SOCIAL MEDICINE

Throughout most of medical history the physician's role has been seen predominantly as a personal one in which, for the most part, the one-to-one patient–physician relationship is the one that is considered in medical ethical principles. Although the shocking evidence of physician participation in genocidal activities during World War II led to new ethical statements, such as the Declaration of Geneva, that place physicians' behavior in a social context, such statements nevertheless largely remain codifications of the ethical behavior of a physician toward a particular patient.

Origin and Meaning of Social Medicine

Enlargement of the role of the physician to include social and community aspects of disease prevention, diagnosis, and treatment is of relatively recent development, and is referred to as social medicine. Many definitions of social medicine have been attempted, the more generally accepted ones reflecting the relationship of social factors to disease and death. Today there is a general consensus that social medicine represents the study of the medical needs of society and the interaction of medicine and society, along with the practice of inclusion of social factors in public health, preventive medicine, and the clinical examination and treatment of patients.

The concept grew from a variety of experiences over the centuries. In seventeenth-century London, weekly "Bills of Mortality" listing the previous week's deaths began to be published. Incomplete and inaccurate as they were, they inspired John Graunt (1620–1674) and, later, Edwin Chadwick (1800–1890) to relate social and economic circumstances to death rates.

Similarly, in Italy, Bernardino Ramazzini (1633–1714) documented the relationship of disease to a series of occupations. In the nineteenth century, these inchoate efforts came together into social-policy constructs. In Austria, Johann Peter Frank (1745–1821) published a monumental six-volume work on medical policy as a governmental endeavor—to ensure clean water and sewage disposal, for example, and to promote other regulatory efforts for the benefit of society. Chadwick, in Britain, urged government to take responsibility under the Poor Laws to protect the health of the growing population impoverished by increasing industrialization (Chadwick).

The industrial revolution fostered turmoil throughout Europe and increased the awareness of social causation of disease and death as it brought about far-reaching changes in the lives of working people. Friedrich Engels's study, The Condition of the Working Class in England in 1844, described the relationship of diseases such as tuberculosis, typhoid, and typhus to malnutrition, inadequate housing, contaminated water supplies, and overcrowding (Engels; Waitzkin).

The early nineteenth century therefore saw the beginning of a transformation of the physician's role (Rosen, 1974). As physicians increasingly recognized the impact of social factors on their patients' health, they saw that helping individual patients made it necessary to assess and respond to the social aspects of their lives along with everything else that might cause or prolong their patients' illnesses.

The term social medicine was first used in 1846 to mean "all those aspects of medicine that affect society" (Guérin, p.203), but its popularization in Europe is usually attributed to Rudolf Virchow (1821–1902; see Erwin Heinz Ackerknecht's 1953 work, and George A. Silver's 1987 work). Virchow, who later became a highly respected pathologist (known by his colleagues as the "Pope of Medicine"), was an early exponent of the importance of social factors as contributors to disease. In 1847, at the Prussian government's request, Virchow investigated a severe typhus epidemic in rural Upper Silesia. In his report he recommended a series of dramatic economic, political, and social changes that included increased employment, better wages, local autonomy in government, agricultural cooperatives, and a more progressive tax structure. He described disease causation as multifactorial, including the conditions of people's lives. To be effective, he argued, a healthcare system must go beyond treating pathological problems in individual patients, and health professionals therefore must take responsibility for political action. In a radical medicalpolitical newspaper he edited, the masthead read: "The physician is the natural attorney of (advocate for) the poor." Virchow insisted that "medicine is a social science, and politics nothing but medicine on a grand scale" (Silver, 1987, p. 85).

Early on, social medicine was basically an approach to medical practice; proponents recognized the effects of social conditions and took them into consideration in dealing with illness in patients. During the first half of the twentieth century, when Alfred Grotjahn published his Soziale Pathologie (1912) and René Sand his Vers la Médecine Sociale (1952), social medicine became more than an aspect of medical practice. These works, among others, established the importance and perhaps even the predominance of social factors in disease causation, maintenance, and remission. A whole new field of scholarly study emerged that understood health, disease, and the role of medicine in these terms. Beyond the traditional ethic of a physician's responsibility to a patient or to other physicians, social medicine, which was concerned with the relationship between health and the conditions of society, imposed an added discipline of responsibility to society (Grotjahn; Sand).

