Frustrated in their attempts to access information, seek compensation, and prevent future deaths, the families convinced the flamboyant lawyer, Jan Schlichtmann, to take on what was thought to be a hopeless cause. Suddenly, the case seemed to promise a multi-million-dollar settlement. Large industrial concerns, as well as government officials, began to pay close attention. Obsessed with the enormity of the apparent crime, the creative Schlichtmann amassed a huge amount of damning evidence through careful and expensive scientific research. But the accused companies also invested large sums in experienced lawyers and scientists who used other data and legal technicalities to refute the charges. The families lost their case in 1986, and Schlichtmann was financially and emotionally ruined. By that time, 21 cases of leukemia had been identified – 4 times the anticipated rate for the population. A public health report found “no significant differences” in exposure between the leukemia cases and controls, yet concluded that “it is not possible to rule out exposure to this water as a factor” (Cutler et al 1986). 

Author Jonathan Harr began work on A Civil Action in 1986 before the opening of the trial, and he accompanied Schlichtmann to almost all meetings, relied on court transcripts, and conducted many painstaking interviews with the families and opposing lawyers. The result is an omniscient yet intimate perspective on these true events that reads like an action-packed thriller, complete with dialogue. It won many awards and was on the New York Times bestseller list for 65 weeks. It stands as an interesting commentary on the nature of environmental health and on the American justice system. 

Three years later, Steve Zaillian wrote and directed the award-winning film, A Civil Action (1998), based on Harr’s book and starring John Travolta and Robert Duvall. Shlichtmann received $250,000 for the portrayal rights, but is quoted as saying, “John Travolta made more money playing me than I ever did playing me” (Kix 2009). Forty years later, now at age 75, he continues to champion environmental causes, aiming for settlements rather than court cases and recounting his “lessons learned” on the speakers’ circuit. 

Woburn and A Civil Action had coincided with other prominent environmental disasters, caused by industrial failures: Three Mile Island (1979), Love Canal (1977-1979), Times Beach, Missouri (1983), Bhopal (1984), to name only a few. The book and the film contributed to rising awareness about the health risks of environmental damage, and they added to increasing skepticism over the intentions of private entrepreneurs and the courts. They also heralded a period that saw a growing body of legislation aimed to define responsibilities and regulate industrial pollution – measures coming, alas all too frequently, after new problems arose and covering jurisdictions defined only by political boundaries, which have nothing to do with the flow of water and air. In 2022, the United Nations declared that a healthy environment is a human right. Dozens of countries, including Canada (2023) and several American states, have enshrined that ideal in law, even if practicalities and protections lag far behind. 

Less known is that fact that Woburn triggered a public-health preoccupation with “clusters” and the nature of proof (Alexander et al., 1999; Kingsley et al., 2007) Do clusters indicate important dangers or are they unfortunate but random occurrences? A decade later, the Center for Environmental Health Sciences at Massachusetts Institute of Technology reported on its vain “search for causes” in the industrial toxins of the Woburn leukemia cluster (Durant et al., 1995). In 2002, a controlled study, based on Woburn, failed to establish a causal correlation between disease and contamination; it pointed out that incidence had returned to anticipated levels, while 8 consecutive years had seen no leukemia cases at all (Costas et al., 2002). Woburn has also been cited in efforts to provide better statistical evaluation of “clusters” (Waller, 2000). Woburn prompted recommendations to incorporate qualitative methods into public heath reporting (Brown, 2003) and to recognize the value of citizen science and epistemic differences in lay and professional “ways of knowing” (Brown, 1992; Petteway et al, 2019). Woburn is still being cited in public health assessments of environmental causes of malignancy, often with ambiguous outcomes (Binczewski et al., 2026). 

A Civil Action helped prepare the terrain for these many studies with their controls, statistics, and tracking of chemicals–mind you, only those chemicals that are already recognized and detectable. We no longer question the harm in smog and smoking, while improvements in respiratory diseases proclaim the benefits of keeping air clean. It is dismaying that the idea of water pollution as a harm to human health continues to be such a hard sell, while disasters like Flint, Michigan, or Grassy Narrows, Ontario, roil on. 

Water degradation is bad for flora, for fauna, and for the planet. Therefore, it is bad for us too. But for industry, the courts, and even some epidemiologists in their many ways of knowing, it remains an unproven hunch. 

