Final Review - History of Medicine and Health in America

Final review with all expected terms.

*** The definitions for each term are simple and do not discuss the issue at length or in depth. A more in depth examination will be needed to the nuances in writer language.

Terms/Concepts from First Half

19^th Century prerequisites for the “Golden Age”:


Therapeutic Revolution — A contention that curing people, or societies, of their ills by treatment is impossible. In medicine, it was connected to the idea that many "cures" do more harm than good, and that one should instead encourage the body to heal itself.

Public Health — Rise of community health (Bynum),  public health 3 dimensions to quantification of medicine: surveys (gathering data), surveillance (observing populations), and significance (Using data to determine issues - etiology). Police functions of public health involve medical practitioners that have to report specific contagious diseases (e.g. T.B., smallpox, syphilis), forerunners of intelligence agencies. Cholera proved influential as a disease to promote public health measures as the disease was spread through contaminated water supplies.

Surgical progress — Surgery originally separate class underneath physician, later rise of invasive procedures, first little success due to high rates of infection, improved through asepsis and antisepsis, rise of surgeon specialist with highly invasive procedures.


Koch’s Postulates &Biomedical Model — Koch’s postulates = If disease is caused by microorganism: (1) The organism must be shown to be constantly present in characteristic form and arrangement in the diseased tissue (2) The organism which, from its behavior appears to be responsible for the disease, must be isolated and grown in pure culture (3) The pure culture must be shown to induce the disease experimentally. Biomedical model = (1) Specific causality (2) Objective diagnosis (3) Universal (specific) treatment

Flexner Report and its Impact(s) — Flexner Report: Too many uneducated doctors, standardized acreditdation and schools with hospitals needed, no sect divisions, Coed, Blacks segregated.

Heroic Medicine — Desperate times call for desperate measures, Techniques like blood letting and purging, Advocated by Benjamin Rush, Persisted => (1) They “worked” - buying into placebo (2) Patients believed (3) Doctors believed - Used treatment on themselves (4) They worked = patient death - Using God as an excuse or time; Faded => (1) Nature’s vital power (2) Skepticism about rationalistic certainty (3) Patient demand and competition from other practitioners.

Rise of Workman’s Comp — Midterm question refer to the assumption of risk, contributory negligence, fellow servant rule, company doctors

Authority and Rights (change over four periods) — Pre-19th Century: Local medical authority + moral authority; 19th Century: State authority, beginnings of federal authority + moral authority; Late 19th-Early 20th Century: Progressive, do-good, pretentiousness; New Deal Era (1930-1970s): Massive information of Federal Govt; Since 1970s: Downturn in faith in science, challenge authority of medical expertise

Alan Kraut’s Four Themes — (1) Relationship among health, disease, and nativism, those prejudices and policies that express opposition to the foreign born. (2) Advances and perceived limitations of scientific medicine. (3) Institutional response of national, state, and local governments to both the qualitative and quantitative dimensions of immigration as it affected and was affected by public health considerations. (4) Immigrant and refugee response to differences between themselves and the native-born in matters of therapy, health care, disease prevention, and hygiene (all areas of public health).

Bynum’s Five “Medicines” — (Short) History of Medicine: bedside, library, hospital, community, and laboratory.

The Golden Age of Medicine - By:Rebecca Szczupakiewicz

Burnham's dates (and arguments for the rise of) the Golden Age of Medicine - It's about the history of the criticism of doctors.  People have always complained about doctors, but the complaints changed.  Prior to 1900 it was for ineffectiveness and greed (i.e. they charge too much).  During the Golden Age they still complained about greed, but the critiques were mostly about access (i.e. not enough doctors, too expensive, long waits) because this is a good thing we should have more of. (THERE MIGHT BE MORE TO THIS - READ BURNHAM - HE WILL BE ON FINAL)

What are the chief criticisms of medicine during the Golden Age? - Failed in Sacerdotal role (see below), technical role (they fail to do the golden stuff the right way), social role (as collective, like the AMA, must show socially responsible and not doing things to enrich themselves)

