Does Social Medicine Still Matter in an Era of Molecular Medicine?

To ask whether social medicine still matters may seem to be in poor taste at a symposium to honor Martin Cherkasky, but social medicine has always had the courage to take on difficult questions. There is all the more reason to do so when its legitimacy is challenged. The extraordinary findings emerging from the human genome project will revolutionize diagnostic and therapeutic methods in medicine. The power of medical interventions, for good and for harm, will increase enormously. However, in the next millennium, as in this one, social factors will continue to be decisive for health status. The distribution of health and disease in human populations reflects where people live, what they eat, the work they do, the air and the water they consume, their activity, their interconnectedness with others, and the status they occupy in the social order. Virchow's aphorism is as true today as it was in 1848: "If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life." Increasing longevity resulting from major economic transformations has made ours the age of chronic disease. Changes in diet and behavior transform genes that once conferred selective biologic advantage into health hazards. Although disease risk varies with social status, medical care makes an important difference for health outcomes. Access to care and the quality of care received are functions of social organization, the way care is financed, and political beliefs about the "deserving" and the "underserving" poor. It is a moral indictment of the US that ours is the only industrialized society without universal health care coverage. In educating the American public about the social determinants of health, a goal Martin Cherkasky championed, the very power of the new molecular biology will help make our case. Social medicine is alive and well.