References 

• Alexander, Freda E. 1999. Clusters and clustering of childhood cancer: A review 
• European Journal of Epidemiology 15: 847-852.
• Binczewski, N.R., Morimoto, L.M., Wiemels, J.L., Richardson, D.B., Bartell. S.M., Metayer, C., Vieira, V.M. 2026. Spatial analysis of residential location at birth, PFAS in public water, and childhood cancers in Southern California (2000-2019). Journal of Exposure Science & Environmental Epidemiology 2026 Mar 5:10.1038/s41370-026-00850-1. doi: 10.1038/s41370-026-00850-1. Epub ahead of print. PMID: 41781477; PMCID: PMC13032745. 
• Brown, Phil. 1992. Popular epidemiology and toxic waste contamination: lay and professional ways of knowing. Journal of Health & Social Behavior 33(3):267-81. 
• Brown, Phil. 2003. Qualitative methods in environmental health research. Environmental Health Perspectives 111(14):1789-98.  
• Costas, K., Knorr, R.S., Condon, S.K. 2002. A case-control study of childhood leukemia in Woburn, Massachusetts: the relationship between leukemia incidence and exposure to public drinking water. Science of the Total Environment 300(1-3):23-35. 
• Cutler, J.J., Parker, G.S., Rosen, S., Prenney, B., Healey, R., Caldwell, G.G. 1986. Childhood leukemia in Woburn, Massachusetts. Public Health Reports 101(2):201-5. 
• Durant, J.L., Chen, J., Hemond, H.F., Thilly, W.G. 1995. Elevated incidence of childhood leukemia in Woburn, Massachusetts: NIEHS Superfund Basic Research Program searches for causes. Environmental Health Perspectives 103 Suppl 6:93-8. 
• Kingsley, B.S., Schmeichel, K.L., Rubin, C.H. 2007. An update on cancer cluster activities at the Centers for Disease Control and Prevention. Environmental Health Perspectives 115(1):165-71.  
• Kix, Paul. 2009. In the shadow of Woburn, Boston Magazine, City Life, 22 September:  https://www.bostonmagazine.com/news/2009/09/22/in-the-shadow-of-woburn
• Lagakos, S. W., Wessen, B. J., Zelen, M. 1986. An analysis of contaminated well water and health effects in Woburn, Massachusetts. Journal of the American Statistical Association 81(395):583–596.  
• Petteway, R, Mujahid, M., Allen, A., Morello-Frosch, R. 2019. Towards a people’s social epidemiology: Envisioning a more inclusive and equitable future for social epi research and practice in the 21st century. International Journal of Environmental Research and Public Health 16(20):3983. 
• Waller, L.A. 2000. A civil action and statistical assessments of the spatial pattern of disease: do we have a cluster? Regulatory Toxicology & Pharmacology 32(2):174-83. 
• Jonathan Harr discusses A Civil Action on C-Span 

Web image by Medhum.org

When the Food and Drug Administration (FDA) was created in 1930, its mission was to ensure the safety of prescription medications. In 1962, with the passage of the Kefauver-Harris Amendments to the Federal Food, Drug, and Cosmetic Act, the FDA also became responsible for certifying drug effectiveness. Positive results in one or more randomized double-blind clinical trials became the gold standard for approval. Thus, patients were assured that when their doctor prescribed a “hot” new drug that had appeared on the market, it had met the FDA’s rigorous safety and effectiveness criteria.  

Yet, sixty-three years later, near the beginning of Rethinking Medications (2025), Dr. Jerry Avorn writes:  

“In 2021, the Food and Drug Administration (FDA) gave its approval to Aduhelm, a new drug for Alzheimer’s disease that didn’t work, could cause brain damage, and was poised to cost the nation each year a sum the size of NASA’s annual budget. How did the world’s once best prescription drug regulatory body fall so low” (p. 31) 

The FDA not only approved Aduhelm but did so over an almost unanimous negative vote of its scientific advisory panel. What had happened to the promise of safety and effectiveness? Jerry Avorn MD, founder and director of Harvard’s Division of Pharmacoepidemiology and Pharmacoeconomics, argues that the Aduhelm approval resulted from a longstanding decline in the FDA’s regulatory standards, a slippery slope greased by social, political, and especially pharmaceutical industry pressures. Rethinking Medications is a comprehensive assessment of the pharmaceutical industry, the FDA, and their complex relationship in the 21^st century. Much of the book addresses three core issues: Does a new drug work? Is it safe? And what should it cost? Other chapters deal with education, patient empowerment, and the specific examples of psychedelics and pain killers. 

