ANNALS OF BULGARIAN EPIDEMIOLOGY IN THE 20TH CENTURY
Author: Petar Georgiev
Editor's Note: This presentation was written on the insistence of some colleagues from abroad. It does not reflect strictly the state of knowledge exemplary in the field and the preponderant trends of developmental science in Bulgaria. The latter is still stigmatized in the schemata of dialectical materialism — i.e., even in the beginning years of the 21st century — further, the occasional implications from the European Commission of I.E.A. on "change of the courses" and other emissaries mainly from the U.S.A., have been outspokenly neglected. The views of the Bulgarian Epidemiological Association are faulty, while this pretentious monograph written by a collective of some dozen authors reflects merely the "achievements" from a socialist period. The editorship of Prof. P. Georgiev is controversial. We have already presented another book from this author /cf., Georgiev, P. Liquidation and Elimination of Infectious Diseases. Sofia: 1992/; erratically, the rules of the game remain unchanged and to an interested reader we give a glimpse on what is happening on the other side of the iron curtain. Here are two materials reflecting a status of, i./ modern epidemiological approaches of the social science discipline in 20th century; and, ii./ historical retrospective on plague, morality and the state of medicine in early modern ages.
EPIDEMIOLOGY, the study of the health of human populations, is by definition a social science. Its theory and practice have been profoundly influenced by society — by economic, social and political developments. Conversely, epidemiology has become a powerful force in the evolution and transformation of human populations and their social organization. I should like to explore some of these interrelationships.
The basic question of epidemiologic theory in the nineteenth century was the cause of epidemic disease: miasma versus contagion. This question could not be solved in the first half of the century because the scientific evidence was inadequate. Ackerknecht, in a remarkably illuminating article on "Anti-contagionism between 1821 and 1867", has pointed out that "Contagionism was not a mere theoretical or even medical problem. Contagionism had found its material expression in the quarantines and their bureaucracy, and the whole discussion was thus never a discussion on contagion alone, but always on contagion and quarantines. Quarantines meant, to the rapidly growing class of merchants and industrialists, a source of losses, a limitation to expansion, a weapon of bureaucratic control that it was no longer willing to tolerate, and this class was quite naturally, with its press and deputies, its material, moral, and political resources behind those who showed that the scientific foundations of quarantine were naught, and who anyhow were usually sons of this class. Contagionism would, through its association with the old bureaucratic powers, be suspect to all liberals, trying to reduce state interference to a minimum. Anti-contagionists were thus not simply scientists, they were reformers, fighting for the freedom of the individual and commerce against the shackles of despotism and reaction. This second aspect of anti-contagionism contributed probably no less than its scientific aspects to its gaining over the majority of those parts of the medical profession that were independent of the state".
The political background of the anti-contagionist discussion was obvious. The leading contagionists, with the exception of the liberal professor Jacob Henle, were high-ranking royal military or naval officers. The leading anti-contagionists, on the other hand, were known radicals or liberals, and included such major figures as Rudolf Virchow in Germany and Francois Magendie in France. As Ackerknecht has noted, "The anti-contagionists were motivated by the new critical scientific spirit of their time. It is no accident that so many leading anti-contagionists were outstanding scientists. To them this was a fight for science, against outdated authorities and medieval mysticism; for observation and research against systems and speculation".
The great pioneer of cellular pathology, the research scientist Rudolf Virchow, fought on the barricades in Berlin in the 1848 revolution, led the Progressive Party opposition to Bismarck in the Reichstag, was one of the founders of the medical reform movement in Germany, and made major contributions to public health and hospital development. Virchow represented, along with such men as Max von Pettenkofer in Germany, Francois Melier and Louis Rene Villerme in France, and William P. Alison in Scotland, a "sociological" school of anti-contagionists who considered poverty and destitution to be the primary sources of disease. Alison, for example, was critical of the narrowly-oriented miasma theories of Edwin Chadwick and his medical experts. Alison considered sanitary reform to be desirable and necessary but not sufficient; it needed to be accompanied by a general improvement in the standard of living of the lower classes.
The English sanitary reformers, foremost among whom were Edwin Chadwick and John Simon, were ardent supporters of the miasma theory as the basis for their activities. Their views received statistical support from William Farr, who demonstrated that the mortality of cholera was inversely related to elevation above the Thames river. Farr explained this relationship in terms of the miasma theory; he describes the Thames' "dark, turbid, dirty waters from half-stagnant sewers", and notes that the "wide simmering waters were breathing incessantly into the vast sleeping city tainted vapors". Like John Simon and other miasmatists, Farr was familiar with Snow's work but did not accept it; only after Snow's "natural experiment" of 1853-54 did he recognize the importance of the water supply. Even then he continued to interpret the data in terms of the miasma theory.
Why did Snow turn out to be right and Farr mistaken? In a recent article in the International Journal of Epidemiology, Donald Cameron and Ian Jones point out that "Snow used statistics to help to confirm a theory he had already established, by providing supporting evidence he could not conveniently demonstrate in any other way. He did not use the statistics to provide the theory, as Farr had done in his demonstration of an association between the incidence of cholera and height above the level of the Thames. Snow brought all his biological, medical and social knowledge into his enquiries and within medicine he deployed clinical, pathological, microscopic and chemistry skills and knowledge and of course he expressed these skills logically and where appropriate with arithmetical analysis. His epidemiology was by no means one-sided".
Cameron and Jones consider that most modern epidemiologists "are so convinced that there is an epidemiological method and that it is essentially arithmetical, probabilistic and empiricist that they miss the point of John Snow's contribution to science. In doing so they trivialize it as they trivialize epidemiology. John Snow's contribution was to evolve an elegant, internally and externally consistent theory which concerned the mechanisms and processes involved in every aspect of the subject he had chosen to study. In order to do this he did not restrict himself to any method. He used all skills available to himself and his colleagues".
The points made by Cameron and Jones are well taken. But it is not true that Farr used "the statistics to provide the theory". On the contrary, the miasma theory was the dominant explanation for epidemic disease in 1849, and Farr was simply providing evidence to support the theory. The question remains: why did Farr choose the wrong theory?
