exposed to stress hormones in utero (given that their mothers were likewise either “calm/smart” versus “anxious/less smart”), in her experiment she transplanted the mouse fetuses from one strain to the other, thereby altering their pre-birth exposures, and she also did post-birth swaps, exchanging the different types of pups (those whose full gestation was in their original mother and those who were transplanted to the womb of a mother of the other breed), with some kept with the mother from whom they were born and others places with mothers from the two different breeds. A key finding was the mice whose strain predisposed them to be “anxious/less smart” who were transplanted into the wombs of the “calm/smart” breed mothers and raised by them performed just as well as the mice bred to be “calm/smart” on open-field tests regarding their ability to explore in new environments, thereby demonstrating how context shaping gene expression produces the phenotype (despite these mice being “genetically predisposed” to be “anxious/less-smart”). The net implication is that DNA does NOT equal “destiny” and that epigenetic processes – involving regulation of DNA, not altering changes in the DNA sequence – are likely critical for understanding health inequities.

Vickie Mays, as discussant, emphasized how all three projects worked across disciplines, took risks, and produced data that can give us new insights into causes of health inequities and how to address them. In relation to the Health Equity Index, she underscored the importance of combining data on, say, transportation access with data on where shopping markets are located, noting that in the neighborhood where her mother lived in Chicago, the bus stop was so far away from the shopping market (on the other side of the large parking lot built to accommodate the cars of the shoppers) that it made using the bus for shopping very difficult. Emphasizing the importance of animal studies for investigating topics that cannot be studied on people, she praised Francis’ work for how it powerfully challenged the dominant nature/nurture assumptions by bringing attention to the critical role of gene regulation – and showing how parents’ context can affect health of the next generation through epigenetic mechanisms, not just genetic inheritance. Noting her own research on how the pain experienced as a consequence of racial discrimination and social isolation registers in the brain as the same as that produced by physical pain, she said that use of the IAT was one example of how researchers can use new methods to get at exposure to racial discrimination and its consequences, especially in an era of reduced overt bias. Noting the need to consider the psychological and health costs of people’s reliance on stereotypes, she likewise urged that attention be paid to how IAT results may differ by not only education level but also for persons from more individualistic vs more collective societies. The overall message was that we can use 21st technologies to better understand the mechanisms – at many different levels, from societal to gene regulation – that produce health inequities, and that we need to take risks and ask bold questions to move along the work and make a difference.

During the Q&A, questions focused on whether the IAT can be used to look at voter behavior (yes, it has been, but also key is what happens to the voters, in terms of access to voting, voter exclusion, problems with voting machines, etc), whether the Health Equity Index is intended for national use (yes, but first it needs to be tested in a wider range of census tracts, with the next iteration including 800 census tracts), and whether there is any evidence that damage brought about by epigenetic processes can be reversed (sometimes, depending on the degree of damage and also the rapidity, in early life, that conditions are changed, but some good news is that new evidence indicates the social brain is harder to perturb than has previously been thought, such that there is more resilience and plasticity to give grounds for hope).

3) INTEGRATIVE

This session, celebrating 160 years of the Spirit of 1848, was attended by ≈ 150 people, just about all of whom avidly filled in our ever-present sign-in books. We note that this session was held at the same time slot as the APHA “Town Hall Meeting on Health System Reform,” which, with its emphasis on the current election and post-election planning, was a major draw. (NB: the attendance was very good for an APHA session, albeit understandably less than the ≈ 550 who attended our integrative session last year, which was focused on how to use the new film series “Unnatural Causes: Is Inequality Making Us Sick?”).

160 YEARS OF THE SPIRIT OF 1848: CRITICAL REFLECTIONS, CELEBRATION AND INSPIRATION
MON, OCT 27 ***4:30 PM-6:00 PM (SESSION 3433.0) *** SD CONV. CENTER (SDCC) RM 6C/F
4:30 PM — Introduction: Anne-Emanuelle Birn, MA, ScD
4:35 PM — American Indian, Alaska Native, and Native Hawaiian Caucus; Occupational Health and Safety Section and Labor Caucus; Public Health Nursing Section; International Health Section; Lesbian, Gay, Bisexual, and Transgender Caucus; Black Caucus of Health Workers; School Health Education and Services Section; Socialist Caucus
5:08 PM — Reflecting on the events of 1848: Kirby Randolph, PhD
5:13 PM — Peace Caucus; Family Violence Prevention Forum; Trade and Health Forum; Medical Care Section; Sigerist Circle; Social Work Section; Women’s Caucus; Latino Caucus
5:45 PM — Looking forward, building on the Spirit of 1848: Nancy Krieger, PhD
5:50 PM — EVERYONE: sing “Step by Step,” led by Andrea-Kidd Taylor, DrPH

The full-line up, with names of presenters, is as follows, and the program for and photographs of the event and presenters are available at our website (http://www.Spiritof1848.org), as are several of their slide presentations. We also thank the Spirit of 1848 members who helped out with the event: Pam Waterman, for technical assistance with the music & slides, Catherine Cubbin for keeping the presenters moving along, and Suzanne Christopher and Vanessa Watts for ushering.