The discipline was further refined by John Ryle, professor of medicine at Cambridge University, who included social factors in the analysis of the varied responses of patients to illness. Since individual responses were influenced by the patient's family, work, and economic circumstances, he regarded the study and clinical application of these factors as part of the practice of social medicine (Galdston; Ryle). Ryle wrote that social medicine

embodies the idea of medicine applied to the service of man as socius, as fellow or comrade, with a view to a better understanding and more durable assistance of all his main and contributory troubles which are inimical to active health.… It embodies also the idea of medicine applied in the service of societas, or the community of man with a view to lowering the incidence of all the preventable diseases and raising the general level of human fitness.

As it became clear that many of the causative agents of disease were social in nature, social medicine embraced not only what is usually called preventive medicine—that is, advice on the prevention of illness provided to individuals and families within medical practice—but also what is usually called public health—efforts to prevent disease in whole communities. For health and disease, an interface was seen to exist between society and medicine, not just between the doctor and a patient. The family itself, the home, the workplace, the environment, and various other social conditions played a part in whether or not people became sick, how long they remained sick, whether they recovered, and even whether medical care and other healthcare services were available.

Social medicine ranges from the doctor's use of social factors in making a better diagnosis or offering better treatment (that is, an approach to clinical problems) as well as providing preventive medicine, to helping the medical profession recognize social factors that are pathological ortherapeutic in society (that is, an approach to public health). In its contemporary interpretation, social medicine also means influencing the doctor's frame of mind as a professional, so he or she will recognize the need to modify social factors (in effect, an approach to social reform).

Social medicine therefore includes four components:

1. medical care: treatment of the individual patient (or family) to provide comfort and hope, ease symptoms, and, when possible, prolong satisfying and productive life or even "cure" the disease;
2. preventive medicine: guidance for the individual patient (or family) in promoting health and preventing disease;
3. public health: advocacy and action for health promotion and disease prevention in the community; and
4. social well-being (as used in the definition of "health" in the Constitution of the World Health Organization), including amelioration of hunger, homelessness, unemployment, poverty, and hopelessness.

Social medicine in action attempts to

1. ensure equitable access to an effective and efficient medical-care system;
2. encourage preventive medicine by, for example, educating practitioners;
3. support extensive public-health activities; and
4. increase resources and services to improve social well-being.

Social Medicine as an Ethical Model

Physicians engaged in the field of social medicine must concern themselves with a wide variety of problems, disciplines, and factors that encompass what are conventionally understood to be outside the proper concerns of the medical profession. Once the physician recognizes a person as a social creature, the whole range of a patient's needs becomes relevant. Traditionally, physicians have rarely seen themselves as responsible for intervention to correct a social situation outside the family that might be contributing to the patient's illness or obstructing recovery. A sociallyoriented medical profession may need to take vigorous action in its patients' interest to promote improved housing, nutrition, and educational opportunities or to combat racism, discriminatory practices, or the inequities and inadequacies of the medical delivery system and its distribution or availability.

Social medicine holds that the physician has an ethical responsibility to take steps to change pathogenic situations to protect society, of which the particular patient for whom he or she bears responsibility is a part. In such circumstances, the practice of social medicine may place a physician in serious opposition to many powerful forces in society, not excluding the majority membership of his or her own profession. A physician may thereby incur social and professional opprobrium. This was the fate of playwright Henrik Ibsen's Dr. Stockmann, described by his community as an "enemy of the people" because he questioned the safety of the town's springs, the source of its prosperity (Ibsen).

Even in milder efforts, physicians who undertake the practice of social medicine may face resistance in utilizing their professional role to ameliorate pathogenic social situations such as inadequate nutrition or malnutrition; accidents and disease that befall those who live in inadequate housing; unsafe working conditions; environmental hazards or decayed neighborhoods; and polluted air and water. Again, since many of these factors are the result of neglect commonly visited upon the poor, the physician who seeks to modify such situations may find it necessary to engage in social movements that attempt to mitigate or eliminate poverty and to encourage poor people to take action on their own. The physician may be forced to take a political position, even initiate political action, in pursuing this end, just as those who do not act or who oppose such actions are taking political positions.

The remainder of this article will cover specific aspects of social medicine. These aspects—environmental and occupational health, medical-care systems, responsibility of the profession, and medical education—illustrate the range of the field and its relevance to current issues.

Environmental and Occupational Health

When a physician, as a responsible practitioner of social medicine, recognizes the potent and often baleful influence of industry on the health not only of its workers but of the community in which it is located, community education and further action may be indicated. There is increasing recognition of the environmental origins of cancer, for example, including the role of carcinogens in the workplace. Some workplaces are hazardous by the nature of the job; in others, accidents—commonly the result of inadequate safety measures or careless disregard for safety standards—result in thousands of deaths and millions of injuries. Further, in an unfortunately large number of instances, the effluent of factories poisons rivers, lakes, and air, contributing to chronic morbidity and increased mortality among the workers and in the community.