One possible explanation, that Farr was not familiar with the germ theory of disease, is ruled out by the fact that Farr discussed Henle's exposition of the theory in 1840 and rejected it. Another explanation, which tends to support Cameron and Jones' view, is indicated by Major Greenwood's estimate: "I do not think that as a pure epidemiologist Farr was so great as he was as a general vital statistician. Biologically he did not see so far ahead as either Snow or Budd. He lacked basic knowledge; he had not, like Henle or Pasteur, done any biological or chemical research work himself. Farr was neither a profound mathematician nor a gifted biologist".
The lack of a biological orientation is a serious weakness in epidemiologic research. It explains the curious resistance of eminent statisticians like Joseph Berkson, J. Yerusalmy and R. A. Fisher to the etiological role of cigarette smoking in lung cancer; they could see only the statistical issues and were blind to the plausibility of the biological mechanisms involved. Snow was correct because he based his theory of fecal-oral spread of cholera on the biological characteristics of the disease as well as its distribution among different social classes and occupational groups in the population and the multiple instances of person-to-person spread. Snow combined the biological, social and statistical approaches to epidemiology in a remarkable synthesis which solved the problem of cholera long before the bacteriologists confirmed his analysis. He accomplished this because, in his own words, "there is sufficient evidence also, I believe, in the following pages, to prove the mode of communication of cholera here explained, independently of the pathology of the disease; but it was from considerations of its pathology that the mode of communication was first explained". Snow's accurate description of the pathology of cholera, which "invariably commences with the affection of the alimentary canal", was based on his own observations and the descriptions of others; it provided a sound biologic basis for his brilliant elucidation of the epidemiology of the disease.
During the eighteen-fifties and -sixties there occurred a tremendous growth of the science of bacteriology, culminating in the seventies in the definitive proof of the germ theory of disease which Snow had so clearly formulated a quarter of a century earlier. This was not the first time that epidemiology had blazed the trail that the so-called basic sciences would follow belatedly — Lind's "Treatise on Scurvy" was published in 1753, a century and a half before the formulation and acceptance of the deficiency theory of disease.
The victory of the germ theory of disease ushered in the remarkable achievements of the first epidemiologic revolution: the conquest of many of the infectious diseases. Microbiology became the most important science in medicine, and infectious disease prevention almost the sole concern of public health.
The hegemony of the germ theory of disease meant that all diseases were to be explained on this basis, and that every effort would be made to find the organism responsible for each disease of unknown origin. The search proved extraordinarily fruitful, but its limitations also became increasingly manifest. Many diseases of consequence could not be fitted into the microbiologic mold. The continuing attempts to do so proved unproductive; they failed to produce the expected results. The germ theory was not enough; new theories of disease causation had to be developed.
As C. Carter has demonstrated, the history of beri-beri provides a graphic illustration of this process. William Anderson, one of the earliest western writers to investigate beri-beri in Japan, noted in 1876 that most Japanese doctors believed that the disease was caused by some poisonous emanation from the soil. Kamehiro Takaki, the James Lind of beri-beri, was director of the Tokyo Naval Hospital. By 1882 Takaki's observations led him to attribute beri-beri to poor diet. He persuaded the skeptical Japanese admiralty to initiate massive dietary reforms; crews were given more fresh meat and vegetables, and at some meals they were given barley instead of rice. The effects were incredible: in 1882 there were over 400 cases of beri-beri for each 1,000 men; in five years the disease was completely eliminated.
Unfortunately, Takaki's view of the etiology of beri-beri was correct in its generality and false in its specifics. His concept was that "a great deficiency of nitrogenous substances and a great excess of carbohydrates in food, is the cause." This hypothesis was not borne out by the epidemiological facts: those who contracted beri-beri often ate more and a better range of foods, including protein, than those who did not. The Lancet review of Takaki's work in 1887 observed that "the weight of evidence is still in favor of the miasmatic hypothesis."
As microbiology became more prominent, research workers sought, and generally found, the organism responsible for beri-beri. For example, Glockner identified an amoeba, Fajardo a hematozoon, Pereira a spherical microorganism, Durham a looped streptococcus, Lacerda a polymorphous ascomycete, Taylor a spirillum, Pekelharing a staphylococcus, Thomas the ancylostoma duodenale, Nephew a streptobacillus, Rost a diplobacillus, and Dangerfield an areobic micrococcus. There were many others. Theories varied: Hamilton Wright thought the portal of entry was the mouth and that the organism produced a toxin in the pyloric end of the stomach; Herbert Durham believed that beri-beri was similar to diphtheria and was spread by fomites; and Patrick Manson proposed an air-borne toxin produced by microorganisms outside the body. By 1897 Spencer wrote that little doubt remained that beri-beri is a germ-borne disease and that the causative microorganism has a specially toxic influence on the peripheral nerves. This continued to be the most common view throughout the first decade of the twentieth century; most of the standard medical texts of the period treated beriberi as infectious.
In 1897, Eijkman, a microbiologist who had studied in Berlin under Robert Koch, and who had been sent to Java in 1883 to find the organism responsible for beri-beri, accidentally discovered a beriberi-like disease in his laboratory chickens. He could find no pathogens in these chickens, nor could he infect healthy chickens by exposure to them. Further investigation disclosed that the chickens with polyneuritis gallinarum, as he called the chicken disease, had for some weeks been fed surplus cooked rice from the hospital kitchen instead of their usual diet of low-grade uncooked rice. He also discovered that the kitchen rice was polished while the ordinary chicken feed was unpolished rice. In a few trials he found that consumption of polished rice was responsible for polyneuritis gallinarum.
Eijkman's colleague, A. G. Voderman, then conducted surveys of the 27 prisons in Java where inmates were fed the unpolished rice consumed by the local population, and 74 prisons where they were fed the local polished rice. The results were astonishing; of those who ate unpolished rice only 1 in 10,000 had beri-beri, while of those who ate polished rice 1 in 39 had the disease. Subsequently, Bradon reported that in the Malay States, the Chinese, who ate polished rice, were seriously afflicted with beri-beri; Tamils, who ate unpolished rice, and native Malays, who ate rice that was not mechanically milled, were almost free from the disease.
