Social medicine as a medical

science
Nikolai Hristov, MD, PhD
Historical roots
• The concept of social medicine has its roots in 19th century Europe. The idea
that medicine is a social science was formulated first by pioneers such as
Neumann (1847) and Virchow (1848). Their ideas were ahead of their time
and soon supplanted by the emerging germ theory of disease, striving to
explain all human pathology with microbial agents.
• In 1911 the concept of social medicine was revived by professor Alfred
Grotjahn (1869-1931) in Berlin, who stressed the significance of social factors
in the etiology of disease; a notion he called “social pathology”.
Developments in the fields of purely social sciences like sociology,
anthropology and psychology firmly established that man is not only a
biological animal, but a social being and thus, all diseases have their social
causes, social consequences and social therapy.
Contemporary notions
• Historically and in different countries social medicine has had various meanings
attached to it. By definition it studies the influence of social factors on health, i.e.
the study of man as a social being in his total environment. Social medicine
focuses primarily on the health of human communities as a whole.
• It concerns itself with the development of epidemiological methods and their
application to the investigation of disease. It emphasizes the strong relationship
between medicine and social sciences using methods from social sciences and
statistics to elucidate the role of social factors in disease etiology.
• However, not once it has been noted that social medicine should not distance
itself from the real world of health services delivery and remain confined to
academic studies of chronic disease and the health service.
Contemporary notions
• The major emphasis on biomedical science in medical education, health care,
and medical research has resulted into a gap with our understanding and
acknowledgement of the far more important social determinants of public
health and individual disease: social-economic inequalities, war, illiteracy,
detrimental life-styles (smoking, obesity), discrimination because of race,
gender and religion. Paul Farmer gave the following explanation for this gap:
• “One reason for this gap is that the holy grail of modern medicine remains the
search for a molecular basis of disease. While the practical yield of such
circumscribed inquiry has been enormous, exclusive focus on molecular-level
phenomena has contributed to the increasing "desocialization" of scientific
inquiry: a tendency to ask only biological questions about what are in fact
biosocial phenomena.
In essence
• Social medicine refers to understanding how social and economic
conditions impact health, disease and the practice of medicine and
fostering conditions in which this understanding can lead to a
healthier society or, in essence, studies the social determinants of
health.
• Public health refers to "the science and art of preventing disease,
prolonging life and promoting human health through organized
efforts and informed choices of society, organizations, public and
private, communities and individuals".  It is concerned with threats to
health based on population health analysis.
Social detreminants
• Social determinants of health are the economic and social conditions and their
distribution among the population that influence individual and group differences
in health status. They are health promoting factors found in one's living and
working conditions (such as the distribution of income, wealth, influence, and
power), rather than individual risk factors (such as behavioural risk factors or
genetics) that influence the risk for a disease, or vulnerability to disease or injury.
• The World Health Organization states that, "This unequal distribution of health-
damaging experiences is not in any sense a 'natural' phenomenon but is the result
of a toxic combination of poor social policies, unfair economic arrangements
[where the already well-off and healthy become even richer and the poor who are
already more likely to be ill become even poorer], and bad politics.
The changing focus of public health
• Disease control (1880-1920). Sanitary legislation and measures aimed
at controlling man’s physical environment like clean water supply, food
safety, sewage disposal, etc.  
• Health promotion (1920-1960). In the beginning of the 20th century the
idea that the State is responsible for the health of its citizens, began to
take shape. Developed countries engaged in offering mother and child
health care services, school health services, occupational health
services, mental health services, social and rehabilitation services.
Public health nursing appeared as a new medical profession. Basic
health services in the form of primary health care were guaranteed for
the whole population.  
Continued
• Social engineering (1960-1980). With the advances in preventive medicine, the pattern of
disease in developed countries changed completely – from acute diseases (infectious and
parasitic, trauma, complications of pregnancy and birth) to chronic non-infectious
diseases. The concept of risk factors for these diseases came into being. Public health
practice moved into the preventive and rehabilitative aspects of chronic diseases and
behavioral problems. The term “community medicine” started to be increasingly favored.  
