A Timeless Debate with an Old-Timer: A Man-date with Johann Peter Frank by John Tucker

From the multitude of personalities who have contributed to the field of public health across roughly five millennia, from the period of ancient Egypt through the Industrial Revolution, I chose to have dinner with Johann Peter Frank.  I think my choice is interesting not because Frank contributed more to the field than any other figure, although some public health historians do refer to him as “the father of public health,” a title I thought was reserved for John Snow.  Nor do I think he’s an interesting choice because his ideas were particularly revolutionary; as Baron points out, the concept of the “medical police” was discussed and implemented in Germany two full centuries before Frank was even born.  The reason why I consider Frank an interesting choice for this topic is because, based on his principles, he seems like the least enjoyable dinner companion in human history.

            Frank’s legacy in public health is his extreme promotion of enlightened despotism, the social philosophy that calls for the state to formulate thorough policies regarding the health of its citizens and to enforce these policies strictly.  In his magnum opus, a six-volume, 6262-page tome entitled A System of Complete Medical Police, Frank attempted to lay out in painstaking detail such policies, regulating nearly every aspect of human health and behavior, including procreation, marriage, food, drink, clothing, entertainment, public safety measures, burial, and education.  A few of the more absurd suggestions outlined in this work include a mandate that citizens at a dance party take a rest before leaving lest they catch a cold in the nighttime air, a ban on corsets as they restrict a woman’s breathing too tightly, and a ban on public performances in which too many characters are murdered, as these works lead to depression in the public.

            His reasoning for such drastic intrusion into the lives of his countrymen was both humanitarian and patriotic.  As a young physician, Frank observed that the diseases affecting people most severely were often preventable as they were rooted in social conditions.  It seemed obvious to him that people could not reasonably protect themselves and needed guidance from the state to stay healthy and happy.  Additionally, Frank reasoned that the best way to strengthen a nation was to strengthen its citizens, a feat best accomplished by regulating their behavior.  Although the rigidity and intrusiveness of his methods seem abhorrent to modern-day democrats, it sounds like his heart was in the right place – he wanted to save lives and strengthen his country.           

Despite his good intentions, I think Frank was terribly naïve and misguided, and were his plan to be fully implemented, I believe mankind would suffer dramatically.  In addition to restricting all the things that might spice up a good dinner party, such as drinking, drug use, gambling, overeating, promiscuous sexual behavior, and entertainment with gratuitous violence, Frank spent his life promoting a theory with which I fundamentally disagree.  If all that weren’t enough, his resemblance to Hannibal Lecter is uncanny.  Why then would I have this guy over to my house for dinner?

 However terrifying and prude he may have been as a person, and however totalitarian his ideology, I am intrigued by the concept he proposed.  Frank resides on the farthest extreme of a topic which to this day remains relevant in public health debate - the question of state control versus individual liberties.  Somewhere at the headquarters of the ACLU, there’s probably a dartboard with a picture of Frank’s head as the bulls-eye.  His ideas represent a libertarian’s nightmare and the antithesis of Enlightenment philosophies on which modern liberal democracies were founded, although most have adopted many regulations similar to those Frank proposed.  The continuation of this debate makes Frank’s principles pertinent, and I think it’s important that people consider the pros and cons of both sides.

 

The message I would like to convey to Frank in the preparation and setting of our dinner is the concept of personal choice, because after all, this is my house.  For this reason, I’ve set up a buffet of American, British, and French cuisine, representing the various hotspots of Enlightenment thinking, and of course a selection of whatever German foods he deemed appropriate for the public in his manifesto.  Wearing a t-shirt and sweatpants, I pile my plate high with steak frites, fish and chips, and a giant piece of apple pie with a piece of American cheese melted over it.  I pour myself a giant beer, and sit down, being sure to leave the seat at the head of the table open for my paternalistic guest.  Once he sits down, I get us rolling on the debate.  “How’s your gruel?” I ask with a mouth full of steak.