Just as Farr had interpreted Snow's "natural experiment" on water supplies in terms of the miasma theory, so did Bradon and Eijkman attempt to explain the epidemiologic findings by formulations derived from the germ theory. Bradon proposed that a toxin was created by microorganisms in polished rice, while Eijkman considered that the toxin was produced from starch, possibly by a microorganism in the alimentary canal, or in the nerves, and that the rice husks in unpolished rice either prevented creation of the toxin or rendered it harmless.
Further work failed to confirm these theories, and by 1910 the several lines of research were converging rapidly toward a deficiency theory of disease. Whereas at the 1909 meeting of the Society of Tropical Medicine and Hygiene a clear majority were against the dietary theory of beriberi, at the 1911 meeting the consensus was reversed: Patrick Manson was practically alone in his opposition. And in 1912 Casimir Funk finally assembled the results of the epidemiologic studies, animal experiments, and chemical investigations to formulate the new theory in his article on "The Etiology of the Deficiency Diseases." Funk identified a variety of these diseases, including beri-beri, scurvy, pellagra and rickets, and stated clearly that these different diseases were due to different deficiencies. Funk also noted that about 20 years of scientific work had been necessary to establish that these diseases were caused by a deficiency of essential nutrients. The deficiency theory of disease was now in place.
But that was not the end of the story. In February 1914, when Joseph Goldberger was assigned by the Surgeon General of the U.S. Public Health Service to investigate pellagra, which had reached epidemic proportions in the Southern states, the dominant thinking in the United States was that pellagra is an infectious disease. This view had received strong support from the 1911 report of the Illinois Pellagra Commission, and from the Thompson-McFadden Pellagra Commission working in Spartanburg, South Carolina, which concluded, in its first report in 1913, that "The supposition that the ingestion of good or spoiled maize is the essential cause of pellagra is not supported by our study; and Pellagra is in all probability a specific infectious disease communicable from person to person by means at present unknown".
Goldberger came to diametrically opposite conclusions in a very short period of time. After reviewing the literature and making preliminary field observations, he concluded in June 1914 that pellagra cannot be communicable, the cause is dietary, and prevention consists of a "reduction in cereals, vegetables, and canned foods that enter to so large an extent into the dietary of many of the people in the South and an increase in the fresh food component, such as fresh meat, eggs, and milk".
In the introduction to Goldberger's "On Pellagra", it was commented that this achievement is all the more remarkable because it is based almost entirely on a chain of reasoning from three epidemiological facts which were well known to his contemporaries: (1) in institutions where pellagra was prevalent, no cases had ever occurred in nurses or attendants; (2) the disease was essentially rural; and (3) it was associated with poverty. It is not certain whether Goldberger was familiar with Casimir Funk's work at the time he developed his hypothesis. In a paper published in October 1915 on "The Prevention of Pellagra: A Test of Diet Among Institutional Inmates", he mentions "Funk's suggestion that pellagra is a vitamin deficiency, brought about by the consumption of over-milled corn", and cites as references Funk's book, Die Vitamine, published in 1914, and an article by Funk on pellagra, also published in 1914. Without denigrating Goldberger's accomplishment — for Snow on Cholera and Goldberger on Pellagra are indeed the two great classics of epidemiology — we must recognize that he was not operating in a theoretical vacuum. For example, at the meeting of the National Association for the Study of Pellagra in Columbia, South Carolina in 1912, F. M. Sandwith of England and James W. Babcock of South Carolina had raised the issue that pellagra might be due to a dietary deficiency. It is clear that both Goldberger and Snow owed much to their scientific and theoretical predecessors who had created the ideological basis for their great discoveries.
The contagionists did not give up without a struggle. In 1916, W. J. MacNeal of the Thompson-McFadden Commission launched a bitter attack on Goldberger's prison experiments with an article in the Journal of the American Medical Association on "The Alleged Production of Pellagra by an Unbalanced Diet." That same year the Thompson-McFadden Commission made its final report, stating emphatically that the disease was infectious and that the only way to combat it was with efficient sewage disposal systems. In contrast to Snow, however, Goldberger received support from leading members of the public health profession, not only from the Surgeon General, Rupert Blue, but also from David Edsall of Harvard University, Victor C. Vaughan of the University of Michigan, and William H. Welch of Johns Hopkins University. The lag period for acceptance was much shorter in pellagra than in cholera.
A hiatus now occurred in the development of non-infectious disease epidemiology. In 1927, Wade Hampton Frost, Professor of Epidemiology at the Johns Hopkins University School of Hygiene, defined epidemiology as "the science of the mass phenomena of infectious diseases", although he recognized that it was "customary also to apply the term to the mass phenomena of such non-infectious diseases as scurvy, but not to those of the so-called constitutional diseases, such as arteriosclerosis and nephritis". Frost died in 1938, and was succeeded by Kenneth Maxcy; when he took the basic course in epidemiology at Johns Hopkins in 1943, there was no discussion of scurvy or pellagra — Snow on Cholera was assigned reading, but Goldberger's epoch-making work was not even mentioned — and the course was limited entirely to infectious diseases.
Nevertheless, the study of cancer and other chronic diseases had already begun in the United States. The people of Massachusetts had "demanded with increasing insistence that action be taken, and through a legislative resolve passed in 1926 the Massachusetts Department of Public Health was committed to a program of cancer control". George H. Bigelow and Herbert L. Lombard of that Department carried out extensive investigations, both descriptive and analytic, of cancer epidemiology. Their pioneering work on "Cancer and Other Chronic Diseases in Massachusetts", published in 1933, included one of the first case-control studies demonstrating the relation of tobacco use to cancer of the buccal cavity. This study was later extended to include lung cancer, for which the same relationship was reported in 1945.
SOCIAL MEDICINE IN GREAT BRITAIN
Developments in Great Britain were somewhat different. The foremost British epidemiology text, "The Principles of Epidemiology and the Process of Infection", authored by C. O. Stallybrass in 1931, indicated by its title its total preoccupation with infectious diseases. On the other hand, Major Greenwood, Professor of Epidemiology and Vital Statistics at the London School of Hygiene and Tropical Medicine, broke away from this tradition in his text on "Epidemics and Crowd Diseases: An Introduction to the Study of Epidemiology", published in 1935. The last chapter of this book was devoted to the epidemiology of cancer, and included material on secular trends, social class differences, the greater incidence of cancer of the breast in women who have never been pregnant, and, contrariwise, the greater incidence of cancer of the cervix in married women who have been pregnant at least once, there being no relation to the number of pregnancies.
