Known as the father of social medicine, Rudolf Virchow owes this title to his Upper Silesia Typhus Epidemic Report, where he elucidated the social-economic causes of diseases and deaths, in other words, explaining under which societal conditions morbidity and mortality arise (Virchow, [1848] 2006). Embracing Hegel's dialectical method in the analysis of health problems, Virchow presents a successful example of dialectical approach to biological and social issues in his report.
Master of the dialectical approach, Hegel, argued that life couldn't exist without disease; every organism is born with the "germ of death," and treatment sees disease not as the complete loss of health but rather as a conflict within or between physical forces.
However, Virchow, rejecting Hegelian idealism, embraced materialism. In his efforts to form a dialectical materialist approach in biology, he extensively utilized Friedrich Engels' work "The Condition of the Working Class in England" to demonstrate the relationship between poverty and disease (Engels, 1994).
DIALECTICAL MATERIALIST CONCEPTION OF HEALTH
Engels' work, "The Condition of the Working Class in England," published in 1845, highlighted the relationship between capitalist production mode, society's organization according to the needs of capitalism (capital), and health, providing scientific evidence for the first time for the relationship between diseases and death as social determinants such as income, housing, nutrition, education, etc.
Recent research indicates that scientific and technological developments in health contribute only about 25% (some sources say 10-15%) to the expected lifespan, while improvements in material conditions of daily life contribute much more significantly.
Income or wealth is a primary social determinant of health, with differences in health levels between individuals and social classes primarily attributed to differences in income and wealth. This is because income or wealth not only determines health as a factor but also influences other social factors that determine health.
Other social factors determining health, such as the quality of early childhood, education, housing, food, employment, and working conditions, are determined by individuals' incomes and wealth. It is also important to remember that the income variable is determined by the "mode of production" of societies (See: Raphael, 2004: 8; also see: Marmot and Wilkinson, 2009).
Virchow emphasized the historical and material conditions in which diseases arise rather than biological factors. In his multifactorial etiological analysis, he argued that the most significant causal factor in the emergence and development of diseases is people's daily life and working conditions. This perspective indicates that an effective healthcare system cannot limit itself to treating the pathophysiological problems of individual patients.
Consequently, Virchow envisioned a comprehensive healthcare system operated by the state, employing healthcare workers, operating under public ownership, and advocated for a 'public health service' where healthcare is defined as a constitutional citizenship right.
The activities of public health workers, whom Virchow termed "Armendärtzen" (physicians of the poor), include not only direct care but also advocacy for the poor. The other two principles of Virchow's public health concept are prevention and the state's responsibility to ensure the material security of citizens (Waitzkin, 2006).
To summarize the basic characteristics of the dynamic-communitarian approach and its effects on medicine and health understanding:
Focuses on health rather than disease by focusing on the patient's daily life conditions
Emphasizes the societal conditions in which the disease arises
Gives importance to the conditions under which the biological agent of the disease can cause illness
With this understanding, the role assigned to the physician and consequently medical education is to combat the conditions that produce disease and to evaluate patients as whole entities with their bodies, minds, and social and physical environments.
STRUGGLE BETWEEN MECHANISTIC AND DIALECTICAL MATERIALIST APPROACHES
In the mid-19th century in Europe, many physicians, including Villermé, Buchez, and Guérin in France and Neumann, Virchow, and Leubuscher in Germany, worked on the economic, social, and professional causes of diseases. Many researchers have identified inhumane and dangerous working environments, unemployment, miserable living conditions, inadequate nutrition, and general poverty as the main reasons for high disease rates and early deaths among European workers and have statistically documented this situation.
Contemporaries such as Lister, Pasteur, and Koch, however, embraced a mechanistic-individualistic health understanding, focusing on the individual and biological agents in their work, searching for the causes of diseases not in social and economic conditions but in specific microorganisms specific to diseases. This approach is based on the principle that specific pathological conditions will be treated with specific treatments.