The physician with social concern may find both political action and educational efforts unwelcome in a community torn between its need for the jobs provided by the industrial presence and fear of the industry's lethal qualities. In some communities, the answer has been to keep the lethal factory rather than accept unemployment, poverty, and starvation without it. Doctors and communities must begin to deal with a novel ethical conflict: How to modify the paradox of democratic capitalism—the need to restrain the profit motive in order to protect the community from destructive exploitation.

These actions include something more than professional response. The requirements for social change and political action (e.g., nutrition for the children of the poor or occupational safety measures) also demand that the physician act as citizen. In some situations the physician may very well be torn between social concern and his or her livelihood. The physician who works for an industry whose work processes are unsafe or pathogenic may jeopardize his or her job by taking a stand against the employer or the industry of which the employer is a part. Yet failing to take a stand makes him or her complicit and endangers the lives of countless others. A physician cannot be expected ethically to remain silent when the work situation is likely to produce trauma or disease.

Some employed physicians are expected to minimize reports of injury or disease in order to reduce the employer's financial commitment. That is the "job," as the employer sees it, for which the physician was hired. But is the physician's job to put first the interests of the employer who pays his or her salary, or the interests of the patient?

The dilemma of dual responsibility is most vividly apparent in wartime. In addition to the medical oath the physician may have taken at the completion of medical school, on entering military service the physician, like all military officers, must agree to obey military orders. These orders, for example, usually require the military physician to return wounded military personnel to action as quickly as possible. The decision as to which patient to treat first may therefore be determined by which one can be returned to duty most quickly rather than by the urgency of each patient's individual need for medical care. In an extreme case, the military physician would be expected to let a seriously wounded soldier die in order to save the life of one less seriously wounded who was able to return more quickly to battle. And if there were enemy wounded who were more urgently in need of care, when would their turn be?

Medical-Care Systems

In its scholarly manifestation, social medicine initiates studies on a nation's economic and social systems' influence on the structure and function of its healthcare system. Studies and procedures of healthcare in individual countries and cross-national comparisons are an important part of the analytic work of social medicine (Allende; Cochrane; Navarro; Roemer; Sidel and Sidel, 1982, 1983; Waitzkin).

The ethical imperative that arises from this work invites agitation for change and improvement in the structure of the medical-care system to improve its functioning. To that end the results of social medicine studies may generate promotion of the values and methods observed in other national systems, toward better access and improved quality in meeting the needs of the poor and the geographically isolated, and of marginally self-supporting workers. At the turn of the twenty-first century, for example, the inflation of medical costs resulting from disorganization and inequities bankrupted many families and barred adequate access to medical care for many others. What is the physician's role in this situation?

If access to medical care is dependent upon ability to pay, and many people are unable to obtain care for lack of funds, is the physician ethically obliged to oppose ability to pay as a condition for service? Of whom, if anyone, should the physician ethically demand payment? Should physicians demand that medical care be free to everyone at the time of service? When ability to pay interferes with access to medical care, does not the profit motive operate against the best interests of the patient and the ethical principles of the physician?

Newspaper reports and medical journal articles offer accounts of unequal medical treatment by race or gender. Blacks receive fewer advanced technological studies than whites for the same conditions (Kahn, Pearson, Harrison, et al.; Kjellstrand; Wenneker and Epstein); women receive less intensive studies and procedures for heart disease than men (Ayanian and Epstein; Kjellstrand). Ethical principles require reversal of such situations, and social medicine studies and principles guide physicians in taking action (Perkins; Hurowitz).

Evidence accumulates that, with the increase of managed care as a method of cost control in medicine, physicians are urged to limit expenditures by reducing services or narrowing access to expensive studies, hospitalization, or medications. Physicians in medical groups under managed-care controls are offered incentives to conform with such regulations or may be punished financially for not complying.

Official reports as well as media accounts about the scandalous treatment of elderly people confined to nursing homes is another example in point. The profit motive too often leads not only to cutting corners on services and allowing short weights in food or supplies, but to making substitutions of less qualified staff, eliminating necessary services, and waiving safety and protective measures for the helpless inhabitants. Aside from the corrupt financial dealings it encourages in such cases, profit-making often prevents and obstructs both the best care and the provision of alternatives to institutional care. Physicians cannot insulate themselves morally from the mistreatment of elderly people in nursing homes nor from the exploitation of patients through the entrepreneurial mechanics of the pharmaceutical drug industry.