Sacerdotal function - "priestly role", doctor brings knowledge, personality, wisdom to bedside (also patient play "sick" role, embrace this and agree to follow priestly instructions and society will grant leeway)

Halfway Technologies - Things for which there is no cure, but you can live as a lifelong patient.  For example, someone with Diabetes is forever dependent on the insulin corporation.  HIV was a death sentence, but now it's a "life sentence"


Diabetes and "Erstwhile Dead" - Insulin was a major success, changes everything, very "Whiggish", delivery system is so sophisticated that people can function normally in society (Before this only the starvation diet was semi-successful).  Generation before insulin was the "erstwhile dead", because basically dead or starving.  But this is a halfway technology, forever patients

Race, Class and Genetics I - By:Rebecca Szczupakiewicz

Pima Indians and the lure of genetics - "Pima paradox" - this group is most obese Americans, and they are also very tight knit on the reservation in Arizona.  There's high poverty and a diabetes epidemic.  Feds tried to help.  So are they predisposed, genetically, to obesity?  Compelling argument, except that Pima in Mexico are genetically identical, but they live as agricultural peasants and have a very low rate of diabetes.  Is this a failure of big gov't, welfare, unhealthy food?  Is it better to overwork them?  Something cultural in America?

Keith Waloo on Sickle Cell - Article called "Genetic Testing in Conflicted Society," but this is ironic cuz he's not looking at DNA.  Genetic marker is shape of blood cell to determine if someone has sickle cell anemia (microscopic test).  Sickle cell was known as "negro blood", if someone has sickle cell anemia then they had to be black.  This line of racial thinking inhibits proper study of the disease.  Sickle cell is from areas with malaria, because it's a mutation that works against malaria.  Italians have it too. THIS GUY WILL TOTALLY BE ON TEST - READ HIM

Kraut on TB among Jewish immigrants - stigma of "Jewish disease," it was seen racially even though Jews are religious group.  They were perceived that way even in public health literature.  Fear of diseases immigrant is racialized.  Seen as population trait.  Fear them cuz they were close-knit in Europe, and now huge flood comes to worst neighborhoods in cities.  Riis and other Progressives saw Jews as a disease population.  Biggest killer was TB, but their rate in their economic class was actually the same or lower.  (Franz Boaz looked at skulls and saw racial characteristics are actually environmental - conditions better in 2nd gen, and TB rates lower)


Kraut on TB in the 1980s - Haitians and drug resistant TB, cultural sensitivity (I RETURNED MY BOOK TO LIBRARY CAN SOMEONE FILL THIS IN MORE?) - Will do refer below

By: Tom
Kraut (Chapter 10: "Virus and Bacteria Don't Ask for a Green Card" p.261-263) discusses TB as once again seen as a menace from immigrant populations. Careless language in responses from public health officials often unintentionally fueling public fear by lending a "scientific" backing to racial or ethnic prejudice. Epidemiologists discern that foreign-born contribute disproportionately to high TB rates, 22% of all reported cases of TB occurred in foreign-born population. Of particular note are the populations from Asia and Latin America. Such a statistic, though true, could fuel xenophobia and hatred towards foreigners. Thankfully such findings have not generated much public hysteria because public health officials are more sympathetic and cautious in their policies. TB is still prevented from entering the country by being listed as a medically excluded condition. It is important to note that the fact that TB is treatable is also one reason why fears haven't exploded into xenophobia. 

Sex & Disease, and Ethics

Obstacles to controlling VD — Human behavior of just wanting to bang, hard to moralize sex because people are sexual promiscuous.

Salvarsan — 1st organic medicine developed for use to treat syphilis. First synthesized in 1907 by Paul Ehrlich’s lab by Alfred Bertheim. The antisyphilitic activity was discovered in 1909 by Sahachiro Hata.