“Delicious,” he replies, acknowledging my sarcasm.  “It feels good to eat healthily.”

“True, but only if you’ve chosen to eat healthily, rather than being told to do so, right?”

“Wrong, it feels good to be healthy, regardless of how or why you came to be that way.  Trust me.”

“And why should I trust you – what gives you the right to take away my right to choose what to eat and how much?”

“Because your decisions affect me in ways you don’t seem to understand.  The ways you eat, drink, smoke, fornicate, dress, and entertain yourself all contribute to your health, or lack thereof, and as the behaviors in which you choose to engage weaken you, so you weaken my country, and thus weaken me,” he retorts. “I am helping you help yourself and your country.”

“I think you’re ruining my country.  Yes, we’ll all be healthier and we’ll live longer under your system, but we’ll all be miserable wondering what life would be like if we could enjoy the wonderful, dangerous, unhealthy options you’ve taken from us.  And how do you expect the state to progress when you’ve got us stuck in a vacuum?  Personal choice combined with freedom of expression leads to new ideas and progress.  A state that controls its public is stagnant, and that makes it unhealthy,” and as I bring the largest piece of pie I can hold on a fork to my face, Frank slaps it out of my hand. 

“Wrong – you’re unhealthy.”

“Well, that does it.”  I get up out of my chair, lift Frank out of his, and throw him out of my house.  Just as it is society’s duty to revolt against a tyrannical government that breaches its social contract, so it is mine to throw out an aggressive house-guest.

 

Despite this outrageous hypothetical interaction, I actually believe a state should exercise a certain amount of control over its populace when it comes to healthcare decisions.  The enlightened despotism that Frank preached invokes a miserable, Orwellian society, but as awful as that existence would be, there is an equally terrible alternative opposite the spectrum in a pure libertarian state.  Without traffic laws to keep people from running each other over, or the FDA to keep carcinogens out of their breakfast cereals, people would be unsafe, unhealthy, and unhappy, living in fear of all the unregulated, unknown dangers lurking in their environment.  The key is for the state to provide guidance only when absolutely necessary to protect its citizens, without sacrificing personal freedom.  Such balance is obviously difficult to find.

As the causes of mortality rates in industrialized nations have shifted in the last century from communicable to preventable chronic diseases, the debate over state intervention versus individual rights has never been more relevant.  The tricky part about government regulation of the behavioral factors in these diseases (e.g. tobacco, alcohol, unhealthy food) is that their diagnosis doesn’t threaten the public the way that communicable diseases once did.  Therefore, the “well-being of the community” justification doesn’t hold up as much anymore for proponents of coercive public health measures.  This reality forces society today to revisit the question Frank tried to answer two centuries ago – are coercive public health measures necessary to preserve the strength of the state, and if so, is there enough justification to sacrifice some personal freedoms?

When considering the modern debate about state control over public health, it is important to remember Frank’s legacy as a reminder that some government interaction is necessary but too much will crush the individual spirit.  The key to a healthy state lies somewhere in the balance.

Dinner with Ignaz Philipp Semmelweis by Caitlin Patterson

In 1818 in Hungary, a man was born who would influence the development of public health.   Throughout the course of his life, which ended abruptly in 1865, Ignaz Philipp Semmelweis led a dramatic discovery in antisepsis, before full development of the germ theory.  Semmelweis would come to be known as ‘savior of mothers’ when, by mandating hand washing with a chloride of lime solution after performing post-mortem examinations and prior to examining obstetrics patients, he caused significant reductions in maternal mortality rates in Vienna and Budapest in the mid-19^th century.

            Having learned of Semmelweis’ historical significance in my studies of public health, I knew that his discovery of hand antisepsis as a method of reducing disease transmission was not met with widespread acceptance and he was faced by many in the medical community with tremendous adversity.  Although his work had the potential to instantly prevent numerous deaths within hospitals, circumstances and beliefs of the time led to a drawn out period of opposition and therefore unnecessary deaths of mothers and children.  For Semmelweis, the grief of this knowledge was difficult to bear.  Late in his life he was stricken with depression and psychological disease that consequently led to his death. 

