Across a dimly lit table from renowned innovator and activist, Rudolf Virchow, I am struck by the force of this man’s historical impact on medicine and its politics, and awed by the depth of insight I have been invited to witness. His presence is full of energy and contradiction, the challenging attitude that beckoned his contemporaries toward progression still present in his reincarnate state. We are separated by two plates of food, he has ordered the filet, and I the swordfish, and two half-full glasses of an earthy pinot, which has colored his teeth and lips an ashy purple and brought a rosy glow to his nose and cheeks. Illuminated softly by the amber light from the restaurant’s chandelier and a small candle pushed to the side of the table, I see the eyes of a humanitarian, full of years of struggle against health inequity, asking me to come with him as he guides me through a life dedicated to social medicine.
I am interested in how a man of his impact evolves, and I ask him about his path to medicine and then politics. He begins at the beginning. He was born in what was then Prussia, near the border of Poland, on October 13, 1821. Noticed a rebellious intellectual in high school, he was offered a scholarship to study medicine in 1839 at the Friedrich-Wilhelms Institut in Berlin, Germany. He felt a passion to acquire a universal knowledge of nature, and pursued this goal out of medical school in his studies under the guidance of Robert Froriep, a pathologist at the famous teaching school of Berlin, the Charite. Virchow’s ability to read multiple European languages assisted in his analysis of the current medical wisdom, and he quickly learned his opposition to the constructs of theoretical medicine. He sought a practice of medicine based on observation and experiment and spent a lot of time in the laboratory and the autopsy room. He tells me, and it is apparent, that it was his attitude toward medicine and his courage to seek answers to his questions in a new way that enabled his early contributions to the medical field.
While working in Wurzburg in the 1850’s, he professed the concept of cells as the basic elements of the human body, and he blamed disease on the failure of cells to execute their normal and specialized functions. He believed, in a society of opposing thinkers, that advances in patient care would be made through understanding disturbed anatomy, resulting from disease. Through his experimental work, he uncovered understandings of thrombosis, haematosis, and embolism, proved leukemia to be a cancer of white blood cells, and discovered neuroglia, gliomas, giant cells, and the amino acids leucine and tyrosine. He brought to light the process of ischemia and its effect on stroke and heart attack. The Archive of Pathological Anatomy and Physiology and Clinical Medicine, still a highly respected journal 150 years after he started publication, helped to convince germ theorists, Pettenkofer with his “three factors” approach, and Koch the reductionist, cemented to the idea that illness had only one cause which could be pinpointed, to look at medicine with a wider gaze. As a professor at his alma mater, he wrote his book, Cellular Pathology, hoping “to rid medicine of the mysterious,” and gifting the medical profession with answers to Where? Why? and How? of disease.
He stops his story here. The subject of discussion up to this point has focused on innovation in pathology and biomedical advancement, cellular medicine. This work taught the medical profession how to successfully provide patient care through continuous progression in the understanding of cells, anatomy, and disease. I tell him, much of the medical profession has left it there. We continue to innovate scientifically, creating new treatments to improve our patient’s health, and yet we are not seeing the improvements we expect. We think that through creating greater access to cellular medicine for the disadvantaged, we will find success in bridging the inequalities we see in health status. There is such an intense reliance on this cellular medicine that Virchow’s work in social medicine has been forgotten or overlooked. I tell him his work is as relevant today as it was 150 years ago, and he knows and says, "we have often referred to 'the scientific method.’ We now find that through applying it, we have moved from medicine into the social field, and in so doing, we have had to consider some of the fundamental issues of our time."
I ask him to tell me about his work to broaden the role of medicine in society. I want to understand his beliefs and the obstacles he faced in encouraging a cultural change, that I might gain insight into the work I have ahead of me. His eyes brighten and he tells me, "the only goal of our efforts [is] to endeavor to build society on reasonable foundations, or, in other words, to create institutions that guarantee the liquidation of pauperism."
Virchow became the father of social medicine during the typhus epidemic in Upper Silesia. In 1848, at the age of 27, he was asked by the Ministry of Education to investigate the wretched state of a group of textile workers, “ethnic Poles,” in Upper Silesia under Prussian rule. He agreed to study the epidemic and concluded that poor sanitation, lack of basic hygiene, poor access to education, and starvation were the origins of the epidemic, a diagnosis he followed with a public demand for democracy. "The answer to the question of how to prevent outbreaks in Upper Silesia is quite simple: education, together with its daughters, freedom and welfare." Through this statement, and the article he wrote analyzing the issue, he illustrated the fact that although "the improvement of medicine would eventually prolong human life, improvement of social conditions could achieve this result now more rapidly and more successfully.”
Virchow was the first of his time to tie poverty to ill health, and to assess the disease state, encompassing its environmental factors. There were other scholars with similar beliefs in France and England with whom he collaborated, but none addressed the issue completely. Virchow believed that "physicians are the natural attorneys of the poor, and the social problems should largely be solved by them." He himself embodied the role of physician-reformer. “The physician is a citizen uniquely equipped to further the public good, and the practice of medicine cannot be divorced from its social milieu.”
Our world today cannot continue to focus only on scientific medical solutions to poor health. We must broaden our view of medicine to include the environmental factors which so intensely sway our probability of success. This change must include rigorous involvement of physicians who ask questions about education, work status, and social support, enabling research and hence increased knowledge of epidemiology. We know that failure to complete high school is a risk factor for disease as poignant as genetic makeup in our country. In our new approach to healthcare, we may focus on the importance of increased education, equally effective in improving health as the construction of new medical facilities or increased services. It is important that physicians take the lead in illuminating these issues of socioeconomic equity in relation to health in order for politicians and the public to realize the power of their implications.
It is not without politics that the changes we need will be accomplished. “Every individual has the right of existence and health, and the State is responsible for ensuring this,” argues Virchow, who served as Berlin City Counsillor for 42 years, beginning in 1859. At this post, he worked to improve the sewer and water systems of the city, he organized reform of the public hospitals, and he fought for progression. "The progress of medicine should be as the progress of humanity, the measure of its practical and theoretical utility should serve at the same time as a measure of the correctness of what it accomplishes." During the Franco-Prussian war, he served as medical officer at the front and organized the military hospital system. There, he insisted on providing care to any in need, regardless of nationality. Virchow was also a founder of the German Progressive Party, opposing Bismark. He was elected to the House of Deputies in the Prussian legislature, where he took a liberal stance, advocating the address of social inequity.
The restaurant is empty, so is the wine, and as his life story concludes, we feel the weight of the reform ahead. As the first to advocate for the social medicine our societies need, he has done his part, and yet I see the disappointment of his face as he realizes society remains stuck so near the place where he gave it its first budge. There is a lot of work to be done. The work is of the hardest kind. We want to change the way people view the world, change cultural expectation, and specifically change the expectations of medical professionals, so disconnected from the pressing responsibilities to be assumed. But, there are people like me, ready and willing to continue Virchow’s work, and supported by the example he set. There are so many people like me.
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