Brandt, Allan M.

Reviews in American History

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 Medical Nemesis? The Harvard community has made this article openlyavailable.Please share how this access benefits you. Your storymatters.Citation Allan M. Brandt. 1985. Medical Nemesis? Review of Thehealthiest city: Milwaukee and the politics of health reform,by Judith Walzer Leavitt, and A once charitable enterprise:Hospitals and health care in Brooklyn and New York, 1885-1915, by David Rosner. Reviews in American History 13(1):90-93.Published Version http://www.jstor.org/stable/2702017Accessed February 18, 2015 2:12:49 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372907Terms of Use This article was downloaded from Harvard University'sDASH repository, and is made available under the terms andconditions applicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAMEDICAL  NEMESIS? Allan M. Brandt Judith Walzer Leavitt. The Healthiest City: Milwaukee and the Politics of Health Reform. Princeton, N.J.: Princeton University Press, 1982. xvii +  294 pp. Illustrations, tables, chronological outline, essay on sources, and index. $22.50. David Rosner. A Once Charitable Enterprise:  Hospitals and Health Care in Brooklyn  and  New  York,  1885-1915.  New  York: Cambridge University Press, 1982. ix +  234 pp. Notes, bibliography, and index. $29.50. Few social issues are more central than the problems posed by disease. This was  particularly true in  the  late  nineteenth- and  early  twentieth-century American city. As Americans faced the wrenching transformations brought about by  industrialization, immigration, and technology,  the health prob- lems of  the city were severely exacerbated, and the abilities of  municipal authorities and  the medical profession  to  deal with  these problems were sorely tested. Problems as diverse as episodic epidemics, the disposal of grow- ing quantities of  wastes,  the pollution  of  the atmosphere, not  to mention overcrowding -  problems that characterized  virtually all American metropo- lises -  seemed to overwhelm city governments that were organized in simpler times. These  two  important  and  timely  books  assess  the  nature  of  urban America's health problems in the critical years around the turn of the twenti- eth century. Although they have somewhat different focuses, both address the question of how the health needs of the urban masses would be met in the new century. Both Leavitt and Rosner make clear that the history of medicine is no longer a field for antiquarian speculation; the history of medicine and public health is an elemental segment of the new social history. Historians who seek to understand the nature of social experience in the past must con- sider the critical issues of health and disease. As these books demonstrate, the manner in which a society acts to control the environment and responds to those who are dependent, especially to those who are ill, is revealing of the most basic political, social, and cultural values and beliefs. Both Rosner and Leavitt contribute significantly to  our understanding of  these issues in the context of Progressive reform. 90 BRANDT / Medical Nemesis?  91 As urban conditions in late nineteenth-century Milwaukee became literally intolerable, threatening both the health and the continued economic growth of the city, reformers and officials were forced to respond. The stench ema- nating from the river, the visible pollutants in drinking water, the growing piles of uncollected garbage and filth forced a widening of municipal respon- sibility in the area of public health. In addition to medical and technological limits of knowledge, political and social obstacles often had to be surmounted before the growing health bureaucracy could have a positive impact.  The Healthiest City is constructed around three case studies of significant public health interventions: smallpox, the disposal of garbage, and the problem of contaminated milk. In all three instances, the city, after substantial political debate, successfully mitigated these health threats. Leavitt details the various political barriers  to the "abatement  of nuisances" in  late  nineteenth-  and  early  twentieth-century Milwaukee  in  her  well- written, rigorously researched account. She traces the concerns of business interests over quarantines  during times of epidemics, as well as the objections of various ethnic groups to governmental requirements  for vaccination. Some German immigrants refused to  be vaccinated,  seeing the procedure as an invasion of their personal liberty; moreover, some refused to permit family members to be quarantined in public smallpox hospitals. Without a broad coalition of community, business, and political support, the well-intentioned interventions of health officials too often came to naught. Not surprisingly, the basic environmental reforms which public health officials sponsored in Milwaukee did not  generally usurp or  challenge the  ongoing  role  of  the medical profession. When public officials did propose providing health ser- vices to school age children  -  moving from the realm of prevention to treat- ment -  professional opposition was aroused. This had the effect of defining the parameters in which public health officials could work. Sensitive to the large number of forces which shaped public health policy - from medical advances such as diphtheria antitoxin to the political and social orientations of ethnic groups, from business concerns to political personali- ties -  Leavitt avoids  drawing broad generalizations, preferring to carefully reconstruct the political debates that resulted in reforms. Health reform, she argues,  typified  urban  progressivism  in  turn-of  the-century Milwaukee, bringing together a wide alliance of reformers who urged municipal respon- sibility for problems of community welfare. Although Leavitt never defines the  particular characteristics of  the  Milwaukee  reform  coalition,  which achieved greater successes in the area of public health than other comparable American  cities,  one  explanation  is  perhaps  the  powerful  influence  of Socialist politics in  this city,  heavily  populated by  native-born Germans, more ready to accept corporate notions of public responsibility. 