            I have invited Ignaz Semmelweis to join me for dinner.  I have selected this man for several reasons.  First, I would like to gain an understanding of his perspective through the course of his discovery, especially as he was met with opposition from the medical community in Vienna.  Second, I would like to give him the opportunity to speak with someone, who, over 150 years later has a basic understanding of germ theory and modern medicine and can validate his concept of puerperal fever.  He is deserving of recognition for his discovery and an understanding of his own credibility.  Finally, I would like to share with Semmelweis modern views on his contributions to medicine and public health and the steps many have taken to recognize him.

            Semmelweis arrived at my home at six o’clock in the evening.  Prior to beginning our meal, Semmelweis inquired as to whether I had washed my hands.  I smiled and nodded, I had.  I informed him of our modern antiseptic methods of antibacterial hand soap, and could see that he was impressed.  As dinner began, I told Semmelweis about myself and my pursuit of a Master of Public Health, a concept that he was intrigued by.  I told him that I was most interested in hearing his story, and he began. 

            My career in medicine began when I moved from Budapest to Vienna to pursue law.  I quickly changed course, as you know, to study medicine.  After one year studying in Vienna and two at the University of Pest, I completed my degrees in Doctor of Medicine and Master of Obstetrics at the University of Vienna.  I became acquainted with three physicians by the names of Joseph Skoda, a teacher of general medicine and statistics, Ferdinand Hebra, a dermatologist, and Carl Rokitansky, a professor of pathologic anatomy. These men would later become close friends and colleagues. 

            I nodded my head, listening closely.  He continued.

            In 1846 at the age of 28 I was appointed assistant to Dr. Johann Klein, professor of obstetrics.  I began assisting with child births in the First Maternity Division of the Vienna General Hospital.  Almost immediately, I noticed a disturbing rate of maternal mortality in the First Division.  It was devastating to watch a healthy new mother transform to a helpless victim of childbed, or puerperal, fever.  It was a terrible sickness: the patient was seized by a shivering fit and a great degree of heat resulting in perspiration, accompanied by severe, consistent pain in the abdomen.  Death usually resulted within a matter of days.  I was told by my predecessor and others that the women were being killed by an invisible miasm, an unknown epidemic influence of an atmospheric-cosmic-teluric nature. 

            What struck me most about all of this was the fact that in my first year, 459 women died in the First Maternity Division.  Next door, however, in the Second Maternity Division, only 105 deaths occurred: nearly five times fewer.  I found other trends in mortality.  The women who delivered outside of the hospital, on the street, were not dying of childbed fever.  Alternatively, the women who experienced longer period of labor were nearly always victimized by the disease.  These inconsistencies consumed me, and I investigated every possible explanation that I could conceive.  I spent a great deal of time in the deadhouse performing post-mortem examinations; back and forth between autopsies and deliveries.  It was not until the day when I learned of the death of my friend from a knife cut during an autopsy that I realized the cause: physicians, myself included, were carrying decomposed animal organic matter from the corpses to the mothers.  This explained the difference in number of deaths between divisions: in the First Division, patients were examined by physicians who also performed autopsies, in the Second Division, patients were examined by mid-wives and nurses who did not.  It also explained why the women who did not deliver in hospital did not contract the disease: they were never examined by a physician.  The women who experienced longer laboring were examined many times by physicians, hence their higher mortality rates. This was a difficult reality to learn, that I, the doctor who should be providing care for my patients, was actually carrying to them the disease that was killing them.

            He went on.