The struggle between these two approaches is essentially nothing but the struggle in the field of health between the ideology of labor and the ideology of capital. Labor and capital try to explain the world and events from their own perspectives; when it comes to explaining the causes of diseases, intellectuals of both labor and capital agree that the causes of diseases are not 'divine' or 'random,' but while intellectuals of labor insist that these causes have social foundations, intellectuals of capital claim they are individual.
Instead of acknowledging that the causes of diseases lie in the capitalist production relations and the capitalist society built upon them, intellectuals of capital tend to attribute diseases to microorganisms discovered every day during that period (germ theory).
Renowned German physician Emil von Behring claimed at the turn of the twentieth century that there was a "microbe causing every disease" and argued that diseases were completely independent of social conditions, accusing Virchow of denying the "truths" revealed by science.
Virchow, however, persistently argued that there was a 'multi-factorial' relationship between humans and diseases, even in an environment where a new disease agent was isolated almost every day, and treatments were being developed.
Virchow's Upper Silesia Typhus Epidemic Report emerged in this climate. In this study, Virchow scientifically demonstrated that besides the disease agent, many other social and economic factors were associated with the epidemic. This relationship is not simply a 'exposure - disease' relationship as von Behring claimed but a 'exposure - infection - disease' relationship.
This means that not everyone exposed to the same agent gets sick; other conditions play a role in whether the microorganism infects the person, and only those who are infected get sick. This explanation is the basis of the 'epidemiological triangle' concept, which forms the basis of epidemiology science today and is widely used in non-communicable diseases as well.
The open conflict between these two approaches occurred in Berlin in 1882:
When Koch exhibited his discovery (the tuberculosis bacillus) at the Berlin Physiology Society in 1882, many scientists rejected the idea that the bacillus caused tuberculosis.
Virchow and others argued that since pathological microorganisms could live in healthy human bodies, they alone could not be the cause of disease (necessary but not sufficient). According to them, invading microorganisms can only cause disease when the body is weakened by physiological or environmental distress.
Koch and his colleagues succeeded not because they could convince their thesis in scientific circles but because they could provide the necessary financial support from the ruling classes to continue their work (Brown, 1979: 128).
The medicine of labor emerged as a product of these processes against the medicine of capital. The ideas pioneered by Engels and Virchow became widespread among revolutionary physicians in the late nineteenth century and found tangible expression (Semashko Model) first in the Soviet Union with the Great October Revolution of 1917.
Although since the mid-19th century it has been scientifically established that health is not an individual but a social problem, and in this context, the efforts of individual individuals are scientifically insufficient to protect or regain their health, the mechanistic-individualistic approach continues to dominate the mainstream medical and health environment (Flexnerian Model).
Akif Akalın
Citation: Akalın, A. (2015). Sağlığa ve Hastalığa Toplumcu Yaklaşım. İstanbul: Yazılama. Pp. 106 - 110. ISBN: 978-605-9988-35-3
REFERENCES
Brown, E.R. (1979). Rockefeller Medicine Men: Medicine and Capitalism in America. Berkeley: University of California Press.
Engels, F. (1994). İngiltere’de Emekçi Sınıfların Durumu. İstanbul: Sosyalist Yayınlar.
Marmot, M. ve Wilkinson, R. (2009). Sağlığın Sosyal Belirleyicileri. İstanbul: İnsev.
Pridan, D. (1964). Rudolf Virchow and Social Medicine in Historical Perspective. Medical History. 8(3): 274–278.
Raphael, D. (Ed.). (2004). Social Determinants of Health Canadian Perspectives. Toronto: Canadian Scholars’ Press Inc.
Taylor, R ve Rieger A. (1984). Rudolf Virchow on the Typhus Epidemic in Upper Silesia: An Introduction and Translation. Sociology of Health and Illness. 6(2): 201 – 217.
Virchow, R. ([1848]2006). Report on the Typhus Epidemic in Upper Silesia. Social Medicine, 1(1): 11 – 27.
Waitzkin, H. (2006). One and a Half Centuries of Forgetting and Rediscovering: Virchow’s Lasting Contributions to Social Medicine. Social Medicine. 1(1): 5 – 10.
Original article can be reached at https://toplumcutip.blogspot.com/2015/01/sosyal-bir-olgu-olarak-hastalk.html
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