Socialization of Medicine-III | Health and Equity

Socialization of medicine addresses social determinants of health and equity in order to improve health outcomes and eliminate health disparities.
Representational Image [Source:  Arek Socha from Pixabay]
Representational Image [Source: Arek Socha from Pixabay]

Emmanuel-Joseph Sieyès, a French Roman Catholic clergyman and political writer who was considered to be the chief political theorist of the French Revolution and was also the author of "What is the Third Estate", was the first to coin the term "Sociology" in 1780 (Lenzer, 1998). French philosopher of science, Auguste Comte later redefined "Sociology" in 1838 as a new way of looking at society (Rashmi, 2014). In an attempt to unify history, psychology and economics through a scientific understanding of social life, Comte had earlier used the term "Social Physics" and had suggested that social ills could be effectively remedied through sociological positivism. However, seeds of the ideology that "medicine is a social science" were actually sown in the nineteenth century by German Pathologists Salomon Neumann and Rudolf Virchow. In 1911, Alfred Grotjahn of Berlin stressed upon the importance of social factors in the causation of disease, which he termed as "social pathology". John Ryle and his group promoted the concept of social medicine in England and established a chair at Oxford in 1942 that was followed by the establishment of similar centres in other Universities of England.

When Rudolf Virchow, founder of modern pathology wrote in late twentieth-century that "Medicine is a social science and politics is medicine on a large scale", he had envisioned the influence of socio-political control over medicines. He further elaborated that medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution whereas the politician, the practical anthropologist, must find the means for their actual solution (Wittern-Sterzel, 2003). With the passage of time medicine became a personalized and institutionalized service. This led to a feeling that perhaps medicine was not fully rendering its expected and envisioned service to the humanity. As the cost of medicines kept on steadily increasing, two kinds of medical care came to the fore – one for the rich and the other for the poor. This widening gap between the rich and the poor was bridged to a small extent by charitable and voluntary organizations providing free medical care and relief to the poor. Subsequently a thinking developed that the benefits of modern medicines should be equally available and affordable to all people. This is what led to the concept of "socialization of medicine" (Park, 2015).

However, social medicine should not be confused with state medicine or socialized medicine. State medicine implies provision of free medical services to the people at government expense. Socialized medicine on the other hand envisages provision of medical services and professional training by the State as in state medicine, but the programme is operated by professional medical organizations rather than by the government (Park, 2015). Marriam-Webster Dictionary defines socialized medicine as "medical and hospital services for the members of a class or population administered by an organized group such as a state agency and paid for from funds obtained usually by assessments or taxation". Winslow Carlton in his paper entitled, "The problem of social medicine: equilibrating the distribution and technology of medical care" published in NEJM on April 3rd, 1947 had argued that there is need for creation of a new discipline within the domain of medicine that might be called as the "social medicine", which would mainly deal with the relationship and application of the medical arts and sciences to the society. Socialized medicine is a single-payer government-run and govt-administered system. In a socialized medicine model, the government makes all services of doctors and other healthcare providers available to the hospitals and other healthcare facilities, and also makes all payments for those services (Ridic et al, 2012).

Socialized Medicine deals with social and economic structures of health-care delivery and health policy in addition to evolving concepts of the field like doctor-patient relationship in culturally diverse societies. Level of establishment and evolution of social medicine as an academic discipline has been internationally diverse as a result of which a coherent and universal definition of the discipline has so far remained largely elusive. A Professor of Social Medicine at Brussels University, René Sand, has stated that the roots of social medicine lay in ancient Greek philosophies of medicine and health (Sand, 1952) whereas George Rosen, an eminent historian and Professor of Public Health at Yale, while tracing the origins of the social role of medicine back to the nineteenth century, has highlighted the role of French and German health and social reformers like Jules Guerin, Alfred Grotjahn and Rudolph Virchow (Rosen, 1947; Porter and Porter, 1988). Worldwide, the primary mission of healthcare that includes curing illness, relieving pain, repairing injury, preventing disease and saving lives figures among the top national priorities. "Nationalization of Medicine" was achieved in Great Britain by the establishment of National Health Services (NHS) in 1948 wherein independent, charitable, voluntary and municipal hospitals, general and specialized, large and small were owned by the government and hundreds of thousands of doctors belonging to all medical specialties, nurses, ancillary health workers and paramedics were transferred entirely to the state's payroll (Marsland, 2005).

Britain's National Health Services (NHS) is a unique example of truly socialized medicine wherein healthcare care is provided by a single payer i.e., the British government and is funded by the taxpayer. Under this system all appointments and treatments including prescription drugs are free to the patients though paid through taxes. NHS officially came into existence in July 1948, in the wake of World War II, to replace an inadequate and inefficient system of volunteer hospitals that were heavily relying on government funding during the war. Establishment of NHS was vehemently opposed by the doctors and conservative politicians back then using similar arguments as cited by the opponents of greater government involvement in healthcare within USA. Fact of the matter is that today Britain like many other developed nations ranks above the U.S. in most of the indicators of health. Its citizens have a longer life expectancy and lower infant mortality, besides greater number of intensive-care hospital beds per capita and fewer deaths related to surgical or medical mishaps. What is more noteworthy is that Britain achieves all these results while spending proportionally less on healthcare than the U.S. For these and some other reasons, the World Health Organization (WHO) had ranked Britain 18th in a global league table of health-care systems whereas the U.S. was ranked 37th. However, in terms of cancer mortality rates U.S. outperforms Britain.

Socialization of medicine addresses social determinants of health including social equity, parity and universal coverage through govt. health services. It also eliminates the unhealthy competition among physicians in search of their patients. However, maintenance of their pay parity in tune with their valuable services has been a matter of concern in some countries like Cuba. Under this system medical care becomes either completely free for the patients or reduces their out-of-pocket expenditures on healthcare to a great extent with the active financial support of the State. However, it is now recognized that in addition to socialization, "community participation" is also required in equal measure to ensure adequate and equitable utilization of health services and resources. As envisaged by WHO and UNICEF, it is "the process by which individuals and families assume responsibility for their own health and welfare and for those of the community", and take suitable measures to develop their own capacity to contribute substantially towards their community's holistic development and well-being (Ratcliffe, 1984). It also implies community participation in the planning, organization and management of their own health services and has also been denoted as "Health by the People" (Park, 2015).

Socialization of medicine is the natural outcome of the social industrialization, urbanization and productive socialization based on the perspective of the social complexity of disease incidence and development. Medicine is a social enterprise and therefore it is desirable to adopt and implement the socialization of medicine in order to fully realize the great social function of medicine (Ryder, 1965). Though terms like universal health care and socialized medicine are often used synonymously and interchangeably, they fundamentally represent different political and economic approaches for making health services available to the masses. While universal health care simply means that every citizen has an equal opportunity and ability to access basic health care services without suffering any financial impoverishment or catastrophe, it does not necessarily mean that only the government pays for that access all the time (Bloom et al, 2018). Fact of the matter is that most of the countries around the world that offer universal health care to their citizens use a combination of public and private coverage including contributions from the individual households, employers, insurance companies, NGOs and foreign agencies. Contrary to that, in a single-payer system, every citizen gets coverage in which government fully pays for all healthcare services (EMTALA, 2012). Countries like UK, Canada and Germany have a well-functioning socialized medicine structure in place (to be concluded).

(Author teaches Pharmacology at the Department of Pharmaceutical Sciences, University of Kashmir)

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