LECTURE 3

1. LECTURE 3 Public Health to Modern Medicine

2. Overview. • McKeown- medicine and public health • development of modern medicine and the hospital • why did public health became such an important issue? • The question of progressive emancipatory ideals. • The question of the ‘nation’ • the bureaucratisation, rationalization and professionalisation of medicine • the medicalization of everyday life.

3. Public Health to Modern Medicine • The taming of disease • McKeown -medicine played no role before 18th century • for most of history medicine about helping to maintain health and comfort the sick • Medical ‘expert’ opinion unreliable and unscientific for much of human history • Enlightenment changes this • increasing confidence • Idea that we have increased control over our health

4. Public Health and Public Awareness. • Increased awareness of relationship between diseases and their causes. • importance of hygiene • application of this knowledge to organising society • 1860s a watershed. • between 1870 and 1914 issue of public health linked to preventing disease. • city life and health since (John Hogg 1830) • Charles Booth (1880) - one quarter of London living in poverty • Joseph Rowntree (1890s) - calorific intake and health.– Gender and childhood inequality

5. Health as a National Concern 1 • Boer War 1899 • Manchester 8000 out of 11000 volunteers lacked basic fitness • Chronic malnourishment-35% unfit to fight • leads to idea of racial degeneration (Neo Darwinist ideas)

6. Health as a National Concern 2 • Issue of physical degeneration put the public health administration on the defensive • Govt committee on physical degeneration • committee report in 1904 • Health as a class issue • Health as a national/racial concern • Emergence of NHS

7. New scientific approaches to public health • 19th Century Epidemiological surveys, disease surveillance, and statistical analyses integral part of managing public health. • Epidemiology and causes of disease • Looking for patterns. • certain segments unusually vulnerable • Measles most common among children, • lung cancer among smokers, • Until recently it was thought AIDS among gay men or drug users

8. Early epidemiological Discoveries 1 • Percival Pott in 18th Century- chimney sweep and cancer of scrotum • James Lind (1716-1794) and scurvy • (But what could it be – sea water? Touching sails? Millions of things – shows the difficulty) • But often difficult to isolate ‘causes’

9. The Broad Street Pump • John Snow (1813-1858) -Cholera. • His study pointed to drinking water as the cause • The Broad St pump is an obligatory part of medical education now • Use of statistics/ experiments and observations • In modern world- rarely a mono-causal explanation • so many variables. • Environment an example

10. James Le Fanu • against epidemiological studies of small hazards • “The simple expedient of closing down most university departments of epidemiology could both extinguish this endlessly fertile source of anxiety-mongering while simultaneously releasing funds for serious research” (Le Fanu 1999: 3).

11. The Role of Medical Technology • Stethoscope (1819) • thermometer use widespread by 1920s. • x rays (1895) • electrocardiagraph (1901) • a new objectivity?

12. Story of x-Rays • X-rays discovered 1895 - Wilhelm Roentgen (Bleich 1961). • important innovation for the whole future of medicine, • Impact was huge • But ambivalence around this technology • Scientific American described a breakthrough so revolutionary that it: • “almost dangerously increases our power of belief” (cited in Knight 1986: 13). • Frankenstein technology!

13. Was Mc Keown Wrong? • Developments in surgery in late 19th century • Chloroform anesthesia (1850s) • invention of artery clamp and antiseptic • Before 1860s surgery essentially an emergency procedure • After 1860 became increasingly constructive • by 1900 performing operations that enhanced quality of life

14. Medicine and the Wars • role of medicine in the war effort. • new preventative medicine changes patterns of mortality • emergence of reconstructive surgery. • post WW2 period the transformation even more marked than around WW1. • transformation in organization of medical services • hidden legacy of war- eg German and Japanese P.O.W camps and medical

15. Medicalization of Society. • changes in social attitudes • The Health Society? • Health obsessed in modern world • Everyone as expert • greater uncertainty and anxiety • Is this about health or beauty? • 'Fear of Ageing' report (2002 Datamonitor) -average spending on 'fountain of youth products’ £75 per head

16. `Getting better’ but ‘feeling worse' ? • more people register at gyms but life more sedentary • not leading to better contentment • Question of ever-increasing demands • Dalyrymple ‘greater supply leads to greater demand’ • Impact on medical profession. • Doctors are also unhappy.

17. ‘The BMJ's editor has argued that doctors are profoundly disaffected from the character of modern medicine ‑1'000's of respondents to the editorial in BMJ in May 2001 indicated that even American doctors are very unhappy with the profession’ ( Nigel Edwards, policy director of the NHS Federation, writing in the BMJ on 5/4/02).

18. Professional Perspectives • Heavy workload • less autonomy in group practice • government regulation, • a growing blame culture • less respect • Doctor as ‘monster’ • anxiety and alarm around medical treatment.

19. The Role of Sociology 1 • Questions around issues of power • Questions around roles • suspicion of the claims of progress. • Postmodern theory • Erosion of trust

20. The Role of Sociology 2 • For Parsons a central role for medicine in maintaining the stability of society. • Positive functions of medicine for society. • Medicine no longer seen this way • For Marxists an institution of the superstructure. • Interactionist and labelling theorists object to the power of the medical establishment their ability to determine who or what constitutes sickness • Weberian sociology links medicine, power and status

21. Freidson ‘medicine’s success in gaining power and recognition over competing approaches to healing such as homeopathy had little to do with it possessing essential or particularly valid knowledge. It achieved success by having it's definitions of health and illness and treatment accepted as being the only legitimate ones’.

22. Medicine, medical experts and Professional Monopoly • 1858 medical Registration Act • 1911 health Insurance Act • 1946 National health act -all 'unqualified' professionals squeezed out of practicing. • process of professionalisation central to consolidating medical power. • medicalization from above

23. Health As the new religion (Dalrymple). • Zola doctors as the new priests • Gym is the new church? • Link to consumption and lifestyle • Consuming health • a secular theodicy

24. Modernity and Medicine • Undermining of traditional religious discourse. • Scientific explanations over supernatural • Little concept of a great scheme of things- deconstruction of whatever scheme we have held in our minds. • Desire to calculate, predict, control aspects of human behaviour • Weber Disenchantment of the world- loss of magic, mystery, prophecy and the sacred • Affects private as well as public lives • Society more atomised- broken down to it’s smallest parts rather than everything having meaning in a wider context.

25. Health Obsession as a panacea • Self help attract the powerless. • Gives meaning/message, offers compensation. • looser affiliations to fit with modern life. • Need for community in individualistic world. • Crystal healing/spiritual healing/divination/tarot- You can buy into health • Pseudo spiritually- pick and mix approach, supermarket of ideas, fits with consumerist ethos of mod society • Greater choice/autonomy/ Not dogmatic • Can be more flexible about what you believe. • Belief has become more significant than belonging