The Meaning of Freedom
There is much discussion in today’s world about whether or not the founding ideals of America are valid because they were espoused by imperfect men who did not themselves live up to the ideals that they were advocating. Can a slave owner’s demand for freedom be morally right when he enslaves another human being of another race? Can a male dominated society’s demand for liberty be morally right when it does not give equality to women?
The truth of a principle is not dependent on the moral clarity of the person who holds it but is instead dependent on the foundation and validity of that truth. With this statement as our guiding principle, this article will seek to explore the principles upon which this country was founded and how these principles should be implemented in health care today in light of the history of health care in America.
The Declaration of Independence
The Declaration of Independence is of primary importance not only because it is the first document in which the founders outlined their beliefs, but also because of how it lays out the arguments presented. The document itself does not find its authority in itself or in the men who created it. It instead invokes the Laws of Nature and of Nature's God, a higher authority. It is this authority upon which all of the principles laid forth are based. These men may not have completely embraced the full magnitude of the ideas they advocated and may not have implemented those principles as thoroughly as they should have, but with the Declaration and with the US Constitution they put in place governing documents that made it possible for these principles to become a reality over time for all Americans regardless of race, creed, religion, or gender.
The answer to inequality and the answer to the sins of the past is not the destruction of the ideals upon which the country was founded, but on a full realization of these principles in each and every American’s life. With this in mind, it is important to understand just what these principles are so that we can understand what freedom means.
“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” This sentence is the most important sentence in the entire Declaration. It sets forth the foundation for everything that will follow and is the clearest expression of the beliefs of the Founding Fathers. It is also the clearest expression of what freedom means.
First, the truths are self-evident. This means that the principles being set forth are not a gift of any person or any human institution but that they exist of their own accord and should be recognized as such by everyone.
Second, all men are created equal. This means every human being, regardless of race, creed, religion, or gender, is equal in the eyes of God, the Creator.
Third, our rights are the gift of the Creator. Our rights do not derive from any human source or any human institution, but from the Creator.
Fourth, these rights are life, liberty, and the pursuit of happiness. The order of these rights is significant. Without life, liberty would be irrelevant. Without liberty, the pursuit of happiness would be impossible. Note that it is the pursuit of happiness, not happiness. You are guaranteed the ability to seek happiness but you are not guaranteed happiness. Also note that pursuit at the time was not thought of as pursuing as in seeking to accomplish a goal, but rather as a life pursuit or something one was engaged in on a continual basis. It basically means that God bestows on all people the ability to have a life well lived, not just some transient pleasure.
The Declaration then goes on to state that governments derive their authority from the consent of the governed and are instituted among men to protect the rights delineated above. If a government violates this sacred duty, then the governed can form a new government that will protect these God given rights.
The revolutionary idea in all of this was not that governments derive their authority from the divine (the Laws of Nature and of Nature's God), but that their authority also depended on the consent of the governed. This is because God, the Creator, is the source of mankind’s rights and not the government. No government has a right to take away that which God has given.
The United States Constitution
Once the Revolutionary War was won, a new government had to be formed to ensure the rights laid out in the Declaration. This led to the adoption of the Constitution after the failure of the Articles of Confederation.
The Constitution was drafted at a time when property and land were the main means of accumulating wealth. In the United Kingdom, this had been controlled by the crown and through it the nobility. In America, these forces had far less control and commoners could become rich without needing the blessing of the crown. The vast natural resources and the seemingly limitless acres of land found in the colonies made the accumulation of wealth outside of the control of the crown a fact of life. The crown saw this wealth and wanted its fair share. The colonists felt they did not owe the crown as much as the crown wanted and so revolution ensued. In the end it was money that drove the motives of both sides.
Out of this came a form of government that sought to protect the rights of commoners to gain wealth by their own industry as enshrined in the right to the pursuit of happiness of the Declaration. In economic terms, the principles of the Declaration flourish best in a free market where goods and services compete on an equal footing. In philosophical terms, they flourish best in a world where ideas compete equally. This is why freedom of speech, freedom of the press, and freedom of assembly were so important when it came time to adopt the Constitution.
Although the implementation of these rights was imperfect, it was the first time in history that common people were seen to derive their rights from the Laws of Nature and of Nature's God rather than some earthly authority. The idea that it was the divine duty of government to protect the interests of all of its citizens equally regardless of status was the foundation upon which the Declaration and the Constitution were based. The question that arose at this point was could this form of government really work?
