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8 The Dismantling of Pneumonia as a Public Health Concern
- Johns Hopkins University Press
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c h a p t e r e i g h t The Dismantling of Pneumonia as a Public Health Concern The informational void that the pharmaceutical companies could fill with their rhetoric would be enlarged by the dismantling of pneumonia itself as a public health concern by the end of World War II. And as I relate in this chapter, many of the present dilemmas facing public health advocates with respect to respiratory tract infections—from antibiotic overprescribing to apparent pneumococcal polysaccharide vaccine underutilization—can be traced from their post–World War II origins. Such a process, finally, serves to epitomize the general impeachment of “therapeutic rationalism” as practiced, or the “republic of science” embodied , by autonomous practitioners in this era of the wonder drug.1 Understanding its development o¤ers windows into the limitations of the uses of specifics broadly as well as into the contested domains between private practice and public health themselves. Pneumococcal “Transformation”—Again To some extent, pneumonia’s reversion to the domain of the private practitioner reflected the general fate of the public health system during World War II and its aftermath. During the war, as the United States experienced physician shortages nationwide due to enlistment in the armed forces, the pneumonia control programs themselves became depleted.2 Furthermore, in the setting of virulent debate over the 1943 Wagner-Murray-Dingell bill and compulsory health insurance , the American Medical Association and its publicists more rigidly emphasized the primacy of the private practitioner vis-à-vis the government’s representatives in the first place;3 and over the ensuing decade, as attention increasingly focused on the wonders of scientific medicine, the means of its distribution became less of a national priority.4 But even within the public health system, pneumonia increasingly lost its standing as a priority after the advent of the inexpensive and widely accessible sulfonamides . Certain pneumonia control leaders would o¤er persistent claims that “to be more widely e¤ective, the therapeutics of pneumonia, in the light of modern scientific knowledge, should be planned on a statewide basis . . . [such that] the lag between known medical science and its application be reduced to a minimum .”5 Yet in the eyes of the most important former pneumonia-control advocate —Surgeon General Thomas Parran himself—pneumonia would return to the domain of the individual practitioner over the course of the wartime experience . After rendering his final call for pneumonia control in April of 1940,6 Parran increasingly focused on venereal disease and tuberculosis in particular as the nation’s foremost public health concerns.7 And with pneumonia apparently having “ceased to be a major menace” since the advent of the sulfa drugs,8 Parran would, in 1944, exclude pneumonia from a list of disease entities meriting further dedicated research at his envisioned “national institutes for clinical research in . . . fields in which there is a large element of public interest.”9 With such forces in motion, the pneumonia control programs themselves collapsed , with none apparently having survived the wartime e¤ort.10 Pneumonia reverted to a private disease, devoid of state oversight. As William Watt Graham Maclachlan, a prominent Pittsburgh pneumonia expert, would remark before Pennsylvania’s state medical society three months after the society’s own Edward Bortz had extolled the state’s role in pneumonia control: “Now that the sulfonamides are being used so generously for, one might say, almost everyone who has pneumonia, the State’s interest has been satisfied. What we do now, as individual physicians, is to study carefully the results of these drugs on our cases.”11 Tellingly, and not surprisingly, the novel concept introduced in 1940 by the Boston Dispensary to apply to the sulfonamide era the notion of a “pneumonia service”—a dedicated team of physicians or technicians to aid the private physician in the laboratory diagnosis and monitoring of the pneumonia patient— failed to attract adherents even in Massachusetts.12 In this setting, the failure of clinicians to “type” their lobar pneumonia cases became further emblematic of pneumonia’s own transformation back into a private disease, increasingly managed with the use of less rigidly specific chemotherapeutics (or soon, antibiotics) alone. David Rutstein, prior to sulfapyridine’s general release, had already feared that the general release of the drug would lead to a general reduction in pneumococcal typing.13 And by 1941, even in Pennsylvania , which boasted perhaps the largest pneumonia control program in the country , clinicians failed to type nearly half the...