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[NOV. 11, 1944ORIGINAL ARTICLES

SOCIAL MEDICINEAN ACADEMIC DISCIPLINE AND AN

INSTRUMENT OF SOCIAL POLICY *

F. A. E. CHEW, M D, D SC EDIN., F R C P E, F R SBRIGADIER, AMS ; PROFESSOR OF PUBLIC HEALTH AND SOCIAL

MEDICINE IN THE UNIVERSITY OF EDINBURGH

ABSOLUTE health is the state in which there is harmonywithin the individual and between the individual andhis external world. But since life is labile and theenvironment continually changing everything is unstableand health and ill health are but-different aspects of this

instability. The distinction between them is one of

degree, not qualitative but quantitative ; it is a differencein the degree of imbalance or disharmony.

It follows that modern medicine concerns itself notmerely with the alleviation of disease but includeswithin its province all that pertains to man’s well-being,taking into account not only the makeup of man but alsohis external world and his interaction with it. Develop-ments in sociology have led to the acceptance of theview that of all the constituents of the individual’sexternal world nothing is of greater importance than theexistence of other individuals of the same species, andthat in the interrelationships of individuals within thegroup are to be found the major causes of harmony anddisharmony. Moreover it is now fully recognised thatin this external world man-made institutions are not lesssignificant, than are the components of his naturalenvironment. It is for these reasons that social medicineis now proceeding on its active development.

There is a further reason for this. We of medicinehave reason to know that very many of the ills that now

disfigure individuals and communities derive directlyfrom the fact that the development of the differentfields of science and the application of the differentsciences to human and social affairs have been very

, unequal. So great has been the encouragement, bornof necessity, lavished upon the physical sciences thatour knowledge concerning them is vast. Throughtheir application man has been able to bring aboutprofound and rapid modifications of his natural environ-ment. All this has been accomplished in the entireabsence of any real knowledge of human and socialbiology, sociology and of the psychology of communities.

It is not to be wondered at therefore that the environ- ‘

ments that man has created for himself have proved tobe out of harmony with human needs and sentiments.Disharmony between man and the social structures hehas created has in fact been produced and so it is thatthe treatment of disease engendered by such disharmonyhas become a major preoccupation of medicine.The community is now demanding, through medicine

its mouthpiece, that the social sciences shall receive anencouragement at least equal to that given by industryto physics and chemistry, since the most urgent need ofour time, if harmony between man and man and betweenmankind and its environments is to be restored and

disease prevented is an expanding scientific knowledgeof man and of society : the present combination of vastknowledge of inanimate things and an almost completeignorance of ourselves constitutes a danger that maywell destroy us.

It is in an attempt to remedy this imbalance that themedical faculties of universities are now finding a placewithin themselves for social medicine and it is throughassociation with social medicine that the social scienceswill encounter the opportunities they need for healthyand vigorous growth.

WHAT IS SOCIAL MEDICINE ?

Social medicine is medical science in relation to groupsof human beings. Such a definition gives to this branchof medicine the dignity of an academic discipline in itsown right, distinguishes it from clinical medicine andmakes it clear that it is not circumscribed by what hascome to be known as preventive medicine.

Clinical medicine, in so far as it is ’a science, is thescience of the sick individual. Preventive medicine is* Part of an inaugural lecture in the Bruce and John Usher chair

of public health delivered at Edinburgh on Oct. 20.6324

medical science applied to the elimination of sickness byappropriate social and collective procedures based uponthe findings of clinical medicine and , the ancillarysciences of the individual.

Social medicine rooted both, in medicine and insociology includes preventive medicine in this sense aswell as industrial -medicine, which is surely more than avariant of toxicology, but it differs from these in thatit is not merely or mainly concerned with the preventionand elimination of sickness but is concerned also andespecially with the study of all social agencies whichpromote or impair the fullest realisation of biologicallyand socially valuable human capacities. It includes theapplication to problems of health and disease of socio-logical concepts and methods.

