Dr. Virchow’s Cure

A 19th-century doctor revealed how poverty bred disease. How could we have forgotten?

By Jeremiah Creedon

In 1848, Prussian officials in Berlin sent a young doctor to an outlying province to study the spread of a deadly fever. Stung by criticism and fearing unrest, they told Rudolf Virchow, age 26, to find a way to prevent such outbreaks, which earlier efforts had failed to curb. He returned with a shocking plan: Set the people free. Give them more liberties and better schools. It wasn’t the famine that was killing them, he said; it was political oppression.

Virchow’s Report on the Typhus Epidemic in Upper Silesia is regarded today as one of the founding works of modern public health. Its relevance grows as what he called “crowd” diseases continue to spread, feeding on turmoil and hunger around the world. While infectious epidemics, including AIDS, ravage sub-Saharan Africa and other poor regions, North America is not immune. Many of the same diseases have found their way into isolated pockets of poverty in the United States, as the climbing AIDS rate in the rural South so clearly indicates. Meanwhile, in some of the richest cities on earth, tuberculosis, an age-old scourge, rages within blocks of the greatest medical centers ever built.

With so much high-tech medicine now at our disposal, why can’t these diseases be controlled? For one thing, if you’re poor, America may as well be Africa; the best health care is often just as out of reach. For another, the tools of 20th century medicine, however powerful, have blinded us to certain dimensions of disease that to Virchow were obvious. Indeed, the standard biomedical model of illness needs to be updated, some would say. In the words of Harvard physician and anthropologist Paul Farmer, nothing less than a new biosocial analysis will do – “an analysis that draws freely on clinical medicine and on social theory, linking molecular epidemiology to history, ethnography, and political economy.”

Farmer’s critique suggests a couple of trends that could transform scientific research over the next few decades: the rise of “progressive science” (to counter industrial science) and the melding of many social and scientific fields into a new “interdisciplinarity.” Ironically, both are high-tech revolutions in their own right, driven in different ways by the computer. If specialists ruled science in the 20th century, a wider, more flexible, more socially attuned way of thinking may dominate the 21st. Which leads us back to Rudolf Virchow, who was already thinking that way in 1848.

Born in 1821, Virchow was the era’s leading pathologist, a keen observer of disease and its impact on the cell. Though he constantly urged his students to “see microscopically,” his private quest to understand nature led him far beyond the lab. He studied Berlin’s sewer system and the ruins of Troy, held public office, and took part in numerous organizations. An early and vocal champion of democracy in Germany, he also held what was, at the time, a radical belief that freedom and health are basic human rights.

Virchow’s famous report on Upper Silesia (now a part of southwestern Poland) began with a multidisciplinary look at local life, underscoring how even what the people ate and drank bore the mark of religious and political domination. Only then did he introduce his medical findings on the disease. He also explored the psychology of oppression – how it stripped people of the tools and the will to help themselves. He ended with a modern blueprint for nation building based on new democratic freedoms, new schools, new businesses and new cooperative farming methods. “The earth produces much more food than we need,” he states, then calls it folly to argue that the greater good is ever served by funneling profits into the same few hands. In his view, workers deserved not just wages, but also self-fulfillment and pleasure. Nearly all he said could be applied to the world’s embattled people today, from Afghanistan to the countless rural villages suffering the worst effects of globalization.

Virchow’s trip coincided with a sudden cry for democracy across Europe. Back in Berlin, he joined the street protesters calling for revolution, and helped start a weekly journal, Medical Reform, aimed at both his liberal peers and a wider popular audience. He believed that doctors would emerge as the natural leaders of the new democratic order, but they had to be willing to let their knowledge loose. Public health and public education were one and the same.

Within a year, both the revolution of 1848 and his magazine had failed. Virchow lost his hospital post and temporarily left Berlin, but his career had just begun. According to biographer Erwin H. Ackerknecht, when Virchow died in 1902 Germany “lost four great men in one: her leading pathologist, her leading anthropologist, her leading sanitarian, and her leading liberal.”

Virchow had his flaws; in the modern view, what some have called his “anti-feminism” may be the most glaring. His reluctance to accept the era’s newly emerging germ theory of disease is somewhat less clear-cut. We now know that microbes play a key role in many illnesses; but Virchow knew with a similar certainty that these same diseases go hand in hand with human squalor. Wherever people live in misery, disease is sure to find them. What then really causes disease, poverty or germs?

This debate continues today in South Africa, where President Thabo Mbeki and his medical advisors have refused to accept that the HIV virus causes AIDS. Given the compelling evidence that a virus is involved, they seem to have turned Virchow’s thinking into a rigid ideology. Then again, who can believe that the global AIDS pandemic will ever be curbed without addressing the poverty on which it parasitically feeds?

This question lies at the heart of Paul Farmer’s Infections and Inequalities: The Modern Plagues (1999). His clinical work with AIDS and tuberculosis patients in Haiti and elsewhere leads him to believe that “inequality itself constitutes our modern plague.” No real progress can be made until we understand how “fundamentally social forces and processes come to be embodied as biological events.”

Farmer reveals how complicated this process we call disease can be. The variables range from environmental damage and jet-age travel to war, climate change and overpopulation. But the biggest co-factor, he argues, is inequality: Whatever the illness, economic status affects outcome. He and others are turning their gaze on what researchers have often refused, or been unable, to see: the science of inequality itself.

Virchow hoped to turn medicine into a humanistic discipline that would produce both the healers and the leaders of a new democratic age. But as noted by Virchow’s English-language translator, Lelland J. Rather, that didn’t happen. Instead, medicine became “a technical craft working within a very narrow measure of the human being.” In what Rather calls an almost tragic irony, Virchow’s cellular research and its central rubric – see microscopically – would end up encouraging the narrow biomedical view of health.

But as the full range of Virchow’s thinking has become more widely known, his influence has shifted in recent decades. As an inspiration to Farmer and other activist researchers who believe that scientific rigor and humanist passion can coexist, Virchow could yet help lead science back to more fully serving the people.

Meanwhile, Virchow’s famous ability to think across the disciplines, to make unlikely connections between widely disparate facts, has now been wired into our smart machines. Computers may soon help us draw more subtle models of the world – revealing the chemical synergies may trigger certain cancers, for instance, or the social synergies that fuel the modern plagues. Even Virchow’s desire to liberate knowledge is being realized as the internet lets medical information out of the black bag.

Thus Rudolf Virchow lives – in an age that needs to see all of nature, including human nature, in something closer to its full complexity.

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