Is it part of the ethics of social medicine to condemn investment in drug industry stocks, in private proprietary hospitals, and in a variety of entrepreneurial enterprises such as laboratories, radiological centers, and other diagnostic and treatment modalities to which they refer their patients? The U.S. Congress and the American Medical Association have strongly condemned "self-dealing" of this nature.

Responsibility of the Profession

In addition to the question of the individual physician's ethics in financial dealings that may compromise patients' best interests, there is the associated question of the physician's responsibility for taking action when he or she observes any unethical or unprofessional behavior on the part of a colleague. If a physician knows first-hand about the poor quality of a particular nursing home, even if his or her particular patient is not affected by it, is the physician required to take steps to correct the situation? Legal steps? Professional steps? Or, more narrowly, if the physician knows of colleagues who do not or cannot adequately carry out their obligations as physicians because of incompetence or because of lack of training, illness, or addiction, what should be done about it? Social medicine holds that there is an ethical responsibility to call attention to these facts even if they do not cause risk to the physician's particular patients.

The physician as social medicine practitioner is asked to make a difficult choice, as a citizen and as a doctor. Social medicine as an ethical model imposes an obligation on the physician to serve his or her individual patient by serving all patients. And, as a member of a profession, the physician must act not only as an individual but as representative of that profession, adopting an advocacy role for the groups in society that require special attention and care. The profession is being asked to act toward society as the individual physician is asked in traditional ethical statements to act toward an individual patient.

Finally, the ethical physician has a responsibility to inform and educate the community on the social nature of health and illness. An educated and knowledgeable constituency is required to provide the necessary support for the political social action. Discussing the dangers of smoking, for example, is hardly enough. Physicians ought also to discuss the economics of the tobacco industry and suggest that steps need be taken to cushion workers from unemployment if the tobacco industry is diminished or eliminated. Moreover, if there is an industrial hazard that needs correction, physicians ought to advise not only on the danger but on means for correcting it.

It is clear, nonetheless, that for physicians to discharge social medical responsibilities in complex areas, they need to see themselves as part of a group larger than the medical profession alone. In 1956, Theodore Fox described the "Greater Medical Profession" and urged "converting the medical empire into a commonwealth" (Fox). To respond ethically to social needs is to recognize the contribution of all health workers and to act in concert with others in the health field and outside it. In doing this the physician may wish to join with others in professionally oriented groups—such as the American Public Health Association, the International Physicians for the Prevention of Nuclear War, Physicians for Human Rights, and Physicians for Social Responsibility.

Social Medicine in Medical Education

Medical education should include not only the technical, laboratory, and clinical models of what a physician can do, must know, and be able to deal with; it should also give the future physician the tools to recognize the social circumstances—industrial, neighborhood, legislative, administrative—that play a part in the production of disease or that influence medical care. Exposure to social medicine as an important component of medical education, along with the example of role models and the fact that faculty members have such interests, will influence students' and later practicing physicians' ideas as to what their responsibilities are and how these responsibilities can be discharged (Silver, 1973).

Although departments of social medicine had long existed in medical schools and hospitals in other countries, it was not until the 1950s that Ephraim Bluestone and Martin Cherkasky organized the first department of social medicine in a U.S. medical institution, Montefiore Medical Center in New York City (Levenson). Other institutions such as Harvard Medical School, the University of North Carolina College of Medicine, and the Albert Einstein College of Medicine later adopted the term in department names or titles of professorships, but the pace of this development in the United States has languished.

Conclusion

Early medical ethics was largely restricted to the concept of a physician–patient dyad. Social relationships of pathogenic factors were unknown or ignored. By the beginning of the twenty-first century, it had become clear that the social aspects of the prevention, causation, maintenance, or cure of disease cannot be adequately dealt with solely in the one-toone relationship. Expanded notions of the physician's responsibility based on social factors ought to be included in modern medical ethics statements. The physician should learn to recognize and articulate social demands for change in situations that are harmful to patients and to the community, and not simply deal with problems as they arise in his or her patients.

To this end, physicians must know more about the social situations in which disease occurs or which contribute to disease; they must adopt an advocacy role in pursuing change, and join with other health workers in ensuring appropriate social action for correction. In addition to oaths and declarations in which physicians bind themselves to serve individual patients honorably and ethically, service to society must also be required of physicians. Social medicine deserves an integral place within a more traditional medical ethics. Unfortunately, issues of social medicine are often assigned low priority in medical education and in medical practice.

george a. silver

victor w. sidel (1995)

revised by victor w. sidel

SEE ALSO: AIDS: Public Health Issues; Conflict of Interest; Epidemics; Eugenics: Historical Aspects; Genetics and Environment in Human Health; Healthcare Resources, Allocation of; Health Screening and Testing in the Public Health Context; Medical Education; Medicine, Anthropology of; Medicine, Sociology of; Occupational Safety and Health; Population Ethics: Elements of Population Ethics; Public Health; Race and Racism; Responsibility; Sexism; Warfare: Medicine and War; Whistleblowing

BIBLIOGRAPHY

Ackerknecht, Erwin Heinz. 1953. Rudolf Virchow: Doctor, Statesman, Anthropologist. Madison: University of Wisconsin Press.

