Health Care History: Faculty Q&A With David Rosner

Interview by John H. Tucker

Lost in the cacophony of debate swirling around health care reform is the historical context of this hot-button issue. Few are better at explaining the history of America’s health care and its potential future than David Rosner, a historian who holds a joint appointment in the Department of History and the Mailman School of Public Health’s Department of Sociomedical Sciences.

Would-be reformers, he says, would be wise to consider the past as well as the future of health care. Until the 1940s, health care was considered a national social obligation, not something that generated profits for the private sector. “Making money off of health care is a recent historical phenomenon, and it’s something that many historians still find very, very odd,” Rosner says.

Professor David Rosner [Image credit: Diane Bondareff]
Professor David Rosner
Image credit: Diane Bondareff

Similarly, how historians view health care has changed dramatically. “Whereas most Americans have traditionally viewed disease as products of individual behaviors or personal characteristics—like smoking or drinking—historians take a broader viewpoint that treats disease as a product of society’s promotion of polluting industries and unhealthy lifestyles,” he says.

Ten years ago, Rosner founded the Center for the History and Ethics of Public Health, whose mission is to blend the intellectual rigor of history with the real-world policies of public health. “My dream is to find a way to get the two fields to speak to each other,” he says.

Rosner’s approach has garnered him a host of grants and honors, including a Guggenheim Fellowship, a National Endowment for the Humanities Fellowship and a Josiah Macy Fellowship. He’s also a consulting editor at Public Health Reports, the official journal of the U.S. Public Health Service. His books include Deceit and Denial: The Deadly Politics of Industrial Pollution, on the history of lead poisoning, and A Once Charitable Enterprise, which looks at the history of charity and nonprofit hospitals.

For the past year, he has worked with Mailman Dean Linda Fried; James Colgrove, associate professor of sociomedical sciences; Amy Fairchild, associate professor and chair of sociomedical sciences; and others on a proposal for changing public health education. Rosner spoke to The Record about the history of U.S. health care and what he believes a health care bill should include.

Q. How does history address current public health concerns?

It provides a context for understanding how certain issues become problems. What’s obvious to historians, for instance, is that the problems surrounding health care reform run deeper than reimbursement-rate adjustments or other financial details. There have always been deeply held attitudes in this country about health care and who “deserves” it. Why are some groups treated differently than others? That’s a question that goes deep into the realm of American social history. Without understanding attitudes toward the poor, the needy and the dependent, it’s difficult to understand the resistance some people have to reform.

History also allows people to become more aware of the ways societal movements affected health—whether it’s racism, urban crowding or other trends that helped create a “diseased” state. I tell my lecture class that we basically build worlds that kill us. In the 19th century, we created crowded urban conditions with bad water and lousy sewage, which made infectious disease the paradigmatic cause of illness. Now, we’ve created an environment of synthetic chemicals and toxic substances that cause cancers, heart disease and stroke.

Q. What are the roots of health care in this country?

Just after the Civil War, when the charity hospitals were built, health care reflected the moral, social and religious judgments about individuals struck down by disease. Early on, our attitudes were imbued with the notion that health was a sign of an individual’s morality, something that came naturally to upstanding people who lived a good life. Diseased people, in contrast, were often seen as marked or sinful, like they’d crossed some social boundary. So we developed a health care system around moral judgment. We had private care for what we termed “the worthy poor,” but not for the “unworthy,” who were stricken by conditions associated with poor moral habits, sexual promiscuity or other acts that transcended middle-class values. And that carries right over to today. We have public hospitals for the “unworthy” and private hospitals for the “worthy.” We have Medicaid for the unworthy and Medicare for grandma and grandpa. We often try to locate the reason people suffer from disease in their personal behaviors or habits. There have always been attempts to reform health care, to make it a classless system, and avoid social stigma and judgments, but the tensions between blaming the individual for their own suffering and seeing care as a social responsibility are still manifested today in reform debates.

Q. You’ve written about the health care system becoming “medicalized” in the early 20th century. What do you mean?

In the late 19th century, when the public health care field was forming, it was a collection of disciplines. You had sanitarians who cleaned streets, engineers who built water systems, housing advocates who demanded reforms. Their power emanated from their alliances with other societal movements—occupational health advocates aligned with the labor movement to push for factory reforms, women’s health advocates aligned with the suffragist movement to push for women’s rights and so on.

But by the 1920s, the medical model in explaining disease began to dominate. Educators began to believe that illness could only be addressed with curative medicine and pills. So the public health officials cut the alliances that gave them power in the 19th century and formed stronger identities as scientists. That was fine in some ways, like developing antibiotics to cure bacterial infections or vaccinations to prevent polio. But now chronic conditions such as cancers, endocrine disruptions and heart disease have gained increasing prominence as the population ages. We have periodic epidemics of SARS, H1N1 and other infectious illnesses, and we certainly have AIDS, but by and large, Americans’ health concerns are often linked to more fundamental social problems like economic and social disparities, violence and obesity, and environmental degradation. So now there’s an argument that we need to return to the old model—to form alliances with environmental groups to clean up waste sites, for example, or women’s groups, or anti-poverty organizations—and to join our science with social activism and involvement.

Q. You’ve said that health care needs to be discussed in fundamentally different terms. What do you mean?

In the 1960s and ’70s, there was an epidemiological shift away from infectious disease, and some economists and sociologists argued that health was a matter of lifestyle—whether we ate, drank, smoked too much, whether we lived a moral or immoral life, in traditional terms. But others said that this wasn’t a lifestyle issue, but rather an environmental issue. It’s not enough to educate people to buy fresh food, we must ensure there are means of preserving it in refrigerators and that grocery stores sell it nearby. In too many neighborhoods, the dominant restaurant is McDonald’s. If you want people to stop smoking, you can’t simply tell them to stop; you must regulate and control the tobacco industry. So while one group was claiming poor health was the fault of the individual, the other group said it was the fault of industries or other social or economic forces that shape the environment, pollute the water or dump poisons in the air.

Q. What do you believe must be included in a health care bill sent to the president?

There has to be a public plan. There has to be a way of addressing the inequity of the system. As long as we leave it up to industries with enormous financial stakes in it, we’re never going to address the huge disparities in the services people receive. It would take enormous regulatory effort to keep these guys under control; their interests are simply diametrically opposed to equitable distribution of services. The real goal of this bill must be to make sure that health care is universal, not necessarily less costly. In a wealthy society like ours, it’s my belief that we have a moral obligation to one another.

Q. So you don’t worry that the proposed bill is too costly?

That’s always an argument for the status quo, but the current system is bankrupting us faster than any kind of public plan would. What’s “too costly” when it comes to people’s lives? When Social Security was first enacted, it was seen as a budget breaker, too, and it’s been one of the most successful social-insurance systems in world history, existing for 70 years without major changes. Similarly, Medicare has also been attacked as too costly, but it’s proved to be an essential program. Certainly, any meaningful social program will be costly, but the benefits to all of us are huge as well.

Q. What is your biggest hope in the future of U.S. health care and what is your biggest fear?

My biggest hope is that we have substantial reform this year that provides universal access and gets rid of the social distinctions that mar health care systems today. My fear, of course, is that we’re going to lose another opportunity. If we do, we’re going to end up in a real social and economic crisis that could literally kill millions of people. Virtually all other Western societies have long ago figured out ways of caring for their populations. We’re really alone, and I think most societies look askance at us, wondering how we can have 45 million individuals without guaranteed care.

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