Presentation
Musical prelude “Step by Step” and “Ella’s Song”
Spirit of 1848: AE Birn — Introduction
American Indian, Alaska Native, and Native Hawaiian Caucus: Dean Seneca
Occupational Health and Safety Section and Labor Caucus: Peter Dooley
Public Health Nursing Section: Noncenba Lubanga
International Health Section: Samir Banoob
Lesbian, Gay, Bisexual, and Transgender (LGBT) Caucus: Seth Welles
Black Caucus of Health Workers: Jill Dingle
School Health Education and Services: Bill Cissell
Socialist Caucus: Martha Livingston
Spirit of 1848: Kirby Randolph/Lisa Moore – History
Peace Caucus: Kathleen Fagan
Family Violence Prevention Forum: Peggy Goodman
Trade and Health Forum: Susanna Bohme
Medical Care Section: Gordy Schiff
Sigerist Circle: Ted Brown
Social Work Section: Kim Jaffee
Women’s Caucus: Heather Brandt
Latino Caucus: Henry Montes
Spirit of 1848: Nancy Krieger – Closing
Andrea Kidd-Taylor lead everyone in “Step by Step”

Included in the session program are the music and lyric of the song we all sang at the end: “Step by Step,” based on the preamble of the 1863 constitution of the American Mineworkers Association, with the music arranged and adapted in 1948 by Waldemar Hill and Pete Seeger:

Step by step the longest march
Can be won, can be won.
Many stones can form an arch,
Singly none, singly none.
And by union what we will
Can be accomplished still.
Drops of water turn a mill,
Singly none, singly none.

The wide range of presentations – which used song, visual images, and reflected on both the broader social and historical context and the specific work of each APHA caucus, section, and forum that participated – asked all present to think critically about the past 160 years in terms of the struggles and accomplishments we can recognize and celebrate, the setbacks endured and the suffering they have caused and, ultimately, the work we need to do now, in our generation, in our own times, to advance the agenda of social justice and public health.

4) PROGRESSIVE PEDAGOGY

This engaging session was attended by ≈ 100 people (twice the ≈ 50 in 2006, but down from the ≈ 250 in 2007, which drew in many who wanted to know how to teach the content of “Unnatural Causes”).

TEACHING CRITICAL HISTORY OF PUBLIC HEALTH AND HEALTH POLICY: PROGRESSIVE PEDAGOGY IN ACTION
TUES, OCT 28 *** 8:30 AM-10:00 AM (SESSION 4063.0)*** SD CONV. CENTER (SDCC) RM 2
8:30 AM — Introduction. Lisa Dorothy Moore, DrPH and Suzanne Christopher, PhD
8:35 AM — A role for exhibitions: “Making a Difference in Global Health.” Manon Parry, MA MSc
8:50 AM — Literacy, access to information, and social power – 1848 and 2008. Sherry Spence, MD
9:05 AM — Necessity of teaching the history of public health from a critical perspective. John P. Elia, PhD
9:20 AM — University of Toronto’s history of international health course. Anne-Emanuelle Birn, MA, ScD
9:35 AM — Question & answer period

Lisa Moore introduced the session with comments on how the lack of critical teaching about public health history in most US schools of public health was the impetus for the session, since a knowledge of history is part of what enables us not only to better understand the past and how we got to where we are today but also to see ourselves as historical actors who create history in the present by what we do. She also announced that all syllabi discussed in the session will be available at the Spirit of 1848 website, at: http://www.Spiritof1848.org.