Social medicine is nothing new as an interest or as asubject, its present claim to be recognised as a definitebranch of medicine rests upon the facts that there is nowa widespread full recognition of the number and import-ance of health-promoting and disease-provoking elementsin the social milieu, and that recently and especiallyin the medical services of the armed forces its scope andcontent have been clearly defined and its methodologyelaborated. z

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Problems of social medicine are of two kinds : one isconcerned with the definition of the social environmentin relation to the prevalence of morbidity and mortality ;the other is concerned with the social agencies which arepropitious to maximum health in the widest sense of theterm.

THE SOCIOLOGY OF DISEASE ,

So stated, the first group of problems is concernedwith disease in the body politic. This is the province ofvital statistics, an instrument as valuable to medicine,though not so commonly used, as is the surgeon’s knife.In saying this I do not forget that Lister when occupyingthe chair of clinical surgery in this university wrote :

" I have often been reproached for not having publishedstatistics ... the truth is that life is short and that whenevery day begins one has to consider which is the occupationthat is most likely to be valuable ... I have felt thatthere was every day something more congenial and, I hoped,more profitable to do than to compile statistics."

The operative word here is, I submit, congenial. As anessay in profitable speculation it would be interesting toinquire which of the two, John Graunt’s measurementof the rate of mortality in childhood or the Listeriansystem of antisepsis in surgery, has proved historicallyto be the greater contribution to medical science.

It is certainly true to say that the lack of carefullycompiled records of disease has in the past often delayedthe advancement of medicine and led to the acceptanceof mistaken or misleading notions regarding diseasecausation and that it still is doing so. The prevalentabhorrence of figures on the part of medical men is to beregretted, and regarded as the product of a faultyeducation. It must be overcome if social medicine is toflourish ; for this branch of medicine, by definition, mustbe concerned with the health of the group, whether inthe positive or negative sense, and so it must always relyon those basic techniques which are essential to thestudy of groups in general. The research-worker insocial medicine must perforce be a statistician ; but it isimportant to realise what kind of a statistician he or shemust be.What social medicine needs for its immediate develop- ,

ment is a personnel of research-workers who are notafraid of figures and who realise when and where theyshould and can get help from the expert statisticianpossessing highly sophisticated mathematical knowledgeand facility, in order to avoid misunderstanding andmisinterpretation. But it needs even more young menand women who have a keen interest in humanity and

its affairs, for " where there is love of man there is alsolove of the art." Mathematical ability is no substitutefor scientific interest in the social structure. No skilledmathematician who lacks an inclination for biological orsocial studies is likely to be able to make a contributionof any quality to social medicine save in an advisorycapacity. Such as are not skilled in or quick at mathe-matics should not be discouraged from sharing in thishigh adventure, for they can quickly acquire the few

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and simple statistical techniques sufficient for ordinarypurposes and the sense to know when they need toconsult a real mathematician.

It is customary to look upon vital statistics as anaudit of public health and as a yardstick of socialwelfare. But it has another function commonlyunrecognised which impinges on the province of clinicalmedicine. It will be agreed that if we know the sort ofenvironment in which the immediate causal agenciesof a disease are likely to be found we are well on the wayto discovering what these agencies are. It should beone of the main tasks of statistical medicine to supplyrelevant clues of this kind.

In this connexion it is of interest to refer to thehistory of nutritional science. Centuries before theessential techniques of biochemistry had been - evolvedclues pointing directly to the causal factors in certaindeficiency diseases had been discovered by colonialadministrators, navigators, ships’ surgeons and the like.Nutritional science did not begin to advance immediatelybiochemistry had reached the necessary proficiency, forthe reason that, since these clues had not been codified,,their value was not appreciated. Research in thelibrary can on occasion be as profitable and as importantas research in the laboratory. The time has surelycome when the systematic search for information aboutthe climatic, regional, occupational and other moresubtle circumstances associated with the occurrence ofdiseases of unknown origin should be planned andconducted. The urgent need is for data concerningmorbidity as contrasted with mortality, and one of thefirst fruits of the modern renaissance of medicine hasbeen this changed emphasis: .