• Health for All (1980-2000). The glaring contrasts in public health between developed and
underdeveloped countries gained international attention. By that time, most citizens in
developed countries enjoyed the primary positive determinants of health – adequate
income, nutrition, education, sanitation, comprehensive health care. In 1981, the
members of the WHO started the ambitious project to provide “Health for All” by 2000,
that is the attainment of a level of health that will permit all people “to lead a socially and
economically productive life”.
The failures of modern medicine
• In spite of spectacular biomedical advances and massive healthcare expenditures, death
rate and life expectancy are practically stagnant in many developed countries. Modern
medicine has come under heavy criticism amd some extreme critics even describe it as a
threat to health. Some of the most alarming facts are: increased medical costs have not
lead to measurable benefits in health; despite modern advances, the public health threat
of infectious and parasitic diseases in underdeveloped countries has not decreased; same
goes for life expectancy, maternal and infant mortality rates; historical epidemiological
studies disprove the notion that longevity in highly developed countries has been attained
through modern medicine, instead it should be attributed to food supply, sanitation and
tackling economic disparities; access to health care services is limited or outright
impossible for large segments of the world population due to financial or geographical
barriers, understaffing, etc.; modern medicine is elitist oriented (focusing on prohibitively
expensive highly specialized services) even in health systems (European countries, Japan,
Canada, Australia, NZ) addressing social disparities.
continued
• To summarize, modern high-tech and expensive medicine seems to be
getting more and more out of hand and leading national health systems
in the wrong direction – away from health promotion for the many and
towards expensive treatment for the few. Western models of medical
education and medical practice are further copied unquestioningly in
most developing countries, which is a very damaging practice (high-cost
and low coverage health care).
• Added to the increasing concern about the costs and allocation of
medical services are doubts about the efficacy (treatment rate) of
modern medicine altogether; we may have reached the limits on the
health impact of medical care and research.
The social control of medicine
• In 1849 the famous German pathologist Rudolf Virchow wrote that
“medicine is a social science and politics is nothing but medicine on a
large scale”. He may have anticipated the upcoming social (political)
control of medicine.
• Modern advancements in medicine lead to ever increasing (some
describe them as spiraling) costs for health care and geographical
disparities (territorially uneven distribution of services), which
inevitably lead to sub-standard care for majority of the population. The
gap between healthcare for the rich and healthcare for the poor had to
be bridged and the so-called “socialization of medicine” started in
earnest.
Continued
• Germany led the way by instituting compulsory sickness insurance in
1883. England followed suit in 1911 and France in 1928.
• Russia was the first country to socialize medicine completely in 1918,
giving its citizens a constitutional right to all health services, followed
by England in 1946.
• Thus, medicine evolved from private initiative to a social institution,
one more link in the chain of welfare institutions (together with
education, social services and domestic security).
Continued
• The socialization of medicine in itself is a noble idea. It eliminates the
competition among physicians in search of clients (patients).
Furthermore, it ensures social equity, i.e universal coverage by the
whole spectrum of medical services.
• However, practice in countries with complete state control over health
services, showed that socialization by itself does not guarantee the
optimal utilization of medical services by the population. The modern
approach is dubbed “social participation” and as envisaged by WHO
and UNICEF, requires community participation in the planning,
organization and management of their own healthcare services
Discussion
• Modern medicine is no longer solely an art and science to diagnose and
treat the disease in an individual patient. Nowadays it has firmly established
itself as the science for disease prevention and health promotion. The scope
of medicine expanded greatly to include not only health problems of
individuals, but those of communities and whole nations or world regions.
This expansion has led in turn to the reformulation of medicine’s objectives.
• National health systems nowadays focus on health promotion and disease
prevention. This is done across all levels of the national health system with
the aim of delivering quality services to the whole population but is
particularly true of the modern health system foundation – primary health
care.