Manon Parry described the exhibition the National Library of Medicine launched in April 2008, titled “Against the Odds: Making a Difference in Global Health.” Geared especially to a younger audience and to overcome the widespread views that “global health is about them, not us (in the US),” that “the US provides answers, as opposed to solutions coming from elsewhere,” and that “the problems are so overwhelming that nothing can be done,” the exhibition focuses on “missing stories” about the impact of poverty on health and well-being, the connection between health and human rights, the shared values that promote a decent quality of life, the link of the US to the rest of the world, and concrete examples of individuals, organizations, communities, and societies that have made a difference. Using historical and contemporary examples, the themes of the exhibit pertain to: clean water; nutritious food; access to affordable health care; protection from violence; and safe housing. Other “missing stories” addressed pertain to discrimination and HIV/AIDs, to the spending on monies on conflict and war, rather than health needs. The exhibition goals are to: (1) broaden perception of the causes of illness, i.e., not just viruses but poverty, hunger, and other social determinants of health; (2) challenge assumptions about who is at most risk, looking at inequities within as well as between countries; (3) encourage collaboration based on shared values, e.g., human rights; and (4) encourage people to get involved, especially youth activism. Each week, a new question is placed on a comment board at the end of the exhibition, asking “What’s Your Perspective” and, suggesting the exhibit is meeting its goals, when the question on the board asked “can one person make a difference,” one reply from a student concisely stated: “Hell yeah!” The traveling version of the exhibit is intended to be shown at schools of public health, with the only cost being that of covering its shipment by fed-ex, and the encouraging news is that it is already booked up through summer 2010. If you are interested in having your school host the exhibit, contact Manon Parry at: parrym@mail.nlm.nih.gov; to see more about the exhibit on-line, visit: http://apps.nlm.nih.gov/againsttheodds/index.cfm

Sherry Spence then gave a presentation looking at health literacy and the dissemination of public health information in historical context, with attention to the implications of literacy and health literacy for power relations and health inequities. Examples pertained to the invention and dissemination of use of the printing press in Europe during the Renaissance and Reformation, the rise of slave literacy in the US in the mid-19th century, and the current use of the internet and the importance of e-health literacy. Common themes were the link between literacy and power and the need to build capacity for health literacy, including e-literacy. For more discussion of these issues, and also the 50-page bibliography informing the presentation, see: http://sandbox.wikispaces.com/health-literacy-community

John Elias next presented on a new course at San Francisco State University on the critical history of public health in the United States. Geared to undergraduates, the course’s impetus was the lack of any public health courses focused on history, coupled with the lack of any courses in the history of science department that were focused on either medicine or public health. Approximately 75% of the enrolled students were from public health, the other 25% from history, with one discovery being the utility of pairing up students from these two different disciplines, since the public health students could teach the history students about health, and the history students could teach the public health students about both history and analyzing primary as well as secondary source materials. Key to the course was its inclusion of critical, revisionist history, with an emphasis on the intersections between class, race/ethnicity, gender, and sexuality. Each session includes a 30-35 mini-lecture; other components include: (a) students working in groups to critique, from a critical intersectional standpoint, a particular article, with each student writing a 3-4 page analysis that s/he shares with the other students in the group, as the basis for a joint critique developed by the full group; and (b) engaging the students in critiques of different films, regarding what they cover and what they omit, e.g., a film on the “History of Sex in America in the 20th century,” which, when discussing Margaret Sanger, made no mention of her support for eugenics. There is also a mid-term exam and a final 8-10 page paper. Two aspects of student resistance, both the result of prior educational experiences, that needed to be addressed were: (1) their expectation of being “fed” education rather than be engaged in critical education, and (2) their questioning of the legitimacy of studying history from a historical perspective; by going through the course, students came to appreciate the value of a critical stance.

Anne-Emanuelle Birn described the graduated level course she teaches, a seminar on the History of International Health at the University of Toronto. This course looks at the ideologies, institutions and practices of the field of international health, from its imperial origins to the present-day, including in relation to colonialism, class, racism, and gender. Focusing on the political, scientific, and social underpinnings of the principles and activities of the international health field and its embedded cultural values as well as both its continuities and discontinuities, the course relies on both primary sources (e.g., printed documents, whether text, correspondence, or poems, and also photographs and films) and secondary sources (e.g., scholarly research, both books and articles). Each session uses films and documentaries and draws especially on the visual resources available at the National Library of Medicine (with Anne-Emanuelle also acknowledging the work of Elizabeth Fee, who was present in the audience, for her essential work in making more visible and available critical work on the history of public health). The two assignments are: (1) from the perspective of a late 19th or early 20th century medical officer, justify the importance of a particular international health activity or policy, and (2) write a 2050 paper, analyzing early 21st century work in international health, so as to learn how to contextualize the on-going work in one’s own era. Examples of themes of particular sessions are: (a) Colonial vs International vs Global Health: what’s the difference?; (b) Mind, Body, Race, and the Building of Empire; (c) Missionaries and Health; (d) Industry, Research, and “Tropical” Medicine; and (e) Sex, Sickness, and Security: Metropole and Outpost. Examples of two contrasting films, whose use sparks lots of conversation among the students, are an mid-20th century American Medical Association film titled “MD International” (1958), featuring then Vice-President Richard Nixon extolling US efforts to help others abroad, versus a very different, sponsored by the World Health Organization, on “Health for All” (1978), made after the Alma Ata conference, and showing footage of, among other things, a Frelimo rally in Mozambique, making clear how the fight for national liberation was essential for health, with health campaigns to fight disease, conducted in the midst of armed struggle, portrayed as part of a strategy to ensure people would be strong enough to build their nation – and with contemporary students amazed that WHO would ever have included such material in a film, noting how in the current era, prevailing ideologies and power relations have precluded such a critical stance.