Brandt on VD in WWI and WWII — WWI touched off the most vigorous antivenereal disease campaign in American history. Centered on the problem of prostitution —> feared that solders would meet prostitutes, become infected and lose the war. Though it was widely recognized that condoms could prevent the transmission of the disease, the military refused to give them out thinking that it would increase sexual activities amongst soldiers. Promotion of abstinence! WWII Same campaign against syphilis and prostitution as in WWI, Penicillin developed in 1943 began the era of antibiotics (Rita Kumar)

Hippocrates and Plato on medical ethics — Hippocrates: First do no harm, Plato: “Unproductive” citizens should not be aided. If someone is incurably diseased up to the point that the disease will be carried to the next generation, it is unethically to treat that person, and have the person suffer (Rita Kumar)

Nuremberg Code — After the Nuremberg Trials, a new code of ethics concerning experimentation on human beings, Nazi crimes shock the world
Ignored in US? — Nuremberg Code + Ten Points —> came out of the Nuremberg trials in response human experimentation in concentration camps; proper rules for experiments on humans keeping ethics in mind
Nuremberg Ignored? Widely ignored nationally b/c it was believed that these were code that were applied only to Nazi’s (Rita Kumar)

Henry Beecher Report, 1966 — Scathing muckraking essay about human experimentation in US. Pointed out the hypocrisy in medical practice + research and it ethics; called for our attention to Nuremberg code.

I.R.B. s — Institutional Review Boards for judging of medical ethics, importance of the review board increases post WWII 

Tuskegee — Clinical study undertaken by the US Public Health Service from 1932 to 1972 studying the natural progression of untreated syphilis in rural African American men in Alabama. Considered totally lawful and did not break any conditions for human experimentation at the time.

Susan Reverby on Tuskegee and Guatemala — Susan M. Reverby stumbles upon another experiment while searching for documents on the Tuskegee Syphilis Study, another US backed experiment led by John C. Cutler of the US Public Health Service, In Guatemala using syphilis prostitutes to spread disease among prisoners, Actively infecting subjects during this human experiment, Huge political and media debacle.

***Lederer: Tuskegee and Dissection — (Prof. Warren said to check out this one specifically) Placing Tuskegee study in context of human dissection, postmortem analysis, compliance with autopsy rules -> laws in check, burial stipend incentive, long history of Black experimentation.

Eunice Rivers — African American nurse in the Tuskegee study who convinced other African American males to partake within the study and convincing families of the deceased to allow autopsies to be conducted in order to learn more of the disease, and they would receive proper burial. She served as a bridge between doctors and patients. (Humza Bhutta)

R.A. Vonderlehr — Physician in the Division of Venereal Diseases at the Public Health Services —> overseer of the Tuskegee study. He said, “The proper procedure is the continuance of the observation of the Negro men used in the study with the idea of eventually bringing them to autopsy.” (Rita Kumar)

Spinal puncture as “treatment” — Advertised as treatment to African American for their syphilis when really physicians were collecting spinal fluid to study to disease and its connection to neurosyphillis. (Rita Kumar)

Vanessa Gamble on the “Legacy of Distrust” —  Basically an article talking about how the Tuskegee syphilis study had reformed federal regulations on human experimentation but left fear in African Americans (about being used for medical research again). To show the study in its historical context, and to examine how race and racism influence contemporary biomedical research. Link: https://www.researchgate.net/publication/15076538_A_legacy_of_distrust_African_Americans_and_medical_research (By: Humza Bhutta)

Drinking and Drugs in America - By: Rita Kumar

Opium and Cocaine in the South
Postbellum South (after the Civil War) — had an unusually severe narcotic problem characterized by racial preferences for different drugs. Southern Blacks tended to use cocaine more than whites. Southern whites has the highest addiction rate of any region racial group in the country. Confederates has lost the war, more reason for Whites to be more depressed than Blacks. Blacks did not have access to physicians as much as Whites did, therefore were less susceptible to opioid addiction and turned to cocaine instead.

Who used opium, 1895-1975?
1895, most addicts are medical addicts using opium or morphine
1975, nonmedical addicts increase dramatically
Today, medical addicts turn into nonmedical addicts - medical addicts get caught on painkillers but then get cut off by doctors; seek heroine on black market b/c it is much cheaper and thus become nonmedical addicts.