When asked what form of government had been agreed upon at the Constitutional Convention, Benjamin Franklin is said to have replied, “A republic, if you can keep it.” Basically, Franklin recognized that whether or not the government they had just formed would survive, would depend on the vigilance, involvement, and moral character of those who followed. It was clear to him that although the document was not perfect, it was the best that was probably going to come out of the process. In his final speech at the convention he said, “…when you assemble a number of men to have the advantage of their joint wisdom, you inevitably assemble with those men, all their prejudices, their passions, their errors of opinion, their local interests, and their selfish views.”
Franklin realized that built into the very document that sought to guarantee self-government to America, were flaws that must necessarily fall if the principles upon which this new government was founded were to survive and thrive. In order for a government to be established at that point in time, these flaws must be accepted but with the tools built in that would allow these flaws to be addressed at a later date. In point of fact, the Bill of Rights was the first example of flaws being addressed and fixed within the framework of the new governing document.
This then was the legacy of the founding of this country, a tension exists between the ideal and the practical. Even more importantly, a tension exists between blatant self-interests and the greater good. The best way for this tension to be managed is for the principles of life, liberty, and the pursuit of happiness to be jealously guarded by all citizens, for their own benefit and for the benefit of their fellow citizen.
US Civil War
The first and most blatant imperfection of the Constitution was the issue of slavery. Slavery was antithetical to everything the Revolution was fought for and this fact had to be addressed if the nation was to live up to the principles upon which it was founded. Slavery was tyranny pure and simple. In fact, it was far worse tyranny than the colonists fought to free themselves from during the Revolutionary War. To argue that slaves were not persons but were property was at the very least illogical with the founding principles and at the very worst pure evil. The fact that the Constitution had to draft a way to count slaves and yet not give them the rights of citizens shows the ludicrous nature of the logic behind this peculiar institution. If the slave was a person then to deny that person their rights is an affront to the Laws of Nature and of Nature’s God.
If America were truly to embrace the principles upon which it was founded and were stated in the Declaration then slavery must fall. It took a bloody and costly Civil War to decide the issue but in the end the principles won out and slavery died forever. It may not have been a pure act of righting the wrong of slavery that drove the Union cause during the Civil War, but in the end the nation came to the right conclusion and slavery died during the war.
Lincoln summed it up best in the Gettysburg Address when he said, “…that this nation shall have a new birth of freedom; and that this government of the people, by the people, for the people, shall not perish from the earth.” The war may not have started out as a means to resolve the glaring injustice of slavery, but by 1863 when the address was made, it had become inextricably linked. By this time the war could not end in Union victory unless that victory also meant an end to slavery.
It is important to look at the reason slavery existed in America in the first place. It was essentially the product of greed. Africans were enslaved to give cheap labor to the property owning class in the South so that they could profit more easily from their labor intensive agricultural economy.
It was the invention of the cotton gin and cotton becoming a cash crop that actually made slavery far more profitable and increased the demand for it exponentially. This is an important fact. Whether or not slavery would have died out without the invention of the cotton gin as some have advocated, the invention of the cotton gin ensured slavery would not only continue but grow.
Why does this matter? Because it is the first example in American history where the industrial revolution plays a major role in tyranny in America. How slavery came to America and whether or not it would have died out of its own accord as America moved forward, are questions that were made irrelevant by the invention of the cotton gin. The fact is that if America was to truly live up to the ideals set forth by the Founding Fathers, slavery would have to end. The fact that the cotton gin and greed made that impossible is what caused the issue to have to be settled by war and bloodshed. America paid a heavy price for the sin of slavery with the death of over 600,000 citizens.
There is a necessary tension between the forces that ensure personal freedom and those that seek to concentrate wealth and power. This is what the American Revolution was all about. This is what the Civil War was all about. The American Revolution gave the merchant class the right to chart their own destiny by self-government and banished the idea that wealth and prosperity comes from royalty by divine right to be given to the chosen few.The Civil War expanded this to a people who had been enslaved and righted a great wrong from the founding of the country.
