Prescribing Democracy

by Danielle Ofri
New York Times op-ed

In the winter of 1847-48, a typhus epidemic raged through Upper Silesia. The Prussian king dispatched a young Dr. Rudolf Virchow to investigate the outbreak. Dr. Virchow would later achieve scientific sainthood for disposing of Hippocrates’ idea that humors caused disease, solidifying the idea that cells were the basis of biology and coining terms like leukemia, spina bifida, thrombosis and embolism. But in 1848, he was a 26-year-old lecturer in pathology at the Charité hospital in Berlin — a disposable junior faculty member who could be banished to the hinterlands.

What Dr. Virchow found in Upper Silesia was a district ravaged by famine and economic depression. The germ theory of disease hadn’t yet been fully accepted, so Dr. Virchow couldn’t pinpoint a bacterium as the agent of the outbreak. He was, however, able to identify the conditions that promulgated the disease — poor sanitation, terrible working conditions, inadequate housing, meager education and unhealthy diet. In other words, all the concerns of modern public health.

In his report, Dr. Virchow cited exploitation and lack of self-governance as the sources of those disease-promoting conditions. He excoriated the aristocrats who “expropriated great wealth from the Upper Silesian mines” but regarded the workers “not as human beings,” the government functionaries who served “the interests of the state” instead of the people, and the church that demonstrated “contemptible selfishness and lust for power.”

“There cannot be any doubt,” Dr. Virchow concluded, that the epidemic was a result of “the poverty and underdevelopment of Upper Silesia.” The prescription, he stated, should be “free and unlimited democracy.”

A prescription for democracy — not something you get at your average doctor’s visit — is increasingly on the minds of medical professionals these days.

The goal of doctors and nurses is, of course, to improve the health of our patients. We treat the immediacies of illness — antibiotics for pneumonia, inhalers for asthma — but good health requires much more than medications. We have to think about lifestyle: what our patients eat and how much they exercise. But a healthy lifestyle requires adequate housing, so some health centers are now helping homeless patients find a place to live and asthmatic patients rid their homes of mold. And in a country like ours, without universal health care, helping our patients stay healthy means that we have to be concerned about whether they have health insurance.

Suddenly, like Dr. Virchow, we are recognizing that our purview extends to the entire structure of our society and that politics is, as he put it, “nothing else but medicine on a large scale.” Political decisions that affect insurance coverage, access to medical care, housing, minimum wage, immigration law, water sources — just to name a few examples — exert medical effects that are comparable with those of major diseases. Just ask the people of Flint, Mich.

Like many doctors and nurses, I became politically active for the first time during the summer of 2017, when Congress tried to repeal the Affordable Care Act. I could see the direct risk to my patients — all of whom, inconveniently, had pre-existing conditions — and realized that protecting health care coverage was as critical as prescribing insulin.

Now, as our society feels increasingly fractured, the health threats seem even more alarming. Growing income inequality, disregard of environmental hazards and the undermining of social safety nets all stand to harm our patients’ health. Dr. Virchow’s words from 170 years ago about the creep of religion into state affairs, the outsize power of the wealthy and the autocratic impulses of government feel unsettlingly contemporary.