Alcohol consumption in America:
The Alcoholic Republic — Heavy consumption of alcohol in the past

Impact of Victorian America — Looking at the past, large amounts of drinking, later changes with Victorian women who argue against drinking (temperance), drinking rates drop down, present drinking rates still not as high as the past. Temperance Movement and cultural stigmatization (violent men + alcohol abuse) of alcoholism decreases alcohol consumption from 1800 to 1920 (note, Prohibition has not occurred yet). An early “cure” for alcoholism: Coca-Cola.

Impact of Prohibition — Actually decreased drinking rates, legality remains a top reason

 Cigarettes
  “Reach for a Lucky…” — Lucky Strikes cigarettes (Name brand), … instead of a sweet, implication cigarette smoking would keep you slim.

Tobacco use before the cigarette — Early history of tobacco isn’t about smoking, but about chewing tobacco and spitting it into a spittoon; also cigars and pipes were much more popular than cigarettes. Cigarettes only become popular after the 1920s. Snuff: finely powdered tobaccos and sniff it. Smoking from a pipe and cigar was a leisure activity, usually done by upper class American in last 19th century. However, with the breakthrough of cigarettes allow for the convenience of smoking while working in the industry -> which is why it picks up popularity much later in time

Flue cured tobacco — Curing and subsequent aging allow for the slow oxidation and degradation of carotenoids in the tobacco leaf. Makes the tobaccos milder tasting and changes the pH to a closer physiological pH; meaning that the cigarette would carry more nicotine than any other method of injecting tobacco. (Lucky Strikes: “It’s toasted”)

Coca: Crack = Tobacco: Cigarettes (how so?) — Coca and Tobacco are raw ingredients grown in the environment, Crack and Cigarettes used the raw ingredients and process them for the final product.

Surgeon General Report of 1964, and the role of causal evidence — Retrospective and prospective studies: a review of previous cancer rates caused by smoking, and following people who currently smoke and the effects of it. However, no where in the Surgeon General report claims that smoking causes cancer —> rather use of strong association btwn smoking and cancer in certain populations; leadings to initial regulation of cigarette smoking. This is not the first time that someone has associated smoking with cancer, this link was identified by researcher before the report. But the report plays an important role for public policy and its attitudes against cigarettes.

Modern Medicine and its Discontents

Bynum, The History of Medicine, ch. 6 (Tom)
The return of holism — focusing on the whole patient, reaction to reductionism (the specific focus on different aspects of the body) and specialization, minority voice throughout the Golden Age, changes and return during the Vietnam era due to patient empowerment, nature of general practice reformulated, new emphasis on primary care in developing countries.

The electronic library and public access to medical knowledge — library of medical information now available online, publishing materials of books and journals also available online, changes doctor-patient relationship because patients can google their treatments online, problems of misinformation online.
Health internationalism

Health internationalism — More focus on primary care, shift from vertical programs (targeting specific diseases) to horizontal programs (improving general primary care and structure of population).

(By:Rebecca Szczupakiewicz)
The Critics:
Illich - 1974 Medical Nemesis - Appropriation of health. Prometheus (in Greek mythology) brought fire to humans and the goddess of hubris and retribution of crime chains him to a rock and has his liver pecked out for all of eternity.  He argues that the Golden Age has gone too far, doctors are playing God, and they are losing humanity.  People are supposed to suffer, but with this Golden Age they are appropriating health. 

McKeown - 1976 Modern Rise of Population - Diseased disappear before the cures are invented, and this guy argues that this is not because of public health reform.  Rather, it's because of nutrition and the economy.  This thesis was debunked - it was the hygiene and public health that saved lives.  

Dubos - 1959 Mirage of Health: Utopias, Progress, and Biological Change - this guy was a real scientist, a soil microbiologist, studied ecology, won Nobel prize for antibiotics.  He tries to warn medical science that antibiotics are a gift from God but you must use them wisely because germs can evolve.

Contexts:
Epidemiological Transition - infectious acute as the majority burden of health is replaced by chronic lifestyle illnesses.  The relationship between medicine and cure alters - how much do we blame the victim? industry? Do we attack with medicine, education, or legislation?  