The Industrial Revolution
The industrial revolution by its very nature tends to concentrate power and resources in order to feed its own appetites. The American Revolution happened at a time when the world was changing from an agrarian economy and society where property in the form of land was the basis of wealth to one based on manufacturing brought about by the industrial revolution. To be sure the trend had begun before the industrial revolution but the industrial revolution hastened the change. The North embraced the industrial revolution far more aggressively than did the South, which stayed mainly agricultural. Still the effect of the cotton gin and the demand by Northern manufacturers for cotton, showed the impact of the industrial revolution even on the South. In the North, a thriving working class/middle class was developing because skilled labor was needed but the South remained more stratified with a rich upper class that held most of the power and an uneducated lower class that did the manual labor.
This tension between tyranny and freedom, between wealth concentration and the freedom of all citizens to participate in prosperity has existed since the founding of the country. It has in fact existed throughout history. The Declaration was the first step towards the broadening of who had a right to prosper and that this right should belong to everyone. It should belong to everyone because its origin did not derive from any human institution but from the Creator, the God of Nature. It was imperfectly applied but the principle nonetheless was first stated in the Declaration and then enshrined in the Constitution. The Civil War established that these principles should apply to all, regardless of race.
The industrial revolution brought about a new challenge to a government of the people, by the people, and for the people. As certain men gained wealth through the new industries, they used that wealth to try to secure more wealth and more control. They sought to use economic forces as well as government forces to their own advantage, regardless of whether that benefited society and the individual citizen or not. In a sense they sought to become the new royalty, a royalty born of the wealth generated by the industrial revolution.
This led to the term robber baron being employed to describe industrialists who used whatever means necessary to gain more power and wealth. They concentrated their power and crushed whoever stood in their way.These industrialists challenged the principles upon which the country was founded by their greed and by their corruption of the economy and government to work in their favor rather than the country’s favor.
The problem was not the concentration of wealth and power necessarily, it was instead how that concentration was achieved and what was done with it once it was. Two prime examples are Andrew Carnegie and John D. Rockefeller. In one sense they are shining examples of American success stories. Each started with nothing and through hard work built empires. Carnegie was a Scottish immigrant and Rockefeller was a natural born citizen. Their stories exemplify the great promise America holds.
These men also exemplify the very worst of America. Even if you ignore the high probability that they used unfair and unethical business practices to overcome their competition, one fact cannot be denied. They both relied on low wages to their workers to keep their costs low. This is a betrayal of the founding principles of this country. No matter what apparent good they did with their philanthropy, they harmed those they could have helped and impacted the most, their own workers. With as much wealth as each of them accumulated, how hard would it have been to share that wealth with their workers and thereby give more freedom and independence to their fellow citizens? By enriching and empowering their workers they would have done much to establish a more fair and equitable society.
When the concentration of wealth comes at the expense of fellow citizens, then that concentration must be questioned. This is not to say that business owners do not deserve a fair return on their investment but when the driving force behind that return requires exploitation of workers then there is a problem. It is a form of tyranny itself. The company towns of the coal industry or of the steel industry or of the railroad industry at this time in history are perfect examples. The company owned the houses, the stores, everything. The workers had to pay the company for a place to live, for the food they ate, for every convenience so the company basically owned them and they were in effect indentured servants.
Capitalism is neither moral or amoral in and of itself. It can be a very good system that allows for free markets and for all to participate or it can be exploited and used for the accumulation of wealth at the expense of normal citizens. When markets are free and everyone benefits, all of society is raised up. Capitalism offers the best hope of this. But it can be twisted also.
The roots to the abuses practiced by these wealthy industrialists can be seen in American foreign policy before the Civil War. The Mexican-American War is a prime example. One of the driving forces behind this war was the need of the Southern land owners for new land. They wanted to expand American influence across the continent and open new land for their agricultural interests. The war led to just this outcome as America gained over 500,000 square miles of new territory.
In the same way that Southern interests influenced the Mexican-American War, so the industrialists used their power and influence to enrich themselves. The period from the end of the Civil War to the turn of the century is known as the Gilded Age, a term that comes from Mark Twain’s and Charles Dudley Warner's 1873 novel “The Gilded Age: A Tale of Today”. The practices of the industrialists were in direct conflict with the founding of this country. They used their wealth and power to impose a type of tyranny on their workers.
In 1890, the Sherman Anti-Trust Act was passed in an attempt to control the concentration of wealth. More than a decade later Teddy Roosevelt used this act to try to contain the industrialists’ monopolistic tendencies and restore the principles upon which this nation was founded. Concentration of wealth and power are diametrically opposed to individual freedoms for all. It was the concentration of wealth and power under royalty that the colonists had fought against. It was the concentration of wealth and power under the Southern aristocracy that subjugated a whole race that was ended by the Civil War.