According to Avorn, the FDA’s rigor began to break down during the late 1980s when the agency initiated an accelerated or “fast track” review process in response to the AIDS epidemic, a reasonable change in light of the rapid spread of this incurable and deadly disease. (pp. 30-32) Initially, “fast track” approval involved greater FDA monitoring and quicker action but still required evidence of clinical effectiveness. In the case of AIDS, a hematological marker, CD4 T-cell count, was highly correlated with clinical outcome, which made it an excellent index of effectiveness. 

However, not long afterward, the FDA opened its accelerated approval pathway to medications for chronic, progressive diseases and to use a favorable change in such surrogate markers (e.g. blood tests or images) as substitutes for clinical improvement. For example, in the case of Alzheimer’s disease, reduction in the number of amyloid plaques was considered a sufficient reason to approve Aduhelm, though the study had not documented symptom reduction or slower decline in functioning. While some surrogate markers are good predictors of outcome (e.g. Hb A1c in diabetes), most markers used for chronic disease drug approvals lack strong predictive evidence.¹ 

However, the accelerated track includes a presumed fail-safe mechanism. The pharmaceutical company is required to complete a long-term confirmatory study to confirm clinical effectiveness. By 2022, more than half of new drug applications were being processed in the expedited track, and over 80% of these were approved. (p. 77) The confirmatory study requirement, even if honored by the companies, allowed medications to be prescribed for years before a negative finding might cause approval to be revoked. According to Avorn, the increasing use of surrogate markers as endpoints tells the industry, “You can market your drug if it makes a lab test look better in a short study, compared to a placebo. We won’t be on your case too much about those confirmatory follow-up studies.” (p. 37) [Avorn engages in hyperbole here. Aduhelm was shown to be ineffective and withdrawn from the market in 2024.]² 

Avorn next addresses the safety of newly approved drugs. Serious side effects must be recognized, if possible prior to approval. However, according to the author, the profit motive sometimes outweighs evidence of significant harm. He discusses the case of Vioxx (Merck Pharmaceuticals, 1998), a COX-2 inhibitor approved because it had fewer GI bleeding side effects than other NSAIDs. Several studies subsequently showed that patients taking Vioxx had almost double the number of myocardial infarcts and strokes of those taking other NSAIDs. Nonetheless, Merck rigorously disputed this evidence for several years before finally removing Vioxx from the market in 2004. Largely as a result of the Vioxx scandal, Congress passed the FDA Amendments Act in 2007, which introduced several safeguards for ensuring drug safety. These included (a) creating a nationwide system for monitoring adverse effects, (b) preventing companies from hiding clinical trial results by requiring that all trials be registered in a federal registry, and (c) insisting that companies complete follow-up studies after the drug has been approved. (pp. 167-170) 

In 2007, a far more widespread safety failure was still a decade from being revealed. When Oxycontin was approved in 1995, the FDA believed the long-acting form of oxycodone would result in less abuse potential, since the drug would be absorbed slowly without an immediate “rush” to promote abuse. This belief had a theoretical basis, but there were empirical findings that strongly suggested otherwise. Over twenty years later, a presidential commission (2017) “concluded that the FDA’s mishandling of the evaluation, approval, and use (of oxycontin) was an important cause of the nation’s opioid crisis” (p. 393). 

Anyone who watches broadcast television today will find it difficult to believe that prior to 1997, essentially no prescription drug advertising appeared on television. In 1997, the Food and Drug Administration approved a new rule allowing pharmaceutical companies to state only “major risks” in their ads, rather than its previous requirement of a full list of all possible risks, contraindications, and side effects, which had effectively precluded direct-to-consumer advertising. The industry quickly learned how to package major risks into brief statements aired sotto voce at the end of their commercials under images of smiling patients picnicking in a park. Since then, ads for expensive new pharmaceuticals have spread like wildfire.  

Aggressively promoted new drugs are mostly treatments for chronic, malignant, or degenerative diseases that require continued use over many months or years. The producers, in essence, have monopolies on these products because they are protected by patents from competition for a certain number of years. Without competition, companies are able to charge very high prices, which they justify as necessary to compensate for costs of research and development.  

Avorn identifies several reasons to doubt that excessive R & D costs are a determining factor in pricing new drugs. First, many Big Pharma companies spend more on marketing, most of which is direct-to-consumer advertising on TV and other media, than they do on research and development. Thus, much of the actual “investment” is spent in devising ways to convince consumers that new is better.  

