VIRCHOW AND PUBLIC HEALTH: 150 YEARS AND STILL WAITING
A reader kindly gave me a number of Scientific American issues from the turn of the century (about 1898-1903). One of them, dated September 13, 1902 includes an obituary of Rudolph Virchow (1821-1902). He got his MD at 21 and moved from Pomerania to Berlin and became a professor at the University of Berlin in 1847. He was sent to Silesia to study the high death toll among miners there and prepared a report on “nourishment and well-being” and provided a simple solution for the problem – give the miners a higher wage. His timing was bad (the 1848 revolution) and he was forced into exile in Wurzburg. There he founded the field of cellular pathology and established a journal for it. He extended the cell theory and used it to explain the origin of cancers from a single cell origin. His idea of cellular pathology caught on; it was used to diagnose many illnesses. In 1856 he returned to Berlin and ran for office and entered the German parliament and pushed for public health. Under his efforts Germany had the best in the world and American physicians came to Germany to bring public health back to the US. He was resisted bitterly by Bismarck and conservative German representatives and Bismarck even challenged him to a duel!
Over the years public health has had an uneven history. The difficulty involves who should provide health care to the sick and who should keep people healthy so they don’t become sick, at least as children and adult providers for their families. This has led to two strategies of medicine. One is curative and when we get sick that’s what we want – treatment. The other is preventive (and many physicians, being idealists, would prefer to keep their patients healthy, because many of the illnesses they treat could have been prevented or delayed). No physician would prefer to treat smallpox than to prevent it. In 1980, a commission in Great Britain issued “the Black Report” that showed socio- economic status (SES, as sociologist like to call it) is incrementally proportional to health. The more money you have the healthier you are. It’s not the poor versus the rich. You middle class readers are less healthy then the very rich. The rich can buy good health. The middle class only gets what their insurance or the government provides for their health. With the molecularization of medicine likely in this 21st century, that gap between the wealthiest and the middle class will increase because molecular diagnosis and treatment is a big bucks operation and it makes medicine as a whole tilt toward the treatment of the individual rather than the prevention of most chronic illnesses by the government. Why the government? Only the wealthy can purchase the best life style and medicine that keeps them so much healthier than the middle class. For 150 years governments have been stingy in supporting public health because, like Thatcher’s rejection of the Black Report, “it is an inappropriate interference in the British economy.” The US is no better. Try advocating a public health program that offers more people better coverage (including the middle class) and watch how fast it will be tabled or defeated or tilted to the treatment rather than prevention mode of medicine. Clearly we need both, but for 150 years public health has taken a back seat when it is most likely to extend life expectancy, reduce illnesses, and greatly benefit the economy by having a healthier work force.