            Immediately, I mandated hand washing by every medical student and physician with a chloride of lime solution.  Within months, the number of puerperal fever deaths in the First Maternity Division fell to the levels of the Second Maternity Division.  From what I understood about childbed fever, and as I described in my publication later on, there were three sources.  The first, from a dead body.  The second, from a sick person who is afflicted by puerperal fever.  The third, any decomposing matter.  This was identified when the sheets of an afflicted patient were transferred to a healthy patient who subsequently acquired puerperal fever.  The blood that had contaminated the sheets carried the disease.  I found that the disease was transmitted by the hands of the examiners, the hands of the operators, surgical instruments, bed clothes, atmospheric air, sponges, and the hands of midwives and nurses who came in contact with the excrement of afflicted patients.  Subsequently, we began washing medical instruments in the solution between patients as well.

            At this juncture I was compelled to interject.  I explained to him that his discovery was quite remarkable considering the fact that germ theory was yet to be fully uncovered, and also that he was almost completely accurate.  Today, we know puerperal fever to be caused by bacteria called Group A streptococcus.  We also discussed that fact that hand washing was not a completely new concept at the time of his discovery. The unique aspect of his discovery was that he recognized the cause of puerperal fever was being directly transmitted from one individual to another on the hands, and he understood the concept that there was one cause for the disease.  He was ahead of his time.  I told him that today his innovations represent the basis of infection control practice.  In hospitals, where we still face the danger of bacterial infection transmission from patient to patient by way of health care providers, physicians are required to wash there hands frequently, and always before contact with a new patient.  Hospital acquired infections continue to be one of the major preventable, iatrogenic complications of hospitalization.  What I find so fascinating about his compulsory hand washing is that appropriate action was taken to avoid infection based on inadequate information about the infection. 

            Semmelweis stated that he is pleased to hear what I have told him, but that it was an extremely difficult time in the mid-1800s when he was attempted to change the ways of physicians.  Dr. Klein was the first to denounce Semmelweis’ findings.  Others stated that ‘the mere suggestion the puerperal fever might be transmitted by medical attendants was abhorrent, would damage the trusting physician-patient relationship, and that fear engendered in the laboring woman by such a suggestion might in itself cause her to be afflicted by the disease’.  He described the frustration and anger he felt with the medical community.  Differing opinions with Klein led to his dismissal, and he left Vienna for Budapest.  When invited to speak on his findings in Vienna, he initially refused.  His methods of communication seemed, to me, inadequate to accomplish the change in physician behavior he was seeking.

            Listening to Semmelweis, I could sense the frustration and turmoil that he felt during this time in his career.  He went on to explain that when he did publish his work, which he had put off for several years, he could not help the angry tone that came across.  As the end of his life neared, he was not the same doctor he had once been.  He alluded to the final days when he was admitted to the asylum, where he died from an infection that entered through a cut on his hand.

            It was late then, and I thanked Semmelweis for spending this time with me, that it was an honor.  I also told him of the recognition he has been given.  Within 40 years of his discovery, his hand washing technique was adopted by most in the medical community.  I told him that Budapest Medical School is now named Semmelweis University of Medicine.  I told him that although the type of innovation he was attempting was initially accompanied by resistance and hostility, ultimately he is known for making a landmark contribution in the prevention of puerperal fever.  He smiled and thanked me, and I hoped that our conversation had given him a small glimpse into his success as a physician.  We then said good bye.

After Semmelweis left, I had time to process all that we discussed and all that I have learned from my research on his work and life.  His experience offers many lessons in public health: around discovery and innovation, communicating information, and implementing changes necessary for improvement. Semmelweis made a significant discovery at a time when he lacked complete information about the disease he was studying.  The set up of the First and Second Maternity Divisions played an extremely important role in his discovery, as he was able to use them as a case-control study.  Epidemiology played a role through his comparisons of the two divisions and the resulting tables he created.  Semmelweis faced unique challenges in his time.  A majority of the medical community was resistant to his discovery.  They felt that hand washing before each patient would be time consuming.  In some journals, the profession was referred to as believing it was divinely blessed, and therefore it would be unreasonable to think the physicians themselves could be causing the disease. The germ theory was not clearly developed at this time.  These circumstances presented challenges for the acceptance of Semmelweis’ discovery.

