Some historians of medicine seem to imagine readers who have time on their hands. John Burnham’s new book, Health Care in America: A History has a compact title, but when it comes to the page count it’s up there with three famous volumes of the past thirty-five years: five hundred and ninety-six pages of narrative and notes.  It does not seem out of place in that company. (Charles Rosenberg, The Care of Strangers; The Rise of America’s Hospital System ran 437 pages, Paul Starr, The Social Transformation of American Medicine; The Rise of a Sovereign Profession and the Making of a Vast Industry, was 514 pages and Roy Porter, The Greatest Benefit to Mankind; A Medical History of Humanity clocked in at a monumental 831 pages.) 

Why not try a comparative reading of them all?

Burnham’s project is to describe how medicine in America passed from a “traditional” era, through a “modernizing period” and into “a whole new epoch” in which health care has been transformed from a “personal or at most a neighborhood concern” into a “gigantic system that engage[s] a sixth of the productive effort of the nation’s 300 million people.”  It’s not a daring or innovative interpretive scheme; what distinguishes this work from those mentioned in the opening paragraph is the emphasis on “how.”  This is not a social history, a history with something to prove, a work laden with or informed by—the choice of terminology of course implies a position–theory.  Burnham thinks of historical narrative as a river.  He largely avoids, “side eddies and countercurrents,” comparisons with medicine in other parts of the world, controversy.

The author aims for dispassionate balance.  “Bloodletting,” says Burnham, “requires special comment, for it has been greatly misunderstood.”  Taking blood had soporific and anti-inflammatory effects which, “may in part explain the successes of earlier physicians who bled patients but were restrained in their use of the procedure.”

May explain…also, possibly, may not.   

Here is how Burnham introduces the question of the white man’s responsibility for disease and death among Native Americans.  “Almost all scholarship on Native American peoples has become extremely controversial, but some basic facts seem to have survived.  The various Amerindian tribes, or nations, already were living close to nature in 1607, many picking up the increased vulnerability to disease that comes with the transition from hunter-gatherer societies to settled agricultural communities, where pathological organisms found more chances to thrive and spread.  Moreover, the Amerindian societies were already undergoing other major changes.  Some groups were shifting their internal social arrangements, and some were conquering or displacing or trading with others.  To all of these struggles was now added the sudden intrusion of Europeans, who brought not only guns and destructive alcoholic beverages but also diseases.”  No “Jeffrey Amherst was a bad man who wanted to give the Indians smallpox-laden blankets” here. History with nuance and complexity.

Once in a while Burnham inserts an opinion, but even then it is hard to decide where he stands.  On the one hand, “The historical verdict from…[the late nineteenth century]…is remarkably clear: subjecting health care to free-market forces ultimately does not work.”  And on the other, “no one then [at the opening of the twentieth century] thought it strange that wealthy patients had comfortable accommodations, services and privileges or that the poor were crowded into wards and kept under strict discipline.”

Yet there is a politics to and a geographical concentration in this book.  Western radicals like Dr. Marie Equi are left out.  There is room in the main current for, “the famous Doctors’ Riot in New York City in 1788,” which was “famous” not because antagonism between medical students and the general public over ill-treatment of corpse parts was highly unusual, but because it happened in New York. 

Burnham makes room for homeopathy and hydropathy and osteopathy and much that throws light on the origins of today’s complex marketplace. He has a eye for the sort of thing that sticks in your mind: one Civil War sanitary inspector suggested that if one detected “dirt at one end” of a soldier, one would find, “cowardice at the other.”  And Pasteur’s success in treating children who, having been bitten by rabid dogs, were sent from New Jersey to France for inoculation, resulted in New Yorkers rounding up paying customers to view the miraculous survivors.

NewYork, New York. 

Many souvenirs are available to those on the long journey through this book.  Occasionally a simple fact stands out: “around 1920 the incidence of chronic diseases began to exceed that of acute, usually infectious diseases among Americans, although almost no one at that time noticed…”  Or a photograph: here is a band of wind instrument players under a banner that reads, “Come with us to a Tuberculosis Mass Meeting.”

Of course it would be a very unusual long work if an unfortunate word choice did not catch your eye at least once: at the top of a page the Influenza Pandemic of 1918-1919 is fully described.  After it’s revealed that American deaths were approximately 550,000 or one half of one percent of the population, the next section begins, “Quite aside from the influenza incident…”  Incident!

It is when the current washes into the complex estuary that the important questions surface: how did we come to such a peculiar and complex present, and is there hope for the future of American medicine?  Burnham says we have reached what Dr. Jason Karlawish describes as the era of “desktop medicine,” medicine delivered in front of and even through a computer screen.  And this means?  To the end Burnham goes for balance.  He says it’s possible to read the history of medicine as one that raises the question, “whether the whole, ultimately gigantic effort, was not misdirected.”  But Burnham actually concludes, “Perhaps without anyone’s intending it, the story can be inspiring.”

To all? 

It wasn’t just Native Americans who died.  Europeans landing in colonial America brought diseases with them, but they also fell prey to fevers that were endemic or had arrived from other parts of the world.  They came to expect the “flux” or diarrhea, which might prove fatal.  Immigrants called this early adjustment period, “The seasoning.”  Surely everyone can celebrate a farewell to that?

 

© 2015 David Ritchie

 

David Ritchie, Professor of History, PNCA.