The Deadly Truth: A History of Disease in America (review)

By the middle of the last century, shifts had occurred in patterns of disease in America that were producing major changes in societal and medical practices. Chief among these was the decrease in infectious diseases and the increase in chronic degenerative disorders, cancer, diabetes, and cardiovascular diseases. Gerald Grob's book deals with these demographic changes in mortality and morbidity as they affected "social, environmental, and behavioral factors" (p. ix). He divides his approach into what current usage might term macro- and microanalysis.

Grob's macroanalysis involves augmenting mortality data to support the concepts of René Dubos (Mirage of Health, 1959), William McNeill (Plagues and Peoples, 1976), Alfred Crosby (The Columbian Exchange, 1972), and others along the same line. His conclusions do not differ significantly from the analyses of these predecessors. His contribution lies, rather, in pulling together in one book and interpreting vast amounts of data on mortality and morbidity, an achievement that alone should bring him the gratitude of historians yet to come. A most helpful feature of the book is his explication of the modern medical understanding of each major disease as a prelude to its history.

Grob maintains that all modern humans continue to "assume that disease is 'unnatural' and that its virtual elimination is a distinct possibility" (p. 2). Many would disagree with this, certainly many medical scientists, and would doubt that it now applies to most literate Americans, due to the advent of AIDS and the recent years of relentless coverage of medicine by the media.

In his microanalysis, Grob uses mortality figures and other social factors to elucidate differences in the effects of infectious outbreaks on smaller and neighboring communities. Most historians of disease are familiar with the limitations of the bills of mortality and death certificates they perforce employ for demographic purposes. Grob emphasizes this repeatedly, going so far as to say: "many of my interpretations and generalizations are presented as probabilities rather than certainties" (p. x). Still, I doubt that general historians venturing into the history of today's diseases appreciate the truly debilitating magnitude of this problem. A recent study demonstrated that despite all the wondrous technology in today's medicine, clinical diagnoses of cause of death had a staggering 40 percent discordance with autopsy reports. Such modern inaccuracy dictates severe limits to how far historians can hope to go with the microanalysis of disease data, even data of the twentieth century.

Grob questions risk factors as the cause of the major killers of the elderly listed earlier. Precise terminology is critical at this point. He appears to believe that physicians do not understand the difference between risk factors and causes. Physicians today emphasize risk factors because they have no cures for the diseases at hand, and because, as in the case of smoking and lung cancer, decreasing risk factors can be tantamount to curing.

The author strikes me as a bit impatient when he writes that the "cure of most chronic diseases . . . remains only an ideal" (p. ix). Commentators were writing about infectious diseases in much the same vein 150 years ago, but proof of the germ theory suddenly opened the door to the control of infectious diseases that we have today. A recurring feature of the history of science is that discoveries often accumulate large amounts of apparently conflicting evidence until a surprisingly simple key brings the whole thing together. The greatest theoretical achievement of biological science since the germ theory is mapping the human genome; only time will tell if this is the key to curing the chronic degenerative diseases of today.

While the subtitle of Grob's book is straightforward, the title is unclear. Just what is the "deadly truth?" Is it that epidemic diseases have been disastrous over the centuries, or that humans will always have fatal diseases, or that...