Counterculture - High point of Golden Age had aligned with economic boom post-war, but in the 1970s there a global economic downturn and a while new attitude about big government and medical spending.  "Our bodies our selves" was a radical project.  Counterculture also against the culture of supercapitalism.  They promote being healthy, which is a push against the dominant medical capitalist society. Another modern movement based in counterculture that states that the truth is out there, but capitalism doesn't want you to see (ex. Rachel Carson).  

Ecological Science - there are unknowable complex and unexpected side effects, and they cannot thoroughly predict the impact.  Pampered ecosystem invited weeds.  People are scared of new diseases, ex. ADD, Autism.  Polio is also a socially constructed disease that underwent a massive change - In 1800s no universally clean water, and the fecal/oral transmission was common so kids had this as children, had limited immunity, and it was never really diagnosed.  Then when the water got cleaner kids had no exposure so they caught it later and it hit the nervous system instead.  Biggest polio impact is in middle class.

Iatrogenesis:
Clinical - diseases medicine causes (ex. bloodletting to death), create sickness

Social - society's willingness to spend inordinate amounts of $ to make people well, especially at infancy and old age.  Traditionally, the elderly allowed themselves to die.  Now, we tell them it's their duty to live, show that they're brave, and the family will pay.  Sisiphus Syndrome - in Greek mythology, he pushes the boulder up the hill for eternity, he'll never win the battle, but he's doomed to continue

Cultural - Culture defining what had been normal parts of life and death and making them medical conditions, ex. impotence with drop in testosterone, and adolescence is also a social construction with its own branch of medicine

Universal Health Care?

Beatrix Hoffman: social movements role in health care reform — Social movements generated grass movements encouragement for healthcare reform, movements unfortunately limited in scope, pattern of elite decision making has failed, Our Bodies: Ourselves (Major Feminist work), need for unified grassroots movement. 

Health Care in the day of Wilson, Truman, and Clinton — Wilson attempts for compulsory healthcare opposed by insurance companies, employers, AMA. Truman also pushes for healthcare, but defeated by a concerted campaign launched by the AMA. Clinton's health reforms defeated as because of complexity and lack of support.

Laurie Abraham on the human costs of bureaucratic complexity — Personal story of Mrs. Jackson treatment, falling through the cracks in Medicare coverage, Medicaid not applicable unless income low enough, mess of government paperwork to go through.

Harry Truman on Health Care and competing rights — Truman adamantly believed in the idea of a national health care program through his own experiences in the South. He proposes national health insurance by pushing through the Wagner-Murray-Dingell Bill. Right to medical care, need more health services + sick pay.

*** Definitions below under construction

HIV/My Own Country 

Jim Moore’s overview of AIDS in Africa — Four rival theories of AIDS origins: (1) Tainted Polio vaccine (2) Cut hunter theory (3) Contaminated Needles from reuse (glass vs plastic syringes) (4) Heart of Darkness theory (ref. to Joseph Conrad’s Heart of Darkness) Version of cut hunter theory

HIV vs “VD”:
Transportation — Carried from people to other people, HIV: gay populations and truckers vs VD: prostitution

Who gets it — Myths of 4H’s, Started from gay populations in large cities, fans out vs males 

Role of “innocent” victims — Promotes sympathy when those not under the stereotypical 4H’s are infected, Ex. Mr. & Ms. Johnson: Got HIV from blood transfusion and proceeded to transfer the disease to wife through intercourse. Innocent victims are important to moralizing support for those suffering from the STI.

Prevention — Moralization attempts to convince people to stop having sex (fails), Later promotion of condoms and safe sex

Treatment — HIV can only be suppressed whereas “VD” can be cured via antibiotics

Activism by “at risk” populations — AIDS Coalition to Unleash Power (ACT UP): Direct action advocacy group, TAP support group.

My Own Country
Kraut’s themes and___ ???

Verghese as multiple “outsider” — Outsider as Indian, immigrant, doctor, heterosexual

Johnson City and the “Immigrant Menace” — ???
Clyde and Vickie and the “Four-H” norm — 4 H’s: Homosexuals, Heroin users, Hemophiliacs, Haitians; Clyde passes off AIDS to Vickie after gay sex.