Semmelweis lacked important skills to implement change.  He presented his work but did not publicize his discoveries for several years.  When he did communicate his work, he did so in what is described as an angry, resentful, and, at times, threatening tone.  He refused offers to address medical colleagues. Some viewed him as ‘tactless, volatile, single-minded, with a pompous’ personality.  His responses to requests for proof were often rude.  He clearly lacked patience and tolerance that is required when presenting a new concept to a group with established beliefs.  Often success relies on one’s personal attributes and ability to communicate a new idea.  Semmelweis had one half of the requirements needed to improve public health but lacked the other half – the ‘change agent’ skills.  Spending time with Semmelweis helped me to realize some of the challenges I will face in the field of public health and some of the methods that can be utilized to overcome these challenges.  It is apparent that historical figures in public health, like Ignaz Philipp Semmelweis, continue to make contributions to our learning years after they are gone.

Cities of the Poor

Hi all,
Here is a great link. I recommend Public Radio International's Cities of the Poor which is part of an ongoing series on urbanization. This is such a great program because it addresses the experience of slum dwellers in several regions of the world- with input from people living there, members of government, researchers, developers, and economists. It really illustrates how infinitely complex an issue can become when you take into account the interests of all parties involved.
http://www.theworld.org/mp3/citiesofthepoor.mp3

Molokai' Leper (Hansen's Disease) Colony

Hello,

This is a link to a segment that was featured on CBS in 2003 regarding the Leper colony that was established in the late 1800's in Hawaii. It is a short, yet interesting read on how the Hawaiian monarchy dealt with Hansen's disease during the 1860's. The law that was set by the Hawaiian monarchy was upheld until 1965, the year when the quarantine was lifted. I think it is interesting that Hawaii was annexed as a territory by the US in 1898 and was later admitted as a state in 1959. Medical treatment for Hansen's disease was discovered in the 1940's. However, it took 25 years for the quarantine to be lifted in Hawaii and that act happend six years after Hawaii was an admitted state.
The pubmed article outlines the US governments involvement with the leprosy colony in Hawaii and identifies international public health issues (eg health disparities that existed among Hawaiian patients) that developed during the 1900s.

http://www.cbsnews.com/stories/2003/03/22/health/main545392.shtml
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1422729&blobtype=pdf

Ela Macander

Pathologies of Power

I am reading "Pathologies of Power" by Paul Farmer and so far I think that the book is extremely informative and interesting, but I am struggling to comprehend why our abundant world has become so polarized. The book focuses on the injustices and inequalities that Farmer has observed throughout many different parts of the world (Haiti, Chiapas, Russia, U.S.). At this point in the book I have a good understanding of the disparities that exist in this country and in others, but I am trying to wrap my head around why people in power have let this happen. Public health is at the mercy both of biological and social forces. Farmer's focus in the first few chapters is on "structural violence," which I agree plays a significant part in preventing people from obtaining the highest achievable standard of health. However, it is difficult for me, as a compassionate humanitarian, to accept that those in power are solely motivated by greed.

I think an extremely interesting theme that is repeated in the book is "market ideology" and how it negatively impacts those without any power. I would like to learn more about the role of international agreements, trade, and economics. How does WTO and NAFTA agreements impact public health in poor regions of the world? How could things be altered to keep international trade and economics functioning, but at the same time not cause extreme suffering to those in the third wolrd?

Welcome to the blog!

Hello all!

As I mentioned in class, this web space can be used for posting your journal entries and to share your thoughts with the rest of the class.  It is an experiment, as is much of IH 771, but I think it could truly enhance the "learning from each other" goal of this course.  Use it to share your reflections that are either insightful, controversial, provocative, funny, or all of the above.

Anand