The appropriate methodology exists. Recent studieson human fertility, stimulatecl- by interest in modernpopulation trends, furnish a model for proceduresequally appropriate to the study of agencies which makefor disease and death. This differential method,employed with such great profit by the modern demo-grapher, can easily be used in the exploration of groupcharacteristics that are associated with differentialmorbidity and mortality.

It is particularly important at this time that thedemographer shall be encouraged and aided to providefor those who are concerned with planning for thefuture as precise a knowledge as possible of the humanresources that will be available for bringing their plansto fruition-knowledge of the numbers, sex, ages,geographical distribution, reproductive, morbidity andmortality trends of the people on whose behalf and bywhom houses are to be built, food grown, work provided,and educational, health and social insurance and otherservices developed.

THE NEED FOR A SCIENCE OF HUMAN ECOLOGY

When I review the anxious years I have spent in theArmy I am reminded of James Russell Lowell’s lines :

" Not but what abstract war is horrid,I sign to thet with all my heart.But civilyzation does get forrid,Sometimes upon a powdercart."

For it is true that the Army, with its all-in system ofmedical inspection and care has provided uniqueopportunities for the rapid development of socialmedicine. It has been my good fortune to have beenpermitted to exploit these opportunities and to createfor this purpose new machinery. This, designed andexercised in the Army by my colleagues, can be themodel for that which will be needed when peace returns.In these matters I refer not to the military system ofregimentation that has attracted so much attention,but to the Army’s techniques of fact-finding and itsexperimental methods. .

Medicine in the Army differs from civil medicine inmany ways, but especially for the reason that in theArmy it is but one of many coordinated directoratesthat are responsible for health promotion and diseaseprevention. Medicine works along with and in theclosest cooperation with the directorates of manpower-planning, organisation, personnel selection, welfareservices, personal services, education and training, forexample, in the study of disease as a function of the

social environment and in the objective study of humaninstitutions and social groups. Thus in the Army therehas been proceeding an exploration of previously ill-charted territories in social science, and the doctorand the demographer have been working in closecollaboration with the social anthropologist and the,social psychologist.Through the study of differential morbidity and

mortality the social biologist had already created areservoir of information concerning biological differentialswithin the social framework. But when attempts weremade to assess the significance of such differentials itwas found that our knowledge concerning social structuresand human relationships within such lagged far behindour requirements. Social medicine in the Army’demanded for its development a corpus of knowledgeconcerning occupation, locality, social amenities, personalhabits, aspirations, risks and responsibilities, thatcould not be derived from questions the economist asksin peace concerning price and wage levels in a monetarysociety but could be derived from questions to which thesocial biologist, anthropologist and psychologist seek ananswer. The Army needed a new kind of sociology andthis has been created.

This new science of human ecology has been of thegreatest value in its application in the Army; itsfurther development after the war and for the purposesof peace must be encouraged : that university whichcontributes in the immediate future most to the advance-ment of learning and to human betterment will, Isubmit, be the one that develops the greatest instituteof human ecology. Such a development is of specialimportance because the interrelationships of this scienceare so manifold that any discovery within it will animatespeculation and inquiry in many other disciplines.. Sociologr, anthropology, psychology, criminology, ped-agogy, history, law as well as medicine wait upon humanecology and its discoveries concerning human needs,.sentiments and beliefs.

THE SOCIOLOGY OF POSITIVE HEALTH

The second group of problems which fall naturallyinto the province of social medicine are those whichare concerned with .the assessment of the agenciesthat make for positive health in a community. As.would be expected, these loom exceedingly large inmilitary medicine, and experience has shown howlamentable is our ignorance of the strains and stressesof modern life and how little physiological sciencehas probed the range of the normal within the socialgroup.