This concentration of wealth led to a corrupting of the political process and the rise of political machines that sought to control government for the benefit of the wealthy rather than the people. As Franklin had warned, the ability of America to keep its freedoms depended on the moral character of those who followed. Unfortunately, time and again in America, wealth and power have proven to be corrupting influences. It could even be argued that these corrupting influences have been present since the country’s founding because the inclusion of slavery in the Constitution was necessarily incongruous with the principles it sought to enshrine into a government.
As America moved away from its agrarian roots and towards a more industrial society, the production and distribution of food necessarily became more industrialized also. Cities needed to be fed and this had to be done by the rural population. The railroads played an essential role in this and held monopoly power over their tracks. This is what established the wealth of some of the first robber barons and they took unfair advantage of the power they held.
Beyond this, the meat processing centers like Chicago became indispensable. Again, greed reared its ugly head and gross abuses developed. Unsanitary, unscrupulous, and inhumane practices in the meat packing industry were of particular concern and were soon exposed by muckraker journalists. This led to the Meat Inspection Act of 1906.
The legacy of this struggle between the tendencies of the wealthy and powerful to concentrate their wealth and power and the freedom for everyone to participate in a free and fair marketplace continues to this day. It was most starkly seen in the Gilded Age but will never end in a free and open society. Remember what Franklin said, “…when you assemble a number of men to have the advantage of their joint wisdom, you inevitably assemble with those men, all their prejudices, their passions, their errors of opinion, their local interests, and their selfish views.”
Health Care From Colonial Times to 1900
For the purposes of this article, health care will be limited to a discussion of medicines and not the overall practice of medicine. From ancient times, mankind has sought those plants and substances that would bring health and vitality. For most of that time these medicines came from nature (herbs, plants, spices, etc.) and worked harmoniously with the body.
To understand the American experience, it is best to start with the Ancient Greece. In Ancient Greece there was a separation between the physician and the herbalist. The herbalist supplied the physician with the raw materials from which he made the medicines. This arrangement dates from the 4th century BC.
In the first century CE, the most influential book on medicines in Western history, the pharmacopoeia “De materia medica”, was written by Pedanius Dioscorides. Dioscorides was a Greek physician in the Roman army who wrote this five volume work on medicinal plants and substances known at the time. Its influence lasted for 1500 years across Europe and the Middle East. Translations existed in Latin, Greek, and Arabic during this time. With the coming of the Renaissance it was translated into Italian, German, Spanish, French, and finally English. During the Renaissance pharmacists and doctors began to add to this work and expand it. “De materia medica” remained the standard by which all others were measured and was the model for how information should be catalogued and presented.
When the colonization of the New World began, one of the missions was the discovery and cataloguing of new plants for their medicinal value. This was true for all the major colonial powers. One of the best examples of this is cinchona bark from Peru, from which quinine was isolated in 1820. The bark had been used since at least the 1630s for the treatment of malaria and was introduced into Spain in 1636 by Jesuit missionaries. Guaiacum from the West Indies and sassafras from Florida were two other notable plants.
The “London Pharmacopoeia” would have been the most readily available volume in the American colonies, along with the “Edinburgh Pharmacopoeia”. In Europe, physicians and pharmacists/herbalists/chemists followed the tradition of Ancient Greece with each specializing in their own field. Prior to independence, many doctors would act as both physician and pharmacist out of necessity. In 1820, the first“United States Pharmacopoeia” listed 170 medicines (mainly herbals and plants) used by Native Americans and potentially available to American pharmacists. In 1852, the American Pharmaceutical Association was formed.
The industrial revolution also had an impact on medicine. Although most health care revolved around your local doctor/pharmacist, there was a move to be able to manufacture medicines for a broader audience than just the local clientele. These became known as patent medicines. Prior to the American Revolution and into the 1840s most patent medicines in America were imported from Europe. There was also a homegrown manufacturing problem but the bigger problem was the imported medicines. Many of these patent medicines, whether foreign or domestic, relied on alcohol and opiates to make the patient feel better without addressing the underlying issues. One of the reasons the American Medical Association (AMA) was organized in 1847 was to combat the dangers of these drugs by educating the public and lobbied for the Drug Importation Act of 1848.
