Climate Change?: The Environment, Physicians, and Historians

Of the many images I share with my history of medicine students, one always generates animated discussion: those of young children, wearing shorts and no shirts, sitting at desks in an outdoor classroom. The season is winter and the children were believed to be at risk for tuberculosis. The image is from the early 1930s, before antibiotics were available to treat the disease.

“Weren’t they freezing?” students invariably ask. Another might venture that a similar initiative today would be labeled “child abuse.” But I try to get the students to think about what would have made doctors believe that exposure to cold, fresh air and sunlight would have prevented the growth of the tubercle bacillus in the children’s bodies. Part of the reasoning, I explain, was that these conditions seemed to be the exact opposite of those where the youngsters likely first were exposed to tuberculosis: crowded, dirty cities.

Of course, with the introduction of antibiotics beginning in 1947, use of so-called preventoriums to thwart tuberculosis became much less important, as did the use of sanatoriums to treat the actual disease. The goal of physicians became getting as much medicine into patients as consistently as possible, regardless of where and how they had gotten sick. And the drugs worked! At first glance, the war against tuberculosis seems to be a triumph of the “place neutral” mindset so elegantly described by Chris Sellers in his article. But this perception has resulted from a series of choices—made first by the clinicians who treated the patients and then the historians who chronicled what had taken place.

Drawing on a wide range of historical sources, Sellers makes a compelling argument about the gradual elimination of an environmental, or ecological, focus from medicine as the twentieth century progressed. In the nineteenth century, where patients lived, what they did for a living, and what they had encountered in their environment helped doctors arrive at diagnoses. And, in the case of infectious diseases, the widespread acceptance of the connection of filth, poverty, and overcrowding with infections further reinforced this model.

In writing about the history of hospitals, Charles Rosenberg effectively employed the phrase “inward vision and outward glance” to describe how the attention of administrators was with what went on in the hospital itself—not where it happened to be located.¹ In a sense, it is hard to blame physicians and public health officials in the early twentieth century, pleased with the waning of infectious diseases, for their growing interest in the human body—and not where that body lived and worked. After all, despite occasional associations of toxins with particular diseases, newly prominent chronic conditions, such as cancer and heart ailments, did not appear to have specific environmental causes. And, as in the tuberculosis example above, when laboratory discoveries permitted the prevention of polio and the cure of bacterial pneumonia, how and why patients did or did not get these diseases seemed less important. I loved being reminded by Sellers that the Framingham study was meant to be “ecological” by its planners. Yet one can argue that there are no data so reflexively believed to be universal in their applicability than Framingham. The story of how these changes occurred is, in a sense, the story of twentieth-century American medicine.

Sellers is also right to suggest that the growth of fields such as tropical and industrial medicine had the paradoxical effect of making physicians ignore the impact that the environment could have on day-to-day medical practice. That doctors specializing in these specific areas took the environment into account seemed to suggest that other clinicians did not have to do so. Ironically, perhaps, even social medicine—a mid-twentieth-century movement designed to underscore the role that social factors such as poverty played in the causation of disease—focused relatively little on what took place in specific environments. Another contemporaneous movement that further encouraged a narrow focus on the body was psychosomatic medicine; the potential role played by the environment in producing the stressful conditions that supposedly fostered peptic ulcers, ulcerative colitis, and other illnesses was...