Yves here. America, since its foundation, has had a struggle between notions of freedom and bodily autonomy versus the scientific pretenses, and later actual very significant accomplishments, of medicine. KLG argues that restoring the legitimate (as opposed to exaggerated) authority of health professionals will depend on rooting out profit-driven behavior. Sadly, that’s a very tall order.
KLG’s intro:
The past five years have demonstrated that politics and medicine are too often bound up with one another in a politico-medical complex of uncertain and certainly uneven utility. While this may seem unnecessary, it has been true since the beginning of the practice of medicine as a profession, especially in the United States. Where medicine is practiced, the Four Freedoms of Medicine – bodily freedom, economic freedom, freedom of inquiry, and freedom of conscience and religion – have also been important. If we are to return to a Golden of Medicine that existed, with some glaring lacunae, in the middle of the twentieth century, we must do so by heeding the advice of Aneurin Bevan, the British Labour politician who started the National Health Service from scratch in two short years after World War II, by taking what he called commercialism out of healthcare. This will be a project and also a necessary task.
By KLG, who has held research and academic positions in three US medical schools since 1995 and is currently Professor of Biochemistry and Associate Dean. He has performed and directed research on protein structure, function, and evolution; cell adhesion and motility; the mechanism of viral fusion proteins; and assembly of the vertebrate heart. He has served on national review panels of both public and private funding agencies, and his research and that of his students has been funded by the American Heart Association, American Cancer Society, and National Institutes of Health.
Given recent history, it may seem the politicization of medicine is a modern development. Nothing could be further from the truth. The following is based on a presentation I heard in November given by Lewis A. Grossman, Professor of Law and History at American University in Washington DC, explaining why and how politics and medicine have often been partners in conflict in the United States since the Colonial Era. His arguments have been presented at length in Choose Your MEDICINE: Freedom of Therapeutic Choice in America (2021) and much of what follows and all the quotations are based on this book. [1]
The first “Heroic Age of American Medicine” is represented by Dr. Benjamin Rush (1746 – 1813), a Founding Fatherwho was a graduate of the College of New Jersey (later Princeton), apprentice to a Philadelphia physician, and medical graduate of the University of Edinburgh. The practice of American medicine, then and now, was suffused with Four Freedoms of Medicine from the earliest days of the American experiment:
- Bodily Freedom. One has the right to decide what medicine to take (or not). This would have been especially important in the first Heroic Age of Medicine, during which medical practice relied on noxious purgatives such as calomel, (mercury(I) chloride – toxic). It is likely that the physicians treating George Washington during his final illness (severe throat infection) hastened his death when they dosed him with “calomel and tartar emetic, applied blisters to his throat and legs and drained about half of the blood from his body.” One of these physicians had been a student of Benjamin Rush.
- Economic Freedom. This was embodied in the early American fight against aristocratic privilege by the country’s honest, productive citizens, which is sometimes cryptic but nevertheless a perennial theme in American history.
- Freedom of Inquiry. Or, let a thousand flowers bloom and find out what works best. The main argument for freedom of inquiry is to avoid foreclosure of promising paths by adhering to any single “School of Medicine” such as the Thomsonians. [2] But it is important to remember that in the initial Heroic Age, science was natural philosophy (it still is, with a stronger empirical foundation) and the major disciplines according to current standards were physics, astronomy/celestial mechanics, and mathematics. [3] Medicine remained a semi-empirical system of folk beliefs – some valid – until the Germ Theory of Disease and the development of physiology as a discipline by Claude Bernard later in the nineteenth century. At the time of the Civil War (1861-1865) only three treatments worked as expected of modern medicine: quinine for malaria, digitalis for heart failure, and the smallpox vaccine, which George Washington required of soldiers in the Continental Army. The mechanisms for these interventions were unknown. [4]
- Freedom of Conscience/Religion. The Thomsonians thought of orthodox medicine as an established system of belief, perhaps protected by the First Amendment of the Bill of Rights. For Samuel Thomson, a citizen had the right to choose a physician just as s/he had the right to choose a minister. This view has rightfully persisted into the twenty-first century.
These Four Freedoms of Medicine are “American” to their core. And they have become more insistent several times in American history: the Age of Jackson, the Gilded Age, the Progressive Era, and in what can be labeled the Late America in which we currently live. Different freedoms have been more or less important throughout American history and there has been no consistency relative to “conservative” and “liberal” views of politics and culture. William James, the Harvard physician, psychologist, philosopher, and brother of Henry, argued for the “contingency of truth.” Unlike most of his colleagues, he was accepting of what we now call alternative medicine and would have agreed with Nancy Cartwright that the purpose of science is to produce useful knowledge instead of “truth.” This political flux has continued into Late America with Donald Trump’s current Secretary of Health and Human Services designee being something of a political chameleon. He was first a pioneering environmental lawyer. He is now rightfully a health foodie, and good for him and perhaps the rest of us. [5]
The practice of medicine has always been a political issue – who is a physician, who pays, and for what purpose? This inseparability of medicine and politics played out most visibly in battles over medical licensing throughout the nineteenth century and well into the twentieth. The Four Freedoms of Medicine were always present in this debate. For example, the Populists of the early twentieth century “never lost their antipathy for special legislation. Their opposition to a state-supported medical monopoly directly paralleled their denunciations of government grants of special privileges within other industries and trades.” At the time, medicine was just another trade. And the American Medical Association (1847) was the trade group. It still is.