There were several reasons that patent medicines were becoming a problem beyond just the questionable nature of the products themselves. First, as mass media began to grow, newspapers needed advertisers and medicine manufacturers needed exposure. Newspapers did not really care who advertised or why they just needed the income. Unscrupulous manufacturers could make a medicine, advertise it, and disappear before anyone was the wiser. Second, when doctors/pharmacists are part of the community then there is accountability. With urbanization this connection broke down and accountability suffered. Third, many unscrupulous manufacturers traveled from community to community selling their elixirs and cure-alls before moving on thereby ducking accountability of the community in which they had just operated.
At the beginning of the 1800s, there was a push by reputable scientists and manufacturers to isolate the active ingredients of plants from the plants themselves. A German was the first to successfully isolate morphine from opium between 1803 and 1805. Another early isolate was quinine, as noted above in 1820.
By the late 1880s the Germans had figured out organic chemical synthesis from tar, which opened up whole new possibilities. Scientists could now systematically manipulate the structure of chemical substances and then evaluate the biological effects of these structural changes. Up to this point, pharmacology had focused on understanding herbalism and natural substances. The active ingredient in these was hard to isolate and purify. Now that possibility existed in almost limitless potential. These developments throughout the 1800s set the stage for a dramatic transformation of medicine and pharmaceuticals at the turn of the century.
Besides the changes in medicines that were happening during the 1800s, another change was happening. As scientists were seeking to understand the physiology of plants and isolate the active ingredients, others were seeking to understand human physiology and how the body worked. The studies in both of these areas began well before the 1800sand had in fact been for pursued for centuries but the 1800s saw an acceleration of the discoveries. In the second half of the nineteenth century the two joined forces in a new discipline called pharmacology, which applied the principles of scientific experimentation to therapeutic contexts involving specific drugs, poisons, or other substances. Biochemistry was of particular interest. The biochemistry of the body was studied and then how outside agents affected that biochemistry. All of these areas of study were driven by advancement of research techniques.
Also, during the mid to late 1800s, the theory as to the cause of disease was changing to a germ based model. This change was driven most notably by the work of Louis Pasteur and Robert Koch. They theorized that microorganisms were the cause of many diseases. Vaccines were the method of choice to combat many of these microorganisms. This theory currently dominates modern medicine and the pharmaceutical industry.
These new approaches of isolating active ingredients and of isolating how those work on specific parts or systems of the body was a marked change from anything that had come before. The idea that specific pathogens could also be isolated and treated was new. Throughout history, most systems of medicine had taken holistic approaches to both the body and medicine. To now separate the constituent parts was revolutionary. The question remained whether or not this was a good development because the data did not yet exist to properly analyze the new paradigm.
Health Care From 1900 to the Present
The turn of the century brought about changes on many fronts. As noted earlier, industrialization changed the production and distribution of food. The problem of food adulteration and questionable patent medicines led to the passage of the Pure Food and Drug Act of 1906. By 1930, this act had led to the establishment of the Food and Drug Administration.
In 1904,the AMA created the Council on Medical Education (CME) to set standards for medical school education. In 1908, they contracted with the Carnegie Foundation for the Advancement of Teaching to survey all medical schools in the United States and Canada. In 1910, the Carnegie Foundation published the Flexner Report with the results of this survey. Rockefeller poured $100 million ($2.7 billion today) into the effort to get the report’s findings implemented. The money was used to fund hospitals and colleges to get them to fall in line with its recommendations.
With the money and power of Rockefeller behind the report’s findings, medical schools and universities quickly conformed, along with state governments. Soon the AMA in each state gained control over the licensing of doctors and certification of medical schools. The AMA and the Flexner Report embraced the new paradigm of focusing on physiology, biochemistry, and modern research techniques as the foundations of acceptable medical practice. Pharmaceuticals became the focus of their treatment regimens.
The Flexner Report further argued too many doctors were being trained and the number should be drastically reduced. In 1904 there were 28,000 medical students. By 1920 there were only 13,800. There were also too many medical schools with not enough control and oversight over these. Many medical schools were closed or consolidated. Those offering courses in what now became alternative medicine were forced to drop these courses or face accreditation issues. Chiropractic medicine, electrotherapy, eclectic medicine, naturopathy, and homeopathy were all ruthlessly attacked. Flexner argued in his report that these disciplines were not based on modern science or modern research techniques and should therefore be rejected.
