Читать книгу In situ. El cáncer como injusticia social - Natalia Luxardo - Страница 39

Rudolf Virchow was a German physician who lived from 1821 to 1902. He is credited as one of the founders of modern pathology and cell theory. As such, he is also one of the key figures who turned the healing arts into ‘modern, scientific medicine’ during the 19^th century, for which the laboratory and the anatomic theatre stand as symbols. Observation and experimentation were established as the paradigm of modern medicine, and remain so to this day.

The disciplines of ethnology and anthropology also claim Rudolf Virchow as a founding figure. His biographer Ackerknecht has consolidated this legacy in the English-speaking world (Ackerknecht, 1981), and Rudolf Virchow Awards are given by both American and German (medical) anthropology associations (Society for Medical Anthropology, 2018; Berliner Gesellschaft für Anthropologie, Ethnologie und Urgeschichte, 2018). His reputation as an anthropologist comes from his late works in archaeology, but is also based on his early report on the causes of a typhus epidemic in Upper Silesia, which he had been asked to carry out for the Prussian government (Virchow, 2012). His travel to the region and the investigation he undertook had a profound impact on him. In his own and other accounts of his life, it was this experience that turned his interest towards politics. He was shocked by the lethargy and hopelessness that he saw among the population of Upper Silesia, something for which he held regional politics responsible (Andree, 2002; Federsen, 2010).

To understand the situation in Upper Silesia, he conducted a comprehensive study, including observations of agricultural conditions, climate conditions, the cultural, ethnic, and linguistic features of the regional population, the living conditions, the role of the church, and the school system (Andree, 2002). From today’s perspective, this could be termed an anthropological investigation. In his report, Virchow elaborated on the social and political causes of the typhus and hunger epidemic.

Based on his experiences in Upper Silesia and his scientific arguments regarding the social and political origins of disease, he eventually expanded his activities to become a politician. Starting in 1859, he began to use his influence to help shape Berlin politics. As a politician, he turned his attention to the living conditions in Berlin, and successfully lobbied for a sewage system and for the collection of mortality and morbidity statistics, and had a special focus on schools as a place to improve health.

Social medicine, as envisioned by Virchow and others, has had a profound impact on health care delivery in Germany. Germany has almost universal health coverage, with a generally well-functioning health care system that offers access to care for most inhabitants. Germany’s health care system is one of the oldest established health care systems in the world. Initiated by Bismarck’s social laws in the late 19^th century, the contemporary health care system is run on the basis of mandatory health insurance. The system is founded on a range of principles which aim to minimize the socioeconomic impact of sickness (Simon, 2016). Two principles are crucial here: the principle of solidarity and the principle of coverage. Solidarity means that payment to the public health care insurance companies is based on income, with equal shares paid by the employer and employee regardless of the risk profile of the insured. The second principle of coverage ensures that all medically necessary treatments are given in a cost-effective manner to the insured. Here, however, is a first node of conflict, since ‘cost-effective manner’ is a widely contested and rather vague concept. A third principle in the German health care system is relevant from a social medicine perspective: the subsidiarity principle. This suggests that an individual should first care for themselves, while solidarity from the larger community is asked when the individual cannot cope.

In addition to these principles, which shape health care insurance and the delivery of medical care, Germany has a fairly well-established public health system and a strong net of rehabilitation clinics. According to evaluation parameters of health care systems, such as access to care or avoidable mortality, Germany fairs well in OECD comparisons (OECD, 2019; Germany: Country Health Profile, 2019). Despite this, social medicine as a discipline, as it is taught and developed in universities, experienced a strong setback during the Third Reich and after World War II, particularly in West Germany (Michel, 2015; Hubenstorf, 2015). Furthermore, the more profound understanding of medicine as a study of the Anthropos, as Virchow understood it, may have fallen short in German medicine today. Social epidemiology and public health, two other aspects of Virchow’s legacy, have, however, gained increasing importance in unified Germany (Lampert, 2005; Lampert & Koch-Gromus, 2016) since the 2000s.

Let us turn back to the anecdote given at the beginning of this trail of thoughts, in which social medicine is equated with Rudolph Virchow, a 19^th century physician. Surely times have changed, and with it the problems that social medicine should address (or not)?

Exploring Virchow’s legacy in Germany further, I look at three quotations drawn from Virchow texts, which I take from his successor David Heinz, in his laudation given for the 200^th anniversary of Virchow’s death. I relate these quotes both to research as well as to medical and clinical practice today.