Suzanne Christopher then opened up the session for Q&A, noting how the presentations had made vividly clear how many “missing stories” there were and why a critical historical perspective is needed. From the floor, Elizabeth Fee underscored the many resources that are available at the National Library of Medicine, including not only films but also syllabi of courses taught world-wide about the history of public health and medicine, and noted that the NLH is currently producing a DVD-series to make the films more widely available. For these and related resources, see:
— for films: http://www.celebratingresearch.org/libraries/nlm/healthfilms.shtml
— for syllabi: http://www.nlm.nih.gov/hmd/collections/digital/syllabi/index.html
An additional resource mentioned by Walter Lear is the US Left Health Historical Center, based in the Institute of Social Medicine and Community Health (in Philadelphia) which he directs and whose website is in construction. The Center has available archival documents (e.g., pamphlets, photographs, political pins) and scholarly publications and also produces a news letter; for further information, contact Walter Lear at: ISMCH, 206 N. 35th St, Philadelphia, PA 19104 (phone: 215-386-5327; email: wjlear@critpath.org). Other issues raised during the Q&A period included how to ensure these sorts of courses are taught, or materials are at least included in required introductory courses, given how many other requirements students face, and also how to ensure that whatever is included as session in other courses is presented in a critical way (e.g., simply including photographs of the Broad Street pump and mentioning John Snow is not adequate for critical history of epidemiology) and how to address the problem that most students need remedial education in general history so as to put the public health history in context – with the only way to address this being that there is no short cut around the fact that students do have to read to gain this context …

5) STUDENT POSTER SESSION
Our 7th “STUDENT POSTER SESSION: SOCIAL JUSTICE AND PUBLIC HEALTH” (session 4099.0, Tues, Oct 28, 12:30 to 1:30 pm) had 6 posters accepted (of which 1 had to withdraw). There was a good turn out, with lots of good discussion with the student presenters about their work. The five posters displayed were as follows:
STUDENT POSTER SESSION: SOCIAL JUSTICE & PUBLIC HEALTH
TUES, NOV 7 *** 12:30 -1:30 PM (SESSION 4099.0)*** BOSTON CONV. CNTR (BCEC) HALLS A/B1
Board 1 — Invisible Places, Invisible People: Facing health disparities in urban North Carolina K. Wu, MPH Candidate; J. Kadis, MPH Candidate; C. Katz, MPH Candidate; K. MacGuire, MPH Candidate; A. Agyemang, MPH Candidate
Board 2 — Other side of the tracks: Understanding the historical, social and environmental context of health in an African American community in eastern North Carolina S. Barber, MPH Candidate; J. Tzeng, MPH Candidate; A. George, MPH Candidate; J. Thompson, MPH Candidate.
Board 3 — Interdisciplinary approaches: A student-initiated course on Critical Race Theory J. J. García, MPH.
Board 4 — Goods Movement 101: A training model for community engagement and education J. Lucky, MPH; A. Logan; A. M. Hricko, MPH; I. Ramirez; C. Truax; A. J. Groopman, MHS.
Board 5 — A gender analysis of cervical cancer R. M. Lee

Of note, for all the students involved, their poster presentation at the Spirit of 1848 session was the first time they had ever presented a poster at a scientific conference, and for virtually all it was their first time attending an American Public Health Association annual meeting. They really appreciated the opportunity to gain the experience of presenting their work and meeting so many different people in so many diverse aspects of public health, and likewise felt affirmed in their focus on issues of social justice and public health. All of which suggests our session is meeting its objective, in helping bring forward the next generation to do the work at hand!