The basic effect of all of this was a consolidation and standardization of the medical profession behind the new paradigm. The holistic approach of medicine that had existed for several millennia had given way to a system that focused on understanding in detail specific constituent parts and their interactions with each other. Of primary interest was the understanding the chemistry of specific drugs and how they may interact with other drugs or substances. Along with this there was a need to understand how specific drugs affected specific body parts and systems. Chemistry and biochemistry became of paramount importance.
By the 1930s the new paradigm controlled higher education and the licensing of doctors. When the Food and Drug Administration was established, the new paradigm also controlled the regulations that would govern the new government agency. Under those regulations, it did not matter if a natural medicine had been used safely and effectively for thousands of years, if it did not meet specific guidelines it could not be marketed. Double blind clinical trials became the new standard to prove a drug was safe and effective. Since natural medicines could not be patented, the incentive for businesses to invest in the clinical trials and research necessary to meet the new guidelines was non-existent. Businesses instead focused on the far more lucrative market of synthetic drugs since they could be patented. Patents are essentially legal monopolies for a certain period of time.
One of the effects of this new paradigm’s focus was to find and isolate the properties that made natural medicines work. The problem with many plants and herbs was that isolating the active ingredient and purifying it was difficult. With the new understanding organic chemical synthesis, this problem could be eliminated. Once the active ingredient could be identified, it could be synthetically created in the lab, removing the necessity for purification.
Another effect was the ability to create whole new classifications of drugs that had no equivalent in nature. The ability to manipulate and test many different chemicals and combinations allowed for almost limitless possibilities. Since this could all be tested in the lab before it was actually introduced to the public, the only limitations were the imagination and the cost of the research.
As time moved, researchers realized that many times what nature produces has far more potential than that which can be randomly generated in a lab. This meant that although plants and herbs may not provide the medicines any longer, the necessity to study them and isolate their medicinal properties still existed. The focus became finding and exploiting new plants so that synthetic drugs could be made from the properties discovered.
It can be argued that what happened at the beginning of the 20th century in health care was as big a revolution in medicine as the American Revolution was in government and politics. Just as the American Revolution overthrew thousands of years of tradition in who had a right to govern and where that authority came from, so to the changes that came about in health care as a result of the Flexner Report overthrew thousands of years of tradition as to what medicine was and how it should be practiced. With over a century of experience and data to analyze, it is worthwhile to examine why the revolution in health care happened and whether or not it is in line with the principles upon which this country was founded and the promise this country holds.
By the time of the Revolution, the colonies had produced a strong and vibrant merchant class that had become financially independent by its own hard work and ingenuity. This class was for the most part native born, coming from settlers who had come to the colonies seeking religious and financial freedom. This class did not appreciate having terms dictated to it by a government thousands of miles away that did not have the interests of the colonies in mind when it made policy. As far as the crown was concerned the colonies existed for its benefit and not the other way around.
However imperfect the founders were in living up to their own ideals, the documents they created put in place a system of government that had the potential to fix the flaws of the founding and someday give every citizen the rights they claimed for themselves. It took a bloody and costly Civil War for this to happen but it did happen. Still forces were at work that sought to limit those freedoms that every citizen is entitled to experience.
The industrial revolution brought about a new concentration of wealth that in many ways replaced the royalty that the founders had overthrown. This concentration of power sought to protect itself and its own interests just as royalty had in the past. For many citizens a new tyranny came into being that infringed on their basic rights.
It was in this world where a new set of power brokers ruled that the revolution in health care took place. Just as the industrial revolution changed the source and basis of wealth in America, so to it changed science and medicine in America. Businessmen began to seek ways to manufacture medicines on an industrial scale and they turned to the science of the day for answers. Businessmen brought resources to bear that would not have otherwise been available and advancements in research techniques soon followed. The same forces that began to transform agriculture and food production into big business, came to bear on health care.
The Civil War itself played a large role in the development of big business in America and how its influence was felt throughout the economy. When a government is fighting for its very life, cost is no real object. The Civil War was the first modern war where manufacturing probably played as decisive a role as the armies themselves. The North always had a distinct advantage because of its economic prowess. It could afford to make many mistakes and still win the war which is exactly what happened. The South could not afford the same mistakes and accordingly it lost.
The Civil War also played a big role in health care because more soldiers died of disease than died on the battlefield. This necessarily brought pressure on the doctors and systems of the day to find better ways to care for the men. As has been the case in every American war, advancements in the medicine of the time, especially in the care of traumatic injury, are accelerated.