Through active collaboration with physiology, sociamedicine must bring into being a new kind of physiologywhich for the lack of a better name may perhaps becalled field physiology, using the statistical techniques.perfected by psychologists and industrial efficiencyexperts to assess the significance of biochemical andphysiological tests as a basis for a conspectus of thecriteria of physical fitness.In the Army the term positive health is no empty

phrase ; for a purely negative health standard is notgood enough for a medical service which is called uponto assess training procedures and to promote andprescribe a regimen appropriate to the maintenance ofthe highest level of attainable efficiency for an exactinglife and an increasing variety of specialised activitiesimposed by mechanisation.

Psychologists (non-medical), psychiatrists, primarilyinterested in the preventive aspects of their subject, andspecialists in physical medicine especially have all beenconcerned within the Army in giving to the term positivehealth an exact meaning. It is a quality that ismeasured by performance tests and of it there are grades.Performance in tests of intelligence, agility, endurance,.and strength, is at the same time a measure of theindividual’s will to perform, and of his enjoyment in thepossession of the ability to do so, for " as he thinketh inhis heart so is he." Every job, simplified as far aspossible, that the soldier can be called upon to performhas been measured in respect of the mental and physicalqualities and acquired skills that must be possessed bythe individuals who are to undertake it. Every recruit-is measured in respect of his inherent and acquired

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qualities. As tar as possible his posting and employmentare such as ensure that his attributes are in tune withthe complexities and responsibilities of the r6le which heis required ’to fill. This job-analysis and this selectionof personnel are activities that are of the greatestinterest to social medicine since their effect is the

prevention of disharmony between the individual andthe conditions of his employment. In the Army as incivil life much sickness is nothing more or less thandisinclination born of dissatisfaction and transformedinto disability.

It is of interest to note that in the Army, physicalmedicine has come to be no longer primarily concernedwith the exhibition of physiotherapeutic procedures.It has become that branch of medicine which is especiallyconcerned with what may be called somatology-with thesomatological aspects of those psychosomatic problemsthat refer to the attainment, maintenance and restora-

tion of maximum fitness in a social group.This ombination of psychiatrist interested in group

problems and competent in their investigation and thespecialist in physical medicine must be projected intopostwar civil life and must be employed in -a compre-hensive attack on the criteria of a positive, healthregimen, interpreted in relation to maximum fitness ofthe individual for a particular job in a particularenvironment, and embracing individual variables such assleep and exercise requirements as well as sociallysignificant variables such as the demands on the humansubject of mechanical transport and the best distribution

of leisure. Such matters as these must -have profoundsocial repercussions on our views concerning pre-habilitation, rehabilitation, revocation, vocational guid-ance, town-planning, location of industry, distributionof population, &c. The study of all of them entailsaccess to groups of individuals and an interest in thepsychological and physiological, rather than in thestatistical aspects of social medicine.There is no paucity of existing facilities for the conduct

of such inquiries in civil life. It is sufficient to point totwo examples the factory and the nursery school. Thetime has surely come to take a broader view of industrialmedicine linked with industrial psychology as one of themain diversions within the province of social medicine.The time is ripe also for using the machinery of thenursery school for the intensive study of child life andhealth. Moreover, projects already being devised foryouth services such as the Army Cadet Force and theprospect of compulsory military service will provide fullopportunities for carrying forward such inquiries intoand through adolescence into maturity.The general social conditions within the Army receive

no less attention, and as far as possible they are somanipulated by the welfare, education, medical andother directorates that they are attuned to the needs ofthe soldier. In these activities the psychiatrist, who inthe Army is a social psychologist rather than an alienist,is involved in a consultative capacity.