Allende, Gossens Salvador. 1939. La Realidad Medico-Social Chilena: Sintesis. Santiago, Chile: Ministerio de Salubridad, Prevision y Asistencia Social.

Ayanian, John Z., and Epstein, Arnold M. 1991. "Differences in the Use of Procedures Between Women and Men for Coronary Heart Disease." New England Journal of Medicine 325: 221–225.

Chadwick, Edwin. 1842 (reprint 1965). Report on the Sanitary Conditions of the Labouring Population of Great Britain, ed.M. W. Flinn. Edinburgh: Edinburgh University Press.

Cochrane, Archibald Leman. 1972. Effectiveness and Efficiency: Random Reflections on Health Services. London: Neuffield Provincial Hospitals Trust.

Engels, Friedrich. 1845 (reprint 1968). The Condition of the Working Class in England in 1844. Stanford, CA: Stanford University Press.

Fox, Theodore F. 1956. "The Greater Medical Profession." Lancet 2(6946): 779–780.

Galdston, Iago, ed. 1949. Social Medicine: Its Derivations and Objectives. New York: Commonwealth Fund.

Grotjahn, Alfred. 1912. Soziale Pathologie. Berlin: A. Hirschwald.

Guérin, Jules. 1848. "De l'intervention du corps médical dans le situation actuelle; programme de médecine sociale." Gazette Médicale de Paris, series 3, 3(12): 203.

Hurowitz, James C. 1993. "Toward a Social Policy for Health." New England Journal of Medicine 329(2): 130–133.

Ibsen, Henrik. 1882 (reprint 1935). "An Enemy of the People." In Eleven Plays of Henrik Ibsen. New York: Modern Library.

Kahn, Katherine L.; Pearson, Marjorie L.; Harrison, Ellen R.; et al. 1994. "Health Care for Black and Poor Hospitalized Medicare Patients." Journal of the American Medical Association 271: 1169–1174.

Kjellstrand, C. M. 1988. "Age, Sex, and Race Inequality in Renal Transplantation." Archives of Internal Medicine 148: 1305–1309.

Levenson, Dorothy. 1984. Montefiore: The Hospital as Social Instrument: 1884–1984. New York: Farrar Straus Giroux.

McKeown, Thomas, and Lowe, Charles Ronald. 1974. An Introduction to Social Medicine, 2nd edition. Oxford: Blackwell Scientific Publications.

Navarro, Vicente. 1992. "Has Socialism Failed? An Analysis of Health Indicators Under Socialism." International Journal of Health Services 22(4): 563–601.

Perkins, Jane. 1993. "Race Discrimination in the American Health Care System." Clearinghouse Review (special issue): 371–383.

Roemer, Milton. 1991. National Health Systems: Comparative Strategies. New York: Oxford University Press.

Rosen, George. 1947. "What Is Social Medicine? A Genetic Analysis of the Concept." Bulletin of the History of Medicine 21(5): 674–733.

Rosen, George. 1974. From Medical Police to Social Medicine: Essays on the History of Health Care. New York: Science History Publications.

Ryle, John A. 1943. "Social Medicine: Its Meaning and Its Scope." British Medical Journal 2(4324): 633–636.

Sand, René. 1952. "The Advent of Social Medicine." In The Advance to Social Medicine. London: Staples Press.

Sidel, Ruth, and Sidel, Victor W. 1982. The Health of China. Boston: Beacon Press.

Sidel, Victor W., and Sidel, Ruth. 1983. A Healthy State: An International Perspective on the Crisis in U.S. Medical Care. New York: Pantheon.

Silver, George A. 1973. "The Teaching of Social Medicine." Clinical Research 21(2): 151–155.

Silver, George A. 1987. "Virchow, the Heroic Model in Medicine: Health Policy by Accolade." American Journal of Public Health 77(1): 82–88.

Waitzkin, Howard. 1989. "Marxist Perspective in Social Medicine." Social Science and Medicine 28(11): 1099–1101.

Wenneker, Mark B., and Epstein, Arnold M. 1989. "Racial Inequalities in the Use of Procedures for Patients with Ischemic Heart Disease in Massachusetts." Journal of the American Medical Association 261: 253–257.