In 1943, John A. Ryle, the Regis Professor of Medicine at Cambridge, resigned his position to become the first Professor of Social Medicine in Great Britain, accepting the Chair which had just been established at Oxford University. This dramatic event signalized the leap from infectious disease to non-infectious disease epidemiology. As Ryle stated, "Public health has been largely preoccupied with the communicable diseases, their causes, distribution, and prevention. Social medicine is concerned with all diseases of prevalence, including rheumatic heart disease, peptic ulcer, the chronic rheumatic diseases, cardiovascular disease, cancer, the psychoneuroses, and accidental injuries — which also have their epidemiology and their correlations with social and occupational conditions and must eventually be considered to be in greater or less degree preventable". The British movement toward social medicine which Ryle symbolized and spearheaded was essentially a movement toward non-infectious disease epidemiology.
That movement was in a sense a resurrection of the sociological school of the nineteenth century, which had included such outstanding physicians as Rudolf Virchow and Max von Pettenkofer in Germany, Louis Rene Villerme in France, and William P. Alison in Scotland. As indicated earlier in this paper, these physicians considered that sanitary reform was insufficient, and that poverty and destitution were the primary sources of disease. Their views were sharply divergent from those expressed by Edwin Chadwick and his colleagues, who have been described by Frances Smith in her recent book on "The People's Health, 1830-1910", as follows: "The new men, S. Smith, Chadwick, Dr. Neil Arnott and other Benthamite political economists, had by the late 1830s become thoroughgoing mechanists. They projected a closed circle of causation which avoided the moral questions of deprivation and redistribution. They argued that the source of high mortality in cities was not due to want of food and greater misery, but in the generation of effluvial poisons. This conveniently narrow doctrine was to be influential for the next 100 years, and beyond".
That there was a strong flavor of class interest and prejudice in the humanitarian and reforming zeal of Chadwick and his medical experts is clear from Michael Cullen's account on "The Statistical Movement in Early Victorian Britain: The Foundations of Empirical Social Research". In a paper read to the Manchester Statistical Society, one of the members of the group, J. P. Kay, indicated his antipathy to the old poor law, stating that relief should not be given where it would not "encourage industry and virtue". Kay argued in his book on "The Moral and Physical Condition of the Working Classes" that with the continued existence of the corn laws, a reduction in the hours of labor would merely mean a reduction in wages; the answer was free trade. An educational system was also needed so that the poor would be trained to use their leisure time and inculcated with the realities of "their political position in society, and the duties that belong to it." The evils of long hours, bad sanitation, working-class agitation, improvidence and vice would disappear in this more moral society.
Edwin Chadwick, in his Report on the Sanitary Condition of the Laboring Population of Great Britain, expressed much the same concerns when he indicated "the importance of the moral and political considerations, viz., "that the noxious physical agencies depress the health and bodily condition of the population, and act as obstacles to education and moral culture; that in abridging the duration of the adult life of the working classes they check the growth of productive skill, and abridge the amount of social experience and steady moral habits in the community: that they substitute, for a population that accumulates and preserves instruction and is steadily progressive, a population that is young, inexperienced, ignorant, credulous, irritable, passionate, and dangerous, having a perpetual tendency to moral as well as physical deterioration".
The need for sanitary reform so that workers would live long enough to attain "steady moral habits" was emphasized by Chadwick. Commenting on workers' meetings in Manchester, he observed that "the bulk of the assemblages consisted of mere boys, and that there were scarcely any men of mature age to be seen amongst them. Those of mature age and experience, it was stated, generally disapproved of the proceedings of the meetings as injurious to the working classes themselves. These older men, we were assured by their employers, were intelligent, and perceived that capital, and large capital, was not the means of their depression, but of their steady and abundant support. They were generally described as being above the influence of the anarchical fallacies which appeared to sway those wild and really dangerous assemblages".
Chadwick noted that it was not only "anarchical fallacies", but "the folly as well as the injustice of their trade unions, by which the public peace was compromised by the violence of strike after strike", that older workers disclaimed. It was the younger workers, "mere boys, who were furious, and knew not what they were about".
The statements by Chadwick are consistent with the embarrassing fact that Edwin Chadwick was the Secretary of the Poor Law Commission responsible for the infamous Poor Law of 1834, which was based on these principles: (1) no relief except within a workhouse to the able-bodied; (2) such relief to be less eligible than the most unpleasant means of earning a living outside; and (3) separation of man and wife to prevent childbearing. Thus, "the approved unpleasantness of relief was to be secured by offering it only in the workhouse — the hated 'Bastille', as the poor soon learned to call it — and in addition keeping those who accepted the workhouse test in a contrite frame of mind by means of a low diet, a severe discipline, and a rigid segregation of the sexes which separated man and wife." Chadwick, the great pioneer of sanitary reform, also "made himself rightly the best hated man in England" by administering "the new Poor Law with a mercilessness which provoked widespread revolt".
William Farr did not escape this inherent contradiction. John Eyler points out that "Farr's writings reveal a genuine sympathy for human suffering, absent in Edwin Chadwick and more professionally obscured in John Simon." In 1837, Farr wrote that "even under our reform government, we blush to say that the poor and the weak, who are always least able to defend themselves, have been, in the case of the new Poor Law, very harshly dealt with." Yet he defended the law throughout his life. In the 1870s he wrote that without abuse, the Poor Law "is an insurance of life against death by starvation, and of property against communistic agitations".
The Benthamite views of the British reformers of the nineteenth century stand in very sharp contrast to those of the advocates of social medicine 100 years later. Profound political changes had occurred in the intervening century. Foremost among these was the emergence of labor as a major independent political force, with the result that intellectuals who in the previous century had to choose between Tory landowners and middle-class Liberals, now found the alternatives to be Conservatives versus the Labor Party. The concomitant growth of labor and socialist ideology among both workers and middle-class professionals created an intellectual climate concerned with the societal causes of social problems. It was this intellectual climate that produced the movement toward social medicine, the extension of epidemiology to become concerned, in Sir John Ryle's words, "with all diseases of prevalence, which also have their epidemiology and their correlations with social and occupational conditions and must eventually be considered to be in greater or less degree preventable".