It is recognised that the military quality of troops isdetermined very largely by factors that pertain to thesocial environment of the Army-that for example therecord of performance in battle, the incidence of crimein a military sense, the rate of deterioration of moralethat is a function of the duration of service especiallyoverseas, no less than the incidence of preventablesickness, are profoundly influenced by such factors asthe quality of the educational, entertainment andrecreational agencies provided and the frequency andregularity of.the.mail. -

We of the Army have cause to know the prophylacticproperties of the postage stamp and to appreciate the

.i value of medal ribbon as a wound dressing. We knowthat sickness is rare in such as enjoy a sense of partici-pating in a goodly enterprise, the purpose of which isunderstood by the troops and applauded by the com-munity of which they are part. We know that thefeelings of being forgotten and of being frustrated arethe prodromata of much serious sickness, which for itscure demands treatment that is outwith the scope ofmedicine itself. ’

The Army organisation is such that insofar as this ispossible under the conditions of actual war it is anenvironment-natural, occupational and social-which isharmonised with the needs of those who serve in it.

Since intraspecific warfare can by us be regarded only asa disgraceful anachronism, a denial of man’s moralityand intelligence and a ghastly betrayal of science, itfollows that it remains impossible within the Army, aninstrument of war, to create an environment that ispropitious to the cultivation and expression only ofthose human attributes that are socially valuable and tothe satisfaction of those needs that are beneficent.Nevertheless .since battles are rare events in war andremain the experience only of the minority of those inuniform there is much in Army life that approximatesclosely the conditions of peace. For this reason there ismuch in military sociology that could with advantage becarried over into peace-time society.

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ORGANISATION OF A UNIVERSITY DEPARTMENT OF

SOCIAL MEDICINE

From the foregoing it will be apparent that in my viewto the specialists iri public health and industrial medicinewho heretofore have constituted the staff of a typicaldepartment of public health there should now be- addedspecialists in social biology, demography, social a-ithro-pology, social psychology and physical medicine to forman integrated group; behind which there should be astrong statistical laboratory. Such a group has beenfashioned by the needs of and by the opportunitiesafforded by the Army. Nothing would be more

reasonable than that with the restoration of peace thisgroup should be transplanted to form the- staff of auniversity institute of social medicine. - The groupshould so organise and exercise itself in teaching andresearch that it would come to be-regarded by clinicians,medical officers of health and their staffs and oth rs, asthe centre to which they naturally turned for help in thedesign of investigations in the field of social medicine, inthe conduct of investigations, and in the interpretationand .presentation of the results that emerged there-from. Nothing is more certain than that the lack ofa centre of this kind has prevented scores of isolatedmedical men up and down the land launching upon theinvestigation of problems that beset them in the courseof their daily work and that the existence of such acentre to which these men could turn for technicalassistance would multiply the volume and value ofresearch in the field of social medicine a hundredfold.

SOCIAL MEDICINE AS A NEW WAY OF LIFE

What has gone before has been an attempt.to state incoldly academic terms the scope of the problems withwhich teaching and research in social medicine are

concerned, the techniques on which it must rely,-andthe personnel required for the task. There is no need todisplay its social worth for this is surely self-evident.Its elevation to rank as a discipline in its own right,however, signifies much more than the provision of anew instrument to be used in the interests of socialpolicy in matters affecting community health. Itsignalises also the birth of a new outlook on humanaffairs, a new interpretation of human relations in a freesociety and a new scale of social values.During the past two centuries advancing medical

knowledge has generated new communal aspirations byexposing common perils. The process of democraticgovernment has become increasingly involved inresponsibility for administering the results of newscientific knowledge concerning human needs in respectof such things as food, homes and work. The publichealth is now one of the major preoccupations ofgovernment in a democratic society, and our professionis therefore robed somewhat uneasily in the mantle ofthe elder statesman: its own special responsibilities,already great, will certainly increase in the postwarworld.The discoveries of medical science are quickly made

known to the general public and an appreciation of theirimplications is quickly and widely diffused. Out of thisawareness there is emerging a new social phenomenon,the rational recognition of common needs. So it is thatpolitics, which used to deal with human rights anddesires, is now concerned more and more with humanneeds. It is the aim of social medicine to definethese needs and ceaselessly to urge that they shall besatisfied.