The advancement in research techniques that came about in the 1800s, especially towards the end of the century, changed some basic preconceptions on what the scientific method was and should be. As laboratory work became predominant, many of the conclusions of the science that existed for thousands of years were deemed less acceptable. As an example, somehow the observations and practices in the use of herbal remedies for thousands of years could no longer be relied upon because they did not come out of a laboratory. This raises a very simple question, was this wholesale change justified by the evidence at hand or was it an act of faith in the new methodology?
If the rejection of herbs and plants as medicines was based on proof that the observations of thousands of years were wrong then that would be acceptable. The problem is that the rejection was not based on any such evidence but instead on a belief that the new paradigm was better and would produce better results. The sad fact is that over the last 50 to60 years, research into these natural remedies using the new paradigm’s research techniques have confirmed the medicinal properties of many of these plants and herbs. Two examples would be Shilajit that has a rich tradition in Ayurvedic medicine and Traditional Chinese Medicine, and the black cumin seed which has a rich tradition in Arabic and Middle Eastern medicine.
The new paradigm claimed to be based only on the evidence but this is intellectually dishonest. So, what was driving the desire to switch to the new paradigm? It is only necessary to look at the funding for the research to understand. Businessmen are not in the habit of investing money without expecting to get a return on that investment. In fact, basic economics dictates that if you do not turn a profit you will not stay in business. The profit margin on providing herbs and plants that cannot be patented is very small. If, however, you can develop a drug that can be patented, then the profit potential is enormous.
The patented medicines that came about in the late 17th and early 18th centuries may not have been wholly legitimate drugs, but by the end of the 18th century, the research and patenting of drugs had taken on a whole new level of legitimacy that sought proven results. Whether this was a good or bad development remained to be seen because time was needed to collect data on those results.
This then was the setting for the Flexner Report. Since this report was the foundation of the radical changes that took place, it is important to understand how it came about and why. If a report like this were issued today, it would be subjected to review. The chief questions asked would be:
- What qualifies the author or authors as experts in the field they are reporting on?
- What methodology was used in compiling the report?
- Are there any biases or conflicts of interests that the author or authors have in presenting the report?
- What is the source of funding for the report and does the source have any vested interests in the outcome of the report?
- 1. What qualifies the author or authors as experts in the field they are reporting on?
The man tasked with writing the report was Abraham Flexner. He was a graduate of Johns Hopkins University with a BA in the Classics who did further study in psychology at Harvard and the University of Berlin but earned no further degrees from either of these institutions. Flexner taught classics at Louisville Male High School before founding a private school in Louisville that used alternative teaching methods for its students. His graduates became sought after students for leading universities, which garnered his teaching methods considerable attention. In 1908, he published a critique of higher education in America called “The American College: A Criticism”.
Flexner had no training in either higher education or the medical profession. His own experience was limited to his four years as a high school teacher and his fifteen years or so of running his own school. Yes, he had experience as a student of higher education which would lend some insight but in no way would he be considered an expert in either field today.
By writing the report, Flexner was treated as an expert even though he had no qualifications for making the judgments he made. He became an expert because he wrote the report but he had no qualifications to write the report in the first place.
- 2. What methodology was used in compiling the report?
The report itself took less than two years to compile. There was no extensive review of whether or not an institution was turning out qualified doctors or the level of care those doctors were providing to their patients. A true review would have taken years and would have required the work of far more than one man. If the work product of an institution is not evaluated then how can any conclusion be drawn about what they are producing?
The problem is that the methodology of the review was based on preconceived outcomes. The review was not so much a search for the true state of medical education in the US and Canada or the care resulting from the doctors so educated, but rather a review to determine if the school was teaching the new paradigm. The AMA through the CME had an agenda and that agenda was to transform American medicine into the new paradigm. There was no need to know whether or not the needs of the patient were being met because this was about changing how those patients were treated regardless of whether the current systems were working or not.
The attack on osteopathic medicine, chiropractic medicine, electrotherapy, eclectic medicine, naturopathy, and homeopathy was not made because evidence was presented as to the shortcomings of these modalities, but rather because they provided vigorous competition to the new paradigm. If these modalities were such failures in offering effective treatment to their patients, then they would have failed of their own volition. The fact that they had not failed and that they were competition brings the methodology of the report into doubt. While advocating only fact based and science based medicine, it violates these principles while attacking its competition.