The character of medicine began to change during World War I due to improved surgical practice and other interventions necessary to keep the Doughboys healthy. The Spanish Flu that began on a US Army base in Kansas during World War II also led to new medical knowledge and practice. Masks were worn during the Pandemic of 1918, although it cannot be known how well they worked. In the 1920s first “wonder drugs” appeared. Insulin successfully reversed diabetes in the young Billy Leroy in the early 1920s. Vitamin D was used to treat/prevent rickets and the synthetic drug plasmoquine was developed to prevent/treat malaria. Antibiotics soon followed. Tuberculosis was the sixth-leading cause of death in the US in 1930 and twentieth in 1965. This change was due to improvements in public health and the antibiotic streptomycin. Jonas Salk developed the first polio vaccine in the 1950s and was recorded hereexplaining to Edward R. Murrow why the original polio vaccine belonged to the world (the child at 0:55 is receiving the oral Sabin vaccine).
What had begun as a trickle in the 1920s accelerated through the1930s and ran very strongly into the 1970s. It was during this Golden Age of Medicine that doctors “achieved the pinnacle of their social standing and prestige” as people became “less concerned about resisting the authority of regular medicine” because regular medicine had become a lifesaver. Medical freedom activism faded because these movements had rested previously on the reasonable perception that “alternative practitioners had as much healing success as regular (orthodox) physicians.” This was only natural, for the most part.
But medical momentum slowed. Success was not uniform, and progress was sometimes oversold. Deaths from cancer and heart disease tripled from 1930 to 1970. Despite remarkable successes, the “War on Cancer” is still being fought more than fifty years after its declaration by Richard Nixon. And just as nature abhors a vacuum, alternative medicine moved into areas where the progress of modern, sometimes heroic, medicine lagged.
Quack cancer cures [6] such as Krebiozen and Laetrile were as much a response to the dread disease as they were manifestations of a loss of trust in the medical establishment. This led naturally to the reappearance of the patient’s Right to Bodily Freedom. According to Grossman, “In the late 1960s 50% of physicians thought it medically appropriate for a surgeon to perform a mastectomy based on signing a blanket consent form” upon hospital admission. This was, of course, long after it had become clear that a mastectomy only disfigured as often as it surgically cured the disease.
It is important that we remember these were not and are not left-right issues. “Health foods” originated among conservatives in the 1950s. The concept was decidedly “progressive” by the 1970s, and this form of “modern resistance to medical domination” endures among liberal and conservatives, perhaps most visibly in late 2024 in MAHA, Make America Healthy Again. In 1990, 72% of patients who used alternative medicine did not inform their doctors; more admit to it now. In 1991 the Office of Alternative Medicine was established at NIH, now known as the National Center for Complementary and Alternative Medicine. A majority of those polled in 1996 in a national survey expressed “only some” or “hardly any” confidence in the medical establishment. It is a certainty that nominal conservative and liberals were well represented throughout this majority.
And so, it was back to the Four Freedoms, most recently as leaders of a renascent anti-vaccination movement “shared a conviction that an unholy alliance of avaricious private interests and power hungry public officials was conspiring to strip Americans of their fundamental rights.” Indeed, and this was neither “right” nor “left.” It has no need of further explication here, except to briefly note that the actions of the politico-medical establishment during the current pandemic reanimated with a vengeance all Four Freedoms of Medicine.
Which brings us to “Therapeutic Choice and Health Insurance.” In none of the previous ages of American medicine did this matter. The patient paid, one way or another, or did without. With the advent of health insurance on the “American Plan” that for most people linked health insurance to employment, it was assumed that this included a right to therapeutic choice. It did not. But patients generally “do not distinguish between a denial of coverage and a direct interference with their therapeutic choice – especially when they are confronting a personal medical crisis.” Of course they do not, even if deep down they understand they are the unlucky victims of our so-called healthcare system. An expectation is not a right.
Professor Grossman is very good in Choose Your MEDICINE on the nuts and bolts of health insurance coverage, which has developed unevenly in the United States since World War II when healthcare became a widespread fringe benefit as wage and price controls increased competition for workers in the war effort. But neither does he nor most other people grasp that medical insurance is a category mistake. Insurance coverage is for bad things that are very unlikely to happen during a given period – accident, fire, flood, death. That virtually everyone will need medical care is a given, however. Patients are not consumers. They are not clients. They are fellow citizens and residents, human beings in need of care.