The connecting link between infectious and non-infectious disease epidemiology in Great Britain was Major Greenwood, Professor of Epidemiology and Vital Statistics at the London School of Hygiene; President of the Royal Statistical Society; primary author, with Bradford Hill, Topley and Wilson, of the pioneering work on the "Experimental Epidemiology" of infectious diseases; and author of "Epidemiology and Crowd Diseases: An Introduction to the Study of Epidemiology", the first textbook to include cancer in its scope.
Major Greenwood was also a founding member of the Socialist Medical Association, organized in 1930, which was very closely associated with the British Labor Party, and which was largely responsible for that party's decision to establish the British National Health Service. David S. Murray, that remarkable Scot who served as President of the Socialist Medical Association for almost 20 years, paid tribute to Major Greenwood, in his history of the S.M.A., as a founder member who "had been a tower of strength whenever public health and statistical studies of disease were discussed. He had a considerable influence in changing attitudes towards social epidemiology".
Sir Richard Doll, one of the great pioneers in non-infectious disease epidemiology, also played a significant role in the Socialist Medical Association. At the Annual Conference of the S. M. A. in 1946, after Aneurin Bevan had introduced the National Health Service bill with compromises that the S.M.A. considered unnecessary, it was Richard Doll who seconded the resolution that passed unanimously, welcoming the National Health Service bill, accepting the tripartite administration of the NHS as a temporary provision, asking that the bill permit all general practitioners who wished to be paid by salary to have that right, and urging that an occupational medical service be added.
Obviously, the movement toward social medicine in Great Britain included individuals comprising a broad spectrum of political and social viewpoints. Yet there can be no doubt that the general intellectual and political developments indicated above played a significant part in the growth of social medicine and non-infectious disease epidemiology in the U.K., and, probably to a lesser extent, in the United States and other countries. Many years ago, at one of those marvelous IEA. meetings on the Adriatic Coast of Yugoslavia, J. Lee expounded his hypothesis that individuals involved in social medicine in the U.K. tended to fulfill at least two of three conditions: (1) they were pro-Labor; (2) they were Scots; and (3) they had done something else before entering medicine. He assured that the hypothesis stood up rather well when tested; I regret to state that I have never mustered the biographical knowledge required to check its validity.
SECOND EPIDEMIOLOGIC REVOLUTION
A conceptual dedication to the concern of social medicine with non-infectious disease epidemiology — with the effects of social, environmental, and occupational conditions on "all diseases of prevalence" — was not enough, however. Victories had to be won. Methodological tools had to be developed. The citadels of conservatism in the medical schools and the schools of public health had to be conquered, and a whole generation had to be trained in the new epidemiologic concepts and approaches.
Perhaps the most important single factor in the triumph of the new epidemiology was the cigarette smoking lung cancer controversy which began in 1950. Almost the entire methodological instrumentarium of non-infectious disease epidemiology was developed in the course of the fierce battles between the Berksons and Yerusalmys on one side (not to mention the hired hands of the tobacco companies), and the Cornfields and Lilienfelds on the other. The strengths and weaknesses of retrospective and prospective studies, of observation and experiment, were fully elucidated during the course of these intellectual struggles. Furthermore, the primary role of epidemiology in achieving this scientific breakthrough received national and international attention. Funds were freed up for epidemiologic training and research. In the United States, the replacement of the infectious disease-oriented chairs of epidemiology in the schools of public health with representatives of the new approach — a process which took several decades to complete — was begun at Harvard in 1958 with the appointment of Brian MacMahon, an import from England who had been a fellow in social medicine with Thomas McKeown in Birmingham. The first textbooks of epidemiology based primarily on non-infectious disease appeared: Morris's "Uses of Epidemiology" in Great Britain, 1957, and MacMahon, Pugh and Ipsen's "Epidemiologic Methods" in the United States, 1960.
The Society for Social Medicine in Great Britain, and the International Epidemiological Association, organized in the 1950s, and the Society for Epidemiologic Research in the United States, organized in the 1960s — associations which were devoted primarily to non-infectious disease epidemiology — grew rapidly in numbers and influence. Young people flocked to the field, responding to the increased opportunities for training and research and to the excitement of the rapidly growing list of accomplishments of the new epidemiology, such as determining the effects of radiation on health, elucidating the etiology of ischemic heart disease, demonstrating the value of fluoridation in the prevention of dental caries, and establishing the relation of cigarette smoking to chronic obstructive lung disease.
Epidemiology now moved to take all disease and injury as its province. Freed from the bonds of limitation to the infectious diseases, epidemiologists began to study numerous sites of cancer, as well as diabetes, hypertension, arthritis, duodenal ulcer, cirrhosis of the liver, mental illness, suicide, accidental and other injuries, occupational disease, the effects of environmental pollution, and even iatrogenic diseases. They have further dared to question established clinical procedures such as radical surgery for breast cancer, and surgery in the treatment of lung cancer, subjecting increasingly large portions of conventional medical therapy to the critical tools of the epidemiologist in order to determine their effect on disease outcome. Indeed, the epidemiologists have gone beyond disease to study the epidemiology of health, that is, of human vigor, vitality and performance, through such studies as the recent investigations of the effect of maternal and child nutrition on physical growth and mental performance. And they have now begun the important task of subjecting current methods of organizing medical care to epidemiologic scrutiny and evaluation, that is, by determining the effect on outcomes, on the health of the patient.
The epidemiologists have succeeded in giving public health workers powerful weapons to prevent many of the major causes of illness, disability and death. This is already reflected in the 25% decline in age-adjusted mortality from ischemic heart disease in both Canada and the United States during the 1970s, and the 30% decline in Canada and 38% decline in the United States in age-adjusted mortality from cerebrovascular disease during the same decade. It is also reflected in the decline in mortality from cirrhosis of the liver in the United Kingdom, from 10 per 100,000 in 1914 to the current rate of less than 4 per 100,000, and more recently, the decline in the cirrhosis death rate in Cuba from 10 per 100,000 in 1964 to less than 6 per 100,000 in 1978.
