Social Medicine Dr. Dennis Raphael- Canada

Dr.Alejandro Wajner:

I very much look forward to your new project Critica Medicina. I expect
that much of its content will be concerned with how economic and social
conditions -- the social determinants of health -- influence the health of
citizens. Interestingly, the idea that economic and social factors
determine health has a long history. Such ideas need to be rediscovered
ansd applied to contemporary health issues.

During the mid 1800's political economist Frederich Engels studied the
health conditions of working people in England and identified the factors
responsible for social class differences in health. His 1845 work, The
Condition of the Working Class in England, describes the horrendous living
and working conditions which workers were forced to endure (Engels,
1845/1987). Engels showed, as one of many examples, how profoundly
different death rates within a suburb of Manchester were directly
correlated with quality of housing and quality of streets. He was
remarkably perceptive in identifying the mechanisms by which disease and
early death came to the working classes. He described how material
conditions of life - poverty, poor housing, clothing, and diet, and lack of
sanitation -- directly led to the infections and diseases common among the
poor. Engels also explored how the day-to-day stress of living under such
conditions contributed to illness and injury. The adoption of
health-threatening behaviours such as
drink was seen as means of coping with such disastrous conditions of life.
Engels concluded:

"All conceivable evils are heaped upon the poor?They are given damp
dwellings, cellar dens that are not waterproof from below or garrets that
leak from above? They are supplied bad, tattered, or rotten clothing,
adulterated and indigestible food. They are exposed to the most exciting
changes of mental condition, the most violent vibrations between hope and
fear... They are deprived of all enjoyments except sexual indulgence and
drunkenness and are worked every day to the point of complete exhaustion of
their mental and physical energies?(Engels, 1845/1987)p. 129)"

Similarly, German physician Rudolph Virchow's (1821-1902) medical
discoveries were so extensive that he is known as the "Father of Modern
Pathology." But he was also a trailblazer in identifying how societal
policies determine health. In 1848, Virchow was sent by the Berlin
authorities to investigate the epidemic of typhus in Upper Silesia. His
Report on the Typhus Epidemic Prevailing in Upper Silesia argued that lack
of democracy, feudalism, and unfair tax policies in the province were the
primary determinants of the inhabitants' poor living conditions, inadequate
diet, and poor hygiene that fuelled the epidemic.

Virchow stated that "Disease is not something personal and special, but
only a manifestation of life under modified (pathological) conditions."
Arguing "Medicine is a social science and politics is nothing else but
medicine on a large scale", Virchow drew the direct links between social
conditions and health. He argued that improved health required recognition
that: "If medicine is to fulfil her great task, then she must enter the
political and social life. Do we not always find the diseases of the
populace traceable to defects in society?" (Virchow, 1848/1985).

I look forward then to hearing about how economic and social resources such
as conditions of childhood, income, availability of food, housing,
employment and working conditions, and health and social services are
affecting the health of the peoples of Latin America. Discussion should
also includes issues of gender, class, racism and other forms of social
exclusion. This emphasis will a welcome contrast to the traditional focus
upon biomedical and behavioural risk factors such as cholesterol, body
weight, physical activity, diet, and tobacco use. And since a social
determinants of health approach sees the mainsprings of health as being how
a society organises and distributes economic and social resources, Critica
Medicina should direct attention to economic and social policies as means
of improving health. It should be explicitly political.

Best wishes on your enterprise. Please enroll me as a Charter Member.
[Though my high school espanol is a little weak!]

References
Engels, F. (1845/1987), The condition of the working class in England.,
Penguin Classics, New York.
Virchow, R. (1848/1985), Collected essays on public health and
epidemiology, Science History Publications, Cambridge, UK.

Sincere best wishes,

Dennis Raphael, PhD
Associate Professor and Undergraduate Program Director
School of Health Policy and Management
Atkinson Faculty of Liberal and Professional Studies
York University
4700 Keele Street
Toronto, Ontario M3J 1P3
tel: [phone], ext. 22134
fax: [phone]
email: [e-mail]
website: http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/