6) Other:

We co-sponsored & helped organize the P. Ellen Parsons Memorial Session, on “Health Access & The Elections: What Happened, What Didn’t” (Session 4242.0, Tues, Nov 7, 2:30 to 4:00 pm), obviously held before the elections (and we are now very happy to send our reportback in the aftermath of the Obama victory!). The primary sponsor was the Medical Care Section; other co-sponsors were the Women’s Caucus and the Socialist Caucus. It was attended by ≈ 100 people (up from ≈ 75 people the year before, and much higher than the ≈ 35 in 2006).

  • Ellen Shaffer opened the session by reviewing and contrasting the Obama and McCain health plans and their limitations, noting that HR676 in Congress still was putting forth support for a universal single-payer health system and that people in public health need to keep alive support this alternative and sorely needed approach to resolving the problems of the US medical care system.
  • Claudia Fegan, the past president of the Physicians for a National Health Program (see: http://www.pnhp.org), then made the case for why a single-payer universal health system is necessary, including a review of all the US state-level plans that have promised to provide universal coverage but have not succeeded, given their approach of only incremental reform (leading her to quote Moms Mabley: “if you always do what you always did, you always get what you always got …”).
  • Susan Wood, an advisor to the Hilary Clinton and now the Obama campaign, then spoke to how each candidate’s plan did or did not address women’s health needs, noting that the Obama plan opened the door to people “voting with their feet” for single-payer via signing up for a group insurance plan modeled after Medicare and the Federal employees benefit plan, whereas the McCain approach was to have people cut loose from employer-based plans and opt for individual plans, even though evidence indicates women fare much worse under individual-plans, where they are more underinsured than men and everyone is much less able to negotiate, as an individual, for better plans. Her sense is that the Obama plan was cautious so as not re-ignite the fears caused by the “Harry & Louise”-type ads that sunk the prior Clinton attempt at health care reform, and said that advocates need to ensure that the Obama plan, if he is elected, is the floor, not the ceiling.
  • Larry Adelman then spoke about the efforts of the film series “Unnatural Causes” (see: http://www.unnaturalcauses.org/) to get across the message that action is needed on the social determinants of health. So far, there have been over 10,000 screenings and they have more than 350 outreach partners, far more than expected, and remain engaged in a Health Equity Campaign whose goals are to educate the broader public about the root causes of health inequities, to inject the issue of social determinants of health into public debate, and to highlight the health consequences of economic policy. Four key message frames are: (1) focus on the social determinants of health equity (e.g., it takes more than individual choice to deal with toxic dumps, ensure a living wage, or have available affordable quality housing); (2) make health equity an “us” issue (vis a vis the social gradient and rising health care costs); (3) America’s health is America’s choice (demonstrating that health inequities are neither natural or inevitable, cf studies by Singh et al showing how health inequities have widened since 1980, and the 2008 PlosMed study by Krieger showing how health inequities in fact shrank between 1965 and 1980 and thereafter widened, with the progress in shrinking the inequities paralleling the implementation of the War on Poverty, the Civil Rights Act, the creation of OSHA and EPA, etc.); and (4) Common sense: invest now for better health or pay even more later to repair the damage.
  • Linda Rae Murray, as discussant, then spoke to the importance of not staying stuck in an overly complicated policy-wonk mode but instead appealing to people’s sense of fairness, framing health care as a human right, and making clear the current system does not work and incremental efforts at reform have made little or no difference. She also emphasized that one reason that efforts over the past 100 years have failed is that creating a system that fairly provides universal health coverage is a way of redistributing wealth, which goes against capitalist ideology, such that it requires taking this ideology head-on, noting that especially in this time of economic crisis, many people would agree that the “invisible hand of the market” is not an “all-knowing god.” Arguing that we can point to how every other industrialized capitalist country has managed to ensure universal medical coverage, she further noted that this is only one piece, since good health is only possible in a just society, meaning that we need to bring in allies to address the broader social determinants of health.

During the Q&A, a key theme was that health advocates cannot afford to repeat past mistakes, e.g., diluting proposals in order to be “allowed at the table” or directing work only towards policy makers; it is vital to work with the people & public more generally, since they are the source of power and do want universal health coverage and better health.

Finally, the Spirit of 1848 co-sponsored the Occupational Health and Safety health activist dance on the Monday night of APHA.

Posted by Matt Anderson, MD

"The People's Misery: Mother of Diseases": Johann Peter Frank (1790)

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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-20th 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

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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

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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




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