These reductions are not limited to mortality; they hold also for morbidity, that is, for illness and disability as well as for death. The unprecedented declines in cerebrovascular disease mortality did not result from improvements in the treatment of cerebrovascular disease in the 1970s, for no such improvements occurred. Clearly the cause of the decline was increased public and professional awareness resulting in better case-finding for hypertension, the increased use of antihypertensive drugs, and the more effective maintenance of hypertension treatment and control. This was primary prevention of cerebrovascular disease; not only mortality was affected but incidence as well.
Similarly, primary prevention was mainly responsible for the approximately 25% decline in age-adjusted mortality for ischemic heart disease in North America in the 1970s. In view of the fact that 60 to 67 percent of deaths from myocardial infarction occur outside of hospital, while improvements in medical and surgical therapy have been shown to exert only a moderate effect on survivorship, treatment cannot be considered to have played a major role in the decline. On the contrary, all of the evidence points to risk-factor changes as the most important element in this unprecedented reduction.
Nor can we consider the remarkable reductions in mortality from cirrhosis of the liver in Great Britain and Cuba to reflect therapeutic advances, which have been minimal indeed. During the same period, Canada and the United States, which would be expected to make effective use of advances in treatment, have had no reductions in mortality; the cirrhosis death rate has remained stationary in the United States, while it has risen to alarming levels in Canada.
During the coming period, a lower mortality is expected not only from infectious diseases — still the major causes of illness and death on a world scale — and from cerebrovascular disease, ischemic heart disease, and cirrhosis of the liver, but also from accidents, poisoning, and violence; from lung and other cancers caused by tobacco, alcohol, and other environmental and occupational carcinogens; and from chronic lung disease caused by cigarette smoking and by the occupational exposures of miners, textile workers, grain workers and others exposed to harmful dusts. We shall also be effective in reducing mortality from a variety of other diseases caused by toxic chemicals and other environmental and occupational hazards. These victories will be accomplished by primary prevention, by methods which, unlike medical care, reduce incidence as well as mortality. We shall also make effective use of screening programs to discover cervical and breast cancer in the pre-symptomatic stage, thereby also preventing illness as well as mortality.
To implement the programs to prevent these major causes of illness, disability and death will require sustained and well-funded campaigns, led by local, state, provincial and national health departments. "Well-funded" in this case requires only a small fraction of the many billions of dollars which are now spent for the treatment of these preventable diseases.
Implementation of this program is not only a question of achieving a higher level of health, but of achieving equity in health. Just as national medical care programs have been established to assure equity in medical care, so must this aim be pursued for the more fundamental goal of improving health status. The available evidence indicates that life-style modification has been more effective in the more highly educated groups, who now smoke less, drink less, are less overweight, and exercise more. It is essential, therefore, that every effort be made to reach the less highly educated groups that comprise the majority of the population in order to make certain that WHO's Alma-Ata pledge of "Health for All by the Year 2000" is indeed fulfilled for all the people.
HISTORICAL RETROSPECTIVE ON PLAGUE
Plague is one of the best-documented of all the pests of antiquity — and that from literary as well as medical sources. In discussing this documentation, however, several cautions must be observed. First, many things called "plague" were probably other diseases; in fact, some historians have maintained that the word "plague" merely meant any disease which killed large numbers quickly. Second, it must be pointed out that small reliance can be placed in statistics up to the nineteenth century. The concepts of statistical reasoning appear to be those of a sophisticated population. Just as the astronomical figures of the present federal budget do not mean much to most Americans, so to the ancient Romans, the word for six hundred came to mean any large number or infinity. And, finally, it must be remembered that writers attempting to give a picture of a period are more interested in the effect as a whole than in the accuracy of the details. "To add artistic verisimilitude to an otherwise bald and unconvincing narrative" is the prerogative of writers both before and after Pooh-Bear.
The greatest literary descriptions of the plague which have come down to us are those of Thucydides, Petrarch, Boccaccio, Evelyn, Pepys, and Defoe; but many just as vivid descriptions are buried in works not so well known. Nohl has compiled over 250 pages of contemporary descriptions of the plague, while Hecker, Sticker, and Crawford have also collected writings on the subject. To untangle the strands so many hundreds of years later is exceedingly difficult.
Because the plague which hit Athens during the Peloponnesian War does not really come into the period under discussion here, it is only necessary to report that it probably was not bubonic plague but a pneumonic plague, or perhaps even typhus fever. Several features which distinguished the Athenian plague from the bubonic plague of the Middle Ages might be mentioned. No buboes were reported; instead, there was high fever, redness, bilious vomiting, hoarseness, and pain on respiration; there were petechiae throughout the body, and great restlessness of body and mind. However, individuals did recover from this disease, which is rare in descriptions of bubonic plague; and these individuals are described by Thucydides as those in whom the "sick and dying found most compassion." Those who had recovered, also, were immune from a second attack; while another feature which distinguished this epidemic from the later ones was the disappearance of the animals who were the transmitters of the fleas carrying the plague.
In the medieval plagues, it is to be noted, the epidemics usually started at a seaport, where a ship carrying goods from the Orient ("reservoir" of Geddes Smith) docked with one or more sailors or passengers ill with the plague. All accounts speak of the speed with which those who came in contact with the travelers sickened and died in turn. This leads us to the conclusion that plague was a comparatively new disease to Europe, for which people had little immunity; and also that the necessary means for the spread of the plague (rats with fleas, overcrowding, malnutrition, and poor sanitary conditions) were already present when the first dose of the infection was received. That the plague was usually spread by sea routes is shown by the travels of the disease through what is now Russia. One outbreak of the plague started at Caffa on the Black Sea in 1346; from there it went to Constantinople; and from here it was dispersed throughout the seaports of Europe by the galleys that traded at Constantinople. Northern Russia, indeed, received the plague not from Caffa (for the steppes were efficient barriers to the chain reaction where settlements were distant from one another and travel was light), but years later from northern Germany and Poland.