92  REVIEWS  IN AMERICAN HISTORY / March 1985 In any event this group of reformers  had considerable success in alleviating the worst dangers in Milwaukee's environment, leading to the designation of the city in 1930 by  the American Public Health Association  as America's "healthiest  city." In this respect, Leavitt's  account supports a number of recent medical assessments that would suggest that the variables which significantly affected rates of mortality and disease in the nineteenth century rested on environmental and nutritional changes -  and public health activity -  more than on any specific medical therapeutics. Death rates in Milwaukee fell from 23.1 per thousand population in 1870 to 13.90 in 1910, before the introduc- tion of any significant curative interventions. This, of course, calls into ques- tion the role of medical intervention as it has affected overall mortality in the last century.' While Leavitt concentrates on the activities of the municipal government in assuring a healthy environment, Rosner focuses on the principal institution for health care delivery in the twentieth century, the modern hospital. Rosner delineates the developments which led to the transformation of the hospital from essentially paternalistic charity institutions, locally based and under lay control, to major bureaucratic, medical institutions controlled by the medical profession. He argues that it was demographic and economic developments, especially the depression of 1892, which led to major changes in the structure of Brooklyn hospitals, rather than a series of medical advances as many have previously assumed. The new hospital was shaped, as Rosner demonstrates, by the vagaries of finance and politics and the ideology of management and efficiency, forces which did not always lead to the optimum delivery of ser- vices. Because of the longstanding association of the hospital with the destitute, hospital administrators eager to attract paying patients had to devise means of overcoming the traditional stigmas attached to hospital care. As Rosner explains, this was accomplished by offering paying patients better services, creating "hospital hotels" with private rooms, good food,  and attentive ser- vice.  These new  attributes were widely  advertised. In addition,  hospitals revised their prohibition on fees charged by physicians. This encouraged doc- tors to use the hospital and fill beds. With these changes came an important shift in the demographics of hospital use. With the demise of a community- based  health  care  system,  hospitals  now  were  designed  as  a  two-tiered system -  one for the indigent, and one for those who could pay -  a system that  would  characterize the  provision  of  services  in  twentieth-century America. Rosner's  tightly argued, lucid book strikingly demonstrates the interplay of finance, bureaucracy, real estate, and regulation  -  forces which continue to significantly shape the nature of American hospitals. He does not, however, provide us with a look into these hospitals. How did this new organizational BRANDT / Medical Nemesis?  93 structure affect the relationship of patients to doctors,  the employment of medical technologies, and the general quality of patient care in the twentieth century? Rosner, like Leavitt, is eager to separate social from scientific components in explaining developments regarding  hospitals and public health during these years. All too often, the successes of public health and the development of the hospital have been attributed to scientific advances, rather than to political and social change. Both of these studies suggest, with much substantiation, that to understand the nature of health and disease, historians must look beyond  medical progress; and both  question the tendency within medical history to view scientific and social forces as dichotomous variables. Clearly, the contours of medical and public health activities were shaped by broad social,  political, and cultural forces, as well as by  the particular nature of biomedicine. Leavitt and Rosner also underline the importance of carefully constructed local histories and the usefulness of studying the microcosm before drawing broader generalizations. In this light, they invite comparison with develop- ments in other American cities. Indeed, comparatively, there appear to be some significant tensions between these two  accounts. Leavitt is generally praiseful of Progressive efforts to improve the urban environment; Rosner finds that the Progressive emphasis on efficiency and reform in New  York hospitals created a two-class system of care which restricted access for the needy. Why this apparent paradox? What might explain the fact that public health measures were broadened during these years and the urban environ- ment made more healthful, while access to health care facilities became, as Rosner makes clear, more limited? This question raises a more fundamental issue which demands attention: what  distinguished issues of public health from the public provision of health services? What were the parameters of public health intervention during these years? What was considered to be the domain of the municipal government and what was accepted as the exclusive sphere of the private practitioner?  It is this conundrum of public responsibil- ity  which  continues  to  confront American society.  These two  exemplary studies have provided important insights into the history of this debate. Allan M. Brandt, Department of Social Medicine and Health Policy, Harvard Medical  School,  is  the author  of  No  Magic  Bullet: A  Social  History  of Venereal Disease in the United States Since 1880 (forthcoming from Oxford University Press). 1. See Thomas McKeown,  The Role of Medicine: Dream, Mirage, or Nemesis (1980). For a more vigorously polemical statement of the limits (and dangers) of modern medicine, see Ivan Illich, Medical Nemesis (1976). 

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