And this is where politics and medicine have become inseparable, again. Free choice is a political right, but not so with healthcare. Our politico-medical establishment has brought us Medicare Advantage, which enriches “providers” at the expense of the people who need healthcare. Pharmacy Benefit Managers make life very difficult for independent pharmacists, especially in rural areas where the pharmacist is often the healthcare provider of first resort. Electronic Medical Records, ostensibly intended to improve healthcare by making medical records available anywhere in an instant, are designed for billing rather than delivering proper care at the right time.
But finally, we must remember: What a wrongheaded political economy has changed can be changed back. The Golden Age of Medicine in the middle of the twentieth was very real. Vaccines made frightening and inevitable diseases a thing of the past. Antibiotics cured lethal infections, sometimes within hours. [7] Modern molecular biology described the molecular basis of many diseases, cancer most notably among them, and suggested cures that became reality. All of this required generous public support of the basic biomedical and clinical sciences.
Unfortunately, as covered here many times, the Biomedical Sciences have been eclipsed by Big Medicine and Big Pharma and have become what may be called BioMedicine. As required of the Neoliberal Dispensation, the goal of BioMedicine is let the market decide what is best, in preventing disease, caring for the sick, and managing a pandemic. The results have been uneven to horrible. Nevertheless, the Golden Age can be recaptured.
Yes, trust in medicine as a healing art and a science of healing can be regained, along with the Four Freedoms of Medicine: (1) Bodily Freedom, (2) Economic Freedom, (3) Freedom of Inquiry, and (4) Freedom of Conscience and Religion. But this is possible only if we follow in the path of Aneurin “Nye” Bevan (1897-1960). Bevan was the son of a Welsh coal miner who worked in the mines himself before becoming a labor leader and Labour Party politician. As Minister of Health (1945-1951) in the post-war government led by Clement Atlee he established the National Health Service (NHS) in 1948 pursuant to National Health Service Act of 1946, only two years from instruction to implementation. The naysayers were loud, particularly along Harley Street and in The City. Until very recently, despite the politics of the past forty years, the NHS was a “crown jewel” of the British commonweal. But for politics it will remain so.
Medicine and Politics, Politics and Medicine have been intertwined since the eighteenth century. They will remain bound together, whatever happens in the coming political and cultural world. But the relationship is not necessarily antagonistic from the perspective of the people as long as we remember what Aneurin Bevan wrote in his In Place of Fear (1952):
The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health.
Everything in medicine follows from this statement, for good or ill. The same is true for the foundation of healthcare in the clinical and biomedical sciences. This is all we need to remember and act upon.
Notes
[1] This essay is not meant to be a review of Choose Your MEDICINE, but for those interested in digging deeper the book is very accessible to the general reader. It is apparently available only in hardback, so ask your friendly neighborhood librarian to get it for you (I can see my local library and the Post Office from the window of this room – urban living has its advantages).
[2] The Thomsonians came after Benjamin Rush and took their name from Samuel Thomson (1769-1843) who advocated the use of herbal remedies because they were natural (some of them undoubtedly worked) instead of the very unnatural calomel and the like. Thomsonianism lives today as previously described here in Mind the Science. The Medical Medium is one current echo of Samuel Thomson. This does not mean that good food and “clean living” do not produce good health. However, the Blueberry Challenge is unlikely to do much. Besides, what is on the blueberries that come from industrial farms? Another story covered often here.
[3] Well-developed scholarly disciplines, as we would describe them, also included theology, philosophy, and history, the latter still developing a critical apparatus. Experimental chemistry had escaped Paracelsus but was still very much in development, largely as an adjunct of industry. Experimental physics developed along with chemistry.
[4] Surgery was separate from medicine until after the turn of the twentieth century, as illustrated in this quotation from Sir William Osler (1849-1919, pronounced “Oh’-sler”), the founder of modern medical education: “You cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and biochemistry flounders along in aimless fashion, never able to gain any accurate conception of disease, practicing a sort of popgun pharmacy, hitting the malady and again the patient…usually not knowing which.”
[5] However, Robert F. Kennedy, Jr. is still apparently willfully “misinformed” on the utility and safety of vaccines as an essential mechanism of disease prevention.
[6] Quack as a term for medical charlatan is as surprisingly old as it is delightfully descriptive. It was used by Benjamin Rush around the turn of the nineteenth century to describe his rival Thomsonians and their school of medicine. Erasmus used the term (in the 1683 translation from the Latin by White Kennett) in The Praise of Folly,which was published in 1509 (OED Second Edition. XII, p 952).
[7] My first faculty mentor in a biochemistry research laboratory had been a corpsman (medic) in the United States Navy during World War II. He often spoke of giving his first penicillin injection to a sailor near certain death from bacterial pneumonia. He saw the sailor in his hospital bed the next morning, hale and hearty and hungry, instead of in the morgue. My teacher was a member of that greatest generation of scientists who discovered vitamins and how mutations drive cancer progression. This was long before the Bayh-Dole Act of 1980 initiated the virtual eclipse of disinterested biomedical science in the United States.