Bobby and Ed; Ed’s death and “family” — Bobby says Ed request DNR, but no supporting paperwork, family wants resuscitation and wins out

Moralization and health (i.e., smokers on the cancer ward) — Smokers of the cancer ward in the VA continue to do so even after being notified about their poor health and cancer

And history of medicine in mid- to late- 19th Century - General trends???

*** Definitions above under construction

Post-Modern Medicine

Symptom-based conditions – Problem of medical specificity, creating new medical terms for symptoms w/o specific etiology, debate over new terms. Examples of symptoms based medical terms: chronic fatigue syndrome = neurasthenia, fibromyalgia = widespread muscle pain, multiple chemical sensitivities = Flu like symptoms post exposure to chemicals, silicone-rhematic, Gulfwar syndrome, sick building syndrome.

Lead from Modern to Post-Modern – Overtime a decrease in lead death, but an increase in lead consumption, more people surviving lead poisoning w/ chronic health conditions

Diagnosing Lead poisoning from clinical to lab-based to statistical — 1^st lead poisoning diagnosed based on visible symptoms, 2^nd diagnosis based on lab testing, 3^rd diagnosis focusing on statistical studies and connecting to lead poisoning.

Allan Brandt — Americans give new meaning to shifting disease patterns, biomedical model = depersonalize disease, reduction of individual responsibility, elegance of magic bullets tempting. New problems with biomed model b/c chronic diseases. New issues of causality, but not causation, lifestyle risks puts disease responsibility back on individuals.

Epidemiological transition and the rise of lifestyle medicine — Corresponds to lifestyle diseases = Diseases whose occurrence is primarily based on the daily habits of people and are a result of an inappropriate relationship of people with their environment. The main factors contributing to lifestyle diseases include bad food habits, physical inactivity, wrong body posture, and disturbed biological clock. New treatments of healthy habits in response.

Cigarettes and “risk factors” — Social constraints and controls help bring down smoking behavior.*

Ghaemi, “Postmodern Pharmaceuticals” — Analyzing critiques of the pharmaceutical industry: (1) Free market myth: Untrue b/c prescription medicine heavily regulated (2) Drug price myth: Untrue b/c most $ from medicines funneled towards overhead marketing (3) academic-pharmaceutical complex: True, but needs to be solve from academia end (4) Ghost authorship: True, but also academia problem (5) Lack of innovation: True b/c companies afraid to lose $ in experimentation (6) Profit motive: ~ Relative to others, everyone wants profit. Ghaemi proposed pharmaceutical industry as both good and evil b/c of the above. 

Death

Timothy E. Quill — Doctor who advises on euthanasia for Diane, a lady suffering from myelomonocytic leukemia. Diane is convinced about committing suicide, denies hospital treatment, denies comfort care at home, goes for hemlock death (Socrates went out the same!), Quill notes that he registered her cause of death as leukemia rather than suicide to avoid negative repercussions.

The Civil War and America’s views on death and burial — NYT review by Geoffrey Ward for Drew Gilpin Faust’s book, This Republic of Suffering. Death created modern America by shaping national structures and commitments. 1^st “work” of dying, faithful look forward to a good death, unfortunately war robs such glorious death. At start of war there was no system for burial of dead, ad hoc measures taken. Post war reburial of soldiers in Union designated cemeteries, confederates no special treatment. Huge cost demand new sense of national destiny, dead become whatever survivors make of them. 

Jessica Mitford, The American Way of Death — Harsh criticism of American funeral business, Modern American funeral irrational, money schemes over customization of death. New mythology of funeral: (1) American tradition (2) Public being given what it wants (3) New psychiatry about last glimpses (4) New terminology in business, euphemisms. American public is sick of high $$$ of burial.

Can history be a guide in Euthanasia controversies? — Study of historical cases of euthanasia around 1906 America, Three points: (1) Agreed that practiced w/ frequency (2) Influenced along w/ eugenics (3) Opponents against euthanasia used practical reasons more than religious/moral ones.

*NEEDS MORE DEFINITION, WILL GO BACK TO THE READINGS, OR PLEASE PROVIDE SOME HELP IN LOOKING UP. THANK YOU!