The description of the plague given by Boccaccio can be allowed to stand for all the plague outbreaks. The first signs were the plague boils or buboes which appeared in the armpits and groin; later black or livid blotches were seen throughout the body; and both of these signs appeared to be forerunners of certain death. No medicines were of any avail, and practically all patients died within three days of the first symptoms. The obvious contagiousness of the disease resulted in many inhumanities; people would not take care of the sick, and many died merely of starvation. Throughout the chronicles, from one end of Europe to the other, we hear the lament: Parents will not visit their children, nor children their parents. Many shut themselves up in their own houses and would not stir; others sought refuge in flight from the afflicted cities, thereby spreading the disease enormously. The dead were not buried with any of the pomp of former times; later the dead were not buried at all, except for the large plague pits in which hundreds were thrown helter-skelter. At Avignon, for example, the Rhone had to be consecrated for burial purposes, and the smell of decaying corpses is recorded in practically all descriptions of the disease.
The only method of combating the disease was by flight and (conversely) by quarantine; and the conflict between those who were attempting to flee the desolation and those who were determined to keep visitors from the plague cities out of their towns was almost as fatal in some cases as the original disease. Those who had to remain in infected areas covered themselves completely (beak doctors) and held aromatic herbs and vinegar sponges to their noses. While of help psychologically, these methods do not seem to have been very successful. Defoe tells of the butchers who would not even touch the money paid to them, but had the customers throw it into jars of vinegar kept for that purpose. Yet Defoe remarks, "The plague raged so violently among the butchers that it was not advisable so much as to go over the street among them." Later large cities, such as London and Paris, marked all houses where the plague cases were present (see Pepys’ red cross and the words, "The Lord have mercy upon us," and Defoe’s reproduction of the Lord Mayor’s rules on marking the houses and stationed guards at the entrances to these houses to keep all inhabitants strictly within doors.
The luckiest were those who could retire to healthful country estates and hold no communion with the cities. Boccaccio’s seven young ladies and three young men were some of these; they retired to the country, ate daintily, and amused themselves by telling stories. The Pope at Avignon retired within the Papal palace and allowed only a few to visit him. The "I" of Defoe’s tale hides his family safely within the house and does not allow them to venture forth.
How many actually perished of the plague at any one time or over a long period of time? This is a very difficult thing to decide in virtue of the medieval tendency to use round numbers and gross exaggerations. Thus we are told, "nine-tenths died," or "scarce one-tenth remained alive," or "scarce a quarter of the population remained at Avignon," or "seventy died of every hundred," "half and more are believed to have died." A very interesting method of counting the mortality has been worked out by Colton who examined the English episcopal registers for the number of priests dying, resigning, being replaced, etc., during the plague years. While taking into account the fact that the priests lived better than the general run of the population but had to visit more sick people than most of the population, Colton concludes that the mortality was probably close to one third the population. This is probably as near as we can now come to an estimate of plague mortality.
What results did the visitations of the plague have on people? First there was fear. People were afraid for their own lives, and all else went by the boards. Inhumanities are reported from all parts of Europe. Among them was lack of attention to sick people, including the flight of physicians and priests; the breakdown of family ties; and the desire to find a scapegoat. This last resulted in two very different acts, one the flagellants, the other the persecution of the Jews.
The flagellants were individuals who gave up their accustomed lives for a wandering life of 33 1/2 days (representing the 33 1/2 years of Christ’s life on earth) during which they scourged themselves and exhorted all to repentance. Although today we think of flagellation as a sexual aberration — and this was probably true in medieval times to a certain extent — it must also be emphasized that here we have for the first time a lay attempt at divine help by people who were deeply disappointed by the emptiness, the formalism, and even the lasciviousness of the contemporary church. It may, indeed, be considered a forerunner of the Reformation.
Where the rumor first began that the Jews were poisoning wells is hard to say, but it probably came from that group of superstitious, ignorant people who believe any dramatic story, no matter how fantastic. Probably the rumor sprang up from this source in many countries at about the same time, together with a belief in an order which the Chief Rabbis of Toledo are supposed to have given for poisoning wells throughout Europe. There was also supposed to be a series of orders for forging the currency, the ritual murder of Christian children, and the like. Jews were tortured until they confessed and some of their confessions are wonderfully imaginative documents which might be compared with interest with those of the Salem witches. From their confessions they were then burnt at the stake. In 1348 the Pope issued two bulls forbidding this practice but his words were flagrantly disregarded. In Strasbourg, for example, the populace stood up for the Jews, but the Bishop insisted that all who did not vote for the extermination of the Jews were in league with them and worthy to be killed also. However, burning at the stake was one of the best ways to die — the chronicles of the Jewish communities of Nurnberg, Speyer, Maine, Esslingen, and other German towns read something like the battle of the Warsaw ghetto. Altogether about one half of all the Jews of western Europe perished as a result of these persecutions.
One of the greatest changes wrought by the plague was in the economic sphere. Because there were fewer artisans left after the epidemics, the positions of these people became better. They could ask more for their labor and get it, and they could lay down rules for themselves and all who worked in guilds with them. When the nobles and the clergy attempted to turn back the clock to pre-epidemic times, many Peasant revolts resulted; and although most of these were put down bloodily, the uprisings paved the way for the economic reforms of the following centuries.
In the sphere of religion, too, the Black Death brought in a more questioning attitude than had prevailed before it. During the epidemics it had been strikingly brought to the attention of the ordinary man that the priesthood was composed of men like himself, who feared death as he did, who demanded higher wages for work when they could get it, and who even went on strike in times of universal distress. It is not surprising, therefore, that a demand for reform within the Church was heard everywhere. The Lollards, those harbingers of the Protestant Reformation, are described by a contemporary thus: "They multiplied exceedingly, like budding plants, and filled the whole realm everywhere, and became as familiar as though all had come forth upon the same day." The Black Death, it has been said, brought man and God together again.
While the plague cannot really be said to have caused any of the changes which followed it — whether in a religious, artistic, or economic sense — it came when the countries of Europe were prepared for a change, and it swept all before it as if it were a flood tide. Pasteur’s remark that "chance favors the prepared mind" can be paraphrased here. The chance of the plagues of the Middle Ages resulted in upheavals in the socio-economic religious life of Europe which would probably have come about in any case, but which, without the plague, would only have come about at a greatly reduced speed.
