Behavior, Disease, and Health in the Twentieth-Century United States: The Moral Valence of
Individual Risk – Allan M. Brandt
- In the course of the past century, patterns of health and disease in the US underwent a radical
transformation which is reflected in:
o Major demographic indicators
o Nature of the practice of medicine
o Cultural norms and values concerning health and disease
- Not only do Americans live longer, they now die from different causes
- Changing perceptions of what causes disease – the nature of risk, behaviour, and responsibility –
reflect powerful moral beliefs
- These moral beliefs implicitly and explicitly affect patterns of social behaviour and the
organization and delivery of health care.
- Purpose of reading: attempt to examine the cultural implications and meanings of this “health
transition”, to explore how theories of disease causality may reflect powerful social and political
ideologies concerning risk and responsibility
History of Health
- Beginning of 20 century, infectious diseases such as malaria, smallpox, yellow fever, cholera
constituted the predominant causes of death.
- These epidemics were widely feared as they gave a sense of there was little human control over
it, as quarantine, sanitation, and medical efforts often failed to have any influence.
- 1918 Spanish Flu, shows the devastation a disease could have, 20 million people worldwide have
died to this flu
- All of this reflected to show the limitations of human intervention to alter fundamental
biological processes. A deeper recognition of human limits in the face of severe biological
- However, epidemics weren’t really a huge problem in comparison to more basic infections.
Tuberculosis and pneumonia constituted more risk than the time-limited epidemics.
- Infant mortality was generally caused by diarrheal disease from common infections of newborns,
not an epidemic.
- When people realized diseases were selective in their targets (some people would get a disease
and die, some would survive), medical theories that often emphasized the hereditary quality of
susceptibility to particular diseases came up.
- By late 19 century, germ theory of disease radically altered both medical and social meanings
of disease: Robert Koch’s “Postulates”, or the rules to live y in modern biological science.
o Single pathogen is invariably associated with a specific disease
o Organism could be isolated from a lesion and grown in a pure culture, and then used to
reproduce the disease.
- By 1900 nearly 30 “causal” organisms had been identified under microscopic scrutiny
- Soon after these discoveries, the paradox of the “healthy carrier” came into play, where people
could have the germs that cause the disease but be perfectly healthy. o Researchers found that in many urban areas many people had the germs to have
tuberculosis but remained healthy.
- Rene Dubos: “Infection is the rule and disease is the exception”
- The germ theory model had the effect of displacing the idea of the “whole” person, going only
after the disease. This ignored the importance of the social environment.
- Biomedicine – germ theory in particular – led to a more complete understanding of the causes
and nature of many diseases, it did not lead to immediate or effective therapeutic modalities.
o However, infectious diseases did decline, although it was clear that most important
infectious diseases were declining even before germ theory
- Leading causes of death in 1900: Tuberculosis, pneumonia, diarrhea.
- Leading causes of death in 1990: heart disease, cancer, stroke
- Changes in the material conditions of life: sanitation, nutrition, and rates of birth, led to
important chances in patterns of infection and longevity
- The biomedical model essentially “depersonalized” the disease, under the microscope diseases
could not possess the same “moral valence” that they had maintained in the past.
o Juxtaposition from the past where diseases were categorized under religious headings,
and thought to be reflective of sin, moral turpitude, and idleness.
o Also known as “De-moralization of disease”
- This historical context explains the attribution of the word “disease” in reducing individual
o Example of AA jumping on this, calling alcohol dependence a disease so it would reduce
the stigma behind it.
- Disease implies a lack of volition or at least a failure of individual agency
- The biomedical model could remove the discrete phenomena creating the disease, or increase
the resistance to that particular phenomenon. The “golden age” of American medicine had
begun, where people were not dying of diseases that would surely kill them just a decade ago.
- “Magic-bullet” medicine, targeting JUST the disease in the body.
- The rise in life expectancy, end of infectious epidemics, and the growth of effective and
dramatic medical interventions led to an era of rising status and authority for medical profession,
biomedicine was considered “modern medicine” and the solutions that they could give to
problems made them an authority in power.
- However, during the course of the 20 century chronic diseases that did not have an identifiable
single cause such as cancer, heart disease, and stroke came about.
- In addition, certain infectious diseases could not be cured because the therapies would have
limitations such as resistance from the disease or untimely treatments.
o These chronic diseases changed a lot, they were mostly diseases that were “acquired”
instead of “caught”, and thus the question of individual differences came into play once
- Ultimately, germ theory was challenged as these “magic bullets” could no longer deal with the
diseases that were problematic: the chronic ones - New epidemiological studies began to re-evaluate the basic medical principles of causality, and
researchers began to look at social data (housing, work, pollution, poverty, etc) that might
account for particular patterns of disease prevalence
o However, as a result of germ theory, public health research was more focused on
finding and destroying whatever was causing the disease. The bacteriological revolution
caused the interest and concern about social conditions causing disease to decline.
- The above encouraged a “new” epidemiology, into looking at the RISKS: social, environmental,
and behavioural variables that were statistically associated with patterns of chronic disease
o This offered significant potential for the moral categorization of a wide range of
behaviors and social phenomena
- The history of the cigarette is a prime example of this legitimization of new approaches to causal
inference and the moralization of health behaviours.