- 3. Are there any biases or conflicts of interests that the author or authors have in presenting the report?
As an alumni of Johns Hopkins University, Flexner’s use of its medical school as the perfect model is unseemly at best. Then when you consider that he financed his brother Simon’s medical education there it becomes more questionable. Finally, this same brother was then employed by the Rockefeller Institute for Medical Research from 1901 to 1935. It was John D. Rockefeller who then financed the drive to implement the findings of his report.
Any one of these facts should raise serious questions about the objectivity of Flexner and the conclusions he drew. Taken together they raise should be disqualifying and yet they were ignored at the time just like his lack of qualifications and his flawed methodology were ignored. These conflicts of interest along with the other problems should have been red flags to anyone seeking the truth. Flexner's agenda should have been questioned then and certainly should be questioned now.
- 4. What is the source of funding for the report and does the source have any vested interests in the outcome of the report?
John D. Rockefeller retired at the beginning of the 20th century and devoted his time to philanthropy. This sounds altruistic and selfless. He is celebrated for his work in education and medicine. He along with Andrew Carnegie are credited with helping to establish modern medicine in America. Their impact is undeniable.
The use of the Carnegie Foundation for the Advancement of Teaching, which was chartered by an act of Congress in 1906, to produce the report gave the report a government stamp of approval even though no government agency was involved in it. This is disingenuous and misleading.
As noted earlier, Rockefeller devoted $100 million into the implementation of the report. $100 million is the equivalent of $2.7 billion today. That kind of money can buy all kinds of cooperation. Why did Rockefeller do this? For a very simple reason, he had an interest in the chemical and pharmaceutical industries of the day. If the new paradigm was not the sole source of health care in America, then his interests were hurt. If the new paradigm was the sole source then his profit potential from his investments was vast. It takes great investment to discover and make new synthetic drugs. The only way this investment makes sense is if there is a consumer waiting for the new synthetic drug.
The evidence as laid out then, shows that the revolution in medicine that took place during the first part of the 20th century, did not in fact protect the average citizen’s rights to life, liberty, and the pursuit of happiness, but instead took them away. Instead of embracing the ideas of a free and fair marketplace where ideas and products compete on an equal footing and trusting the collective wisdom of the American people as they choose what is right for themselves and their families, the revolution sought to limit these choices and monopolize the marketplace. This was all done in the name of public safety.
The problem with the new paradigm is not that it has nothing to offer or that advancements that have benefited humanity have not occurred, but that by the way it seized control the benefits that other modalities offered were summarily excluded. It should not have to be an either or scenario and yet that is exactly what the revolution in medicine sought to do. The best outcome for the public at large would be to have access to the benefits of any modality that can benefit them and not be denied the right to choose whatever they find best for their family.
Another problem that has developed by the reliance on the new paradigm is the cost of health care has increased dramatically. Not only has the cost to treat patients increased dramatically, but the cost to educate medical students has increased dramatically. By the time a student graduates they are so in debt that they are basically indentured servants working to payoff the debt.
Before the revolution in medicine both higher education at universities and the medical profession were not considered big businesses. As the two became intertwined they both became big businesses. Where great amounts of money are involved corruption necessarily follows. Government funds also became involved in both in the form of student loans and guaranteed health care like Medicare. When government funding is involved corruption follows.
In 1776, this country was founded on the principles of guaranteeing each citizen their right to life, liberty, and the pursuit of happiness. The history of guaranteeing those rights has been a bumpy one. The industrial revolution and the urbanization of America have brought many challenges to maintaining these rights. The rise of big business and the concentration of wealth and power that comes with it, have also brought increasing challenges to maintaining these rights. These rights are most challenged today in the realm of health care where Americans’ freedom to choose has been curtailed in the name of public safety.
At the beginning of the 20th century, a powerful shift happened in American medicine. This shift was financed by one of the biggest giveaways in history by Rockefeller, the equivalent of $2.7 billion in today's dollars. At that time doctors, hospitals, and universities had a choice to make. None of them wanted to miss out on all of the free money so they all gave in to the new paradigm. None of them realized that nothing is ever free and there is always a price to pay. The price was the freedom of choice that Americans had enjoyed in health care. Now there is no freedom of choice, no freedom of thought, no freedom of speech. Either you embrace the new paradigm or you are silenced. This is not what the founders intended. This is not freedom.