PLAGUES AND MORALITY IN EARLY MODERN EUROPE
To understand the obligations of medical practitioners during plague epidemics in early modern England, we need to begin with the general debate on the ethics of flight from plague. This was conducted in the plague tracts that appeared in large numbers across Europe from the fourteenth to the eighteenth centuries. The debate centered on a moral and physical quandary. There was widespread, if not total agreement that flight was the best preservative against plague, and there were clear scriptural injunctions to use all available means to preserve life (these were, after all, the gift of God). However, flight meant abandoning the sick and poor, thereby transgressing against the key Christian duty to love one's neighbor. The acceptability of flight thus presented a frustrating, probably irresolvable, question of conscience.
For medical practitioners in early modern England, the decision to flee from plague was a moral problem which they resolved on an individual basis in the same way as most of their contemporaries. Unlike clergymen and magistrates, they faced no generally recognized special obligation to remain at work during an epidemic. However, during the seventeenth century, practitioners, particularly those outside the corporate system, were increasingly using plague practice as a way to establish a reputation and, within London, as a strategy in regulatory disputes with the College of Physicians. Even if flight could be justified, the polemics of irregulars could easily exploit the gap between cautious departure and heroic staying.
This broad tradition of opposition to the College of Physicians through arguments centered on plague practice was manifested principally in petitions and legal disputes. However, during and after the epidemic of 1665, it was articulated in print at greater length and with more ambition than ever before, as it was appropriated by the organized and vocal medical opposition which had emerged to the College. In large part, this can be seen in protestations of a group of chemical physicians, advocates of a new theory of medicine derived from the writings of Paracelsus and van Helmont, who were campaigning to replace, or at least co-exist with, the College of Physicians. Their discursive use of plague and flight in some of the flurry of printed tracts they produced allows us to see in more detail how some of the representations of plagues in this period were shaped for very pragmatic purposes.
The chemical physicians had incorporated plague into their dispute strategy even
before it arrived in England. Early in 1665, while plague remained restricted to
the Low Countries, their chief pamphleteer, George Thomson, correctly predicted
that the College physicians would ‘run out’ if plague appeared in London. His
claim provoked vigorous denials from William Johnson, the chemist who ran the
College's own laboratory. These proved futile, however: when plague arrived,
the majority of the College physicians departed. Thomson therefore dedicated
much of "Loimologia" (1665), his next pamphlet, to an attack on the flight of
In "Loimologia", Thomson offered his own decision to remain in London as an exemplary alternative to flight, the option Galen had himself advised and taken: ‘although I could enjoy my ease, pleasure, and profit in the Country, as well as any Galenist; yet I would rather prefer to loose my life, then violate in this time of extreme necessity, the band of Charity towards my neighbor, and de-decorate that illustrious profession I am called to, in hopes to save myself ... according to that infamous, and insidious advice which Galen hath given his disciples’.
Thomson's evocation of charity, responsiveness to emergency and Christian neighborliness drew upon the standard irregular framing of plague practice. He linked this to several of the most commonplace tropes of anti-Galenist polemic: the pagan origins of Galenic medicine, the greed of physicians and the questionable civic loyalty of the College were charges of long standing.
In presenting plague practice as a moral norm rather than a sign of exceptional virtue and skill, Thomson set out an unusual vision of the ethical obligations of medical practitioners that conflicted with the general acceptance of their freedom to flee plague. Thomson's position imitated van Helmont's own defiance of plague, just as his medical practices followed his theoretical model. Significantly, by drawing a parallel between physicians and priests, it also allowed him explicitly to extend plague practice from a strategy to improve his own reputation into a weapon against the reputation of the College of Physicians.
It was not until the early nineteenth century that the idea of physicians having an ethical duty to care for the sick during epidemics became generally diffused, let alone accepted, in the English speaking world as part of the creation and dissemination of an ideal type of moral profession capable of self-regulation and deserving of concomitant respect and rewards. With this development, the history of plague epidemics was reinterpreted to provide examples of virtuous doctors who could exemplify the new ethics. The analysis of flight presented here underlines the great differences which separate modern ethical responses to epidemics from those of the early modern period. Retrospective moral diagnoses are all too easy, and all too treacherous, as was underlined in recent attempts to sift the records of early modern plague for guidance on ethical duties in the face of a more modern epidemics.
"Loimologia, or, an historical Account of the Plague in London in 1665, with precautionary Directions against the like Contagion" is a treatise by Dr. Nathaniel Hodges (1629-1688), originally published in London in Latin (Loimologia, sive, Pestis nuperæ apud populum Londinensem grassantis narratio historica) in 1672. An English translation was later published in London in 1720. The treatise provides a first-hand account of the Great Plague of London; it has been described as the best medical record of the epidemic. While most physicians fled the city, including the renowned Dr. Thomas Sydenham and Sir Edward Alston, president of the Royal College of Physicians, Hodges was one of the few physicians who remained in the city during 1665, to record observations and test the effectiveness of treatments against the plague. The book also contains statistics on the victims in each parish.
The English translation (1720) was released while a plague was spreading throughout Marseilles, and people in England were fearful of another outbreak. To this 1720 edition was added "An essay on the different causes of pestilential diseases, and how they become contagious; with remarks on the infection now in France, and the most probable means to prevent its spreading", by John Quincy.
Samuel Pepys, who because he was a magistrate also stayed, was one of Hodges' friends. His medical records which included survivors as well as deaths, supplemented the Bills of Mortality.
"Loimologia" was one of the sources used by Daniel Defoe when writing "A Journal of the Plague Year" (1722).
Pictures 1 & 2: We are not inclined to give definitive judgments on people and events described in this book. As we already said, it is not a reliable and trustworthy source for epidemiology science. Moreover, data on principal leading figures from close proximity past has revealed thwarting with available material in our personal archive. We present the images of Dr. Ivan Golosmanov and Dr. Petar Verbev for the sake of the protocol, ditto.
(i). Dr. Ivan Golosmanov /1874-1941/.
(ii). Dr. Petar Verbev /1891-1977/.
Copyright © 2008 by the author.