- The recognition that cigarette smoking causes serious disease and the eventual decline in
smoking are characteristic of the postwar shift regarding risk, disease, and behaviour.
- Smoking was extremely popular post-war, but concerns persisted about its impact on health.
Rates of lung cancer began to rise alarmingly, and many studies were undertaken that showed
cigarettes were enormous risks to health
- Surgeon General’s Report of 1964 conclusively demonstrated the risks of smoking.
o The report was a critique of the notion of “specific causality”
How do we know what we know? What’s the reliability of causal inference form
o Debate on smoking revealed an intra-professional battle between epidemiology and lab
science (germ theory), an their values, assumptions, and expectations
o Report made a fundamental contribution to medical studies of causality:
“It should be said at once that no member of this committee used the word
“cause” in an absolute sense in the area of this study… All members shared a
common conception of the multiple etiology of biological processes. No
member was naïve as to insist upon the mono-etiology in pathological processes
or in vital phenomena”
o Statement was a clear criticism of germ theory, report underscored the social nature of
the process of creating scientific proof. And they had set a precedent that one did not
have to determine ABSOLUTE causality to state that cigarettes CAUSED cancer.
- Post-report, the government had to put in a warning label that the cigarettes may be a hazard to
your health, which made smoking a “voluntary” health risk, and thus the moral valence of
cigarette smoking had been substantially augmented
Subsequent epidemiological studies
- New theories, that emphasized statistically configured “risk factors”, contained powerful
cultural norms regarding the meaning and significance of disease. o Question of the who the responsibility of disease was on, and its prevention
- There was a point reached in American healthcare where the returns on the investments on
medical technology wasn’t being shown, and preventing disease was not working as it did in the
- John Knowles, President of Rockefeller Foundation:
o Idea that goal of health and longevity rested firmly with individuals, who forfeited their
health in an “orgy” or greed, avarice, and overeating, the “diseases of affluences”.
o “The idea to a ‘right’ to health should be replaced by the idea of an individual moral
obligation to preserve one’s own health… a public duty if you will”
- This put the mantle of responsibility on the shoulders of individuals, and no longer would
disease be viewed as a random event but as a failure of the individual, a lack of self-discipline, or
an intrinsic moral failing.
- This idea of individual moral fault is very close to the religious idea of sin, that you are at fault
for your imperfections
- The fitness movement was bolstered by the medical science movement that showed the
benefits of regular exercise.
o Clinical and basic research led to concrete conclusions about diet and exercise to their
relationship to heart disease
o Millions of people running, buying exercise books and videos, etc.
- Organized medicine cooperated vigorously with the crusade for physical fitness
o Two markets of health: blood pressure and cholesterol, were helped by physical fitness
- Doctors became a “monitor” of health, where one could go and check how “healthy” they were.
An individual’s moral achievements could be monitored and quantified.
- The fitness revolution reflected the desire to assert “control” to reduce the risks of disease or
premature death. Exercise promised this mastery and self-efficacy, and it promised personal
- Fitness could be viewed as a denial of the consumerist culture because it was about self-denial
and control… but the consumer culture marketed directly to this fitness culture (shoes, running
machines, health clubs, etc)
- This also had massive impact on American diet and alcohol consumption, many Americans
attempted to reduce fats in diet, and alcohol consumption went down, any many thought it was
MORALLY INCORRECT to drink.
- While this fitness revolution reflected deep cultural anxieties about health, but also bodily
o Took on a powerful moral and prescriptive dimension
- Massive social change and chaotic social values always incite attempts to gain the assertion of
o Happened post war, happened post industrial revolution, etc.
- Is there a RIGHT to health care of a DUTY to be healthy? - How do we distinguish between assumed risk and imposed risk as they related to patterns of
behaviour and disease?
o Example of smoking again, it is socially stratified (poorer you are, the more likely you
will be a smoker)
Is this really CHOICE or the effects of advertising?
- CAN individuals really have complete control over themselves? Or are there broader processes
that shape behaviour?
- Regardless of all these issues, individuals who “take” such risks are considered ignorant, stupid,
- Example: the “just Say No” antidrug campaign. It insinuates that one can resolve their addictions
by simply saying no, a simple self-denial. This is seen as a solution to a much larger issue, and by
saying one can do this it individualizes the causes.
- First decade of the AIDS epidemic challenged many assumptions of post-war medicine. The idea
that infectious epidemics was largely over.
o Majority of diseases were chronic and affected the old, AIDS affected the young and was
transferrable, and there was a viral cause to it.
- Despite this, AIDS has still been placed in a paradigm of responsibility. If one AVOIDED the risks
involved in getting AIDS, you can avoid it. Having AIDS was a marker of individual risk taking, of
engaging in behaviours that were deviant or criminal.
o Those who are infected with AIDS are responsible or their plight, and AIDS is caused by a
moral failure of the individual
- It’s not simply victim blaming, but also underscoring implicit values of any individual that HAS
- External risks are so hard to control, its human nature to want to control as much as we can,
even if it is very little. It is a psychological defense against the reality that human vulnerabilities
may be out of the realm