Secondly, most newly approved medications are not innovative, but rather modifications of existing drugs for which the patents will soon expire. The manufacturer seeks to have a replacement drug with a claimable advantage (e.g. fewer side effects, fewer daily doses) sufficiently different to be patented and approved before it loses patent protection on a profitable product. When generic versions of the product appear on the market costing up to 60% less than the original, the manufacturer attempts to maintain profits and market share by heavily promoting its “new, improved version.”  

Third, “breakthrough” medications that employ a newly discovered mechanism, or work dramatically better than available alternatives, are generally the result of NIH-funded basic science and clinical trials performed by university faculty. While the Bayh-Dole Act (1980) allows universities to patent promising new drugs, only pharmaceutical companies have the ability to develop and market the drug commercially. When a company purchases the patent from its home university, the scientists and the university profit from the purchase, but lose control over the medication that results. Although Big Pharma does invest significantly in developing these drugs and bringing them to market, the basic research and initial clinical trials are supported by federal grants. “The largest engine driving the nation’s prodigious ability to bring new drugs to market is the hundreds of billions of taxpayer generated dollars in the National Institutes of Health and other public and philanthropic of biomedical discovery.” (p.197) Not Big Pharma.  

Finally, retail prices for the same drugs in Canada, Europe, Australia, and Japan average about 60% lower than in the United States, even though their manufacturers presumably still make a profit. The real reason they set prices much higher in the United States is simply because they can. Most other countries have mechanisms to control drug prices based on realistic cost/benefit estimates.  

Rethinking Medications is a compelling analysis of today’s pharmaceutical industry and its regulation by the FDA. Big Pharma is clearly the “heavy” in Avorn’s analysis. The FDA failures result from some combination of responsiveness to the need for new therapies in chronic diseases, inadequate resources and personnel to enforce the requirement for confirmatory studies, and the withholding of critical data by pharmaceutical companies. The FDA Amendments of 2007 corrected many of these problems, although the FDA’s fate under the Trump administration is yet to be seen. The prospects are not promising because the Department of Health and Human Services is directed by a man who aggressively promoted hydroxychloroquine as a treatment for Covid and doubts the effectiveness of vaccines.  

Despite Dr. Avorn’s focus on failures and deficiencies, the reader should keep in mind that the American pharmaceutical industry does have a remarkable track record of producing innovative and effective medications. This, of course, does not justify the industry’s rampant profiteering and deceptive practices. It would require strong federal regulation, especially regarding pricing, to address these problems. Here again, the current administration’s anti-regulatory stance makes progress in the near future improbable.  

Notes 
1, Wallach JD, Yoon S, Doernberg H et al. Associations Between Surrogate Markers and Clinical Outcomes for Nononcologic Chronic Disease Treatments. JAMA, 2024; 331 1646-1654. 
2, Two anti-amyloid monoclonal antibody medications, Legembi and Kisunla, have now been approved for treatment of early Alzheimer’s disease. Both have been shown to slow its progression by several months.  

RETHINKING MEDICATIONS
Jerry Avorn MD 
Simon & Schuster, 2025: 512 pages 

Web image by Jaretuz 

Rumor is a major source of vaccine rejection. The author discusses in detail the case of Andrew Wakefield and his contention that MMR (measles, mumps, rubella) vaccine causes autism. This belief, based on a 1998 paper in The Lancet (later retracted) has been shown to be false by numerous large-scale studies, but is accepted by perhaps millions of people throughout the world.    

In Stuck, Dr. Larson makes a strong case that vaccine hesitancy and rejection are widespread and growing global problems. The book is much weaker in proposing effective solutions. It’s clear that simple solutions, based on the premise that resistance will fade away as soon as public health agencies “educate” people, have failed.  Dr. Larson recommends listening more carefully to antivaxxers’ concerns and developing creative pro-vaccine messaging. Since the publication of her book, the massive initiative to vaccinate the American population against Covid has confirmed the extent and multiplicity of antivaccine beliefs in our society. It has also led public health agencies to develop more sensitive and engaging messaging than in the past. Nonetheless, the core problem remains.  

Stuck
Heidi J. Larson 
Oxford University Press, New York, 2020:  155 pages. 
A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image by Medhum.org

Although his story opens with the establishment of the Johns Hopkins Hospital in 1876, Barry immediately takes a detour into the history of medicine dating back to Hippocrates, and traces the history of medical/scientific thought from Ancient Greece to the end of the 19^th century. He then introduces a series of physicians, scientists, and medical researchers who will play their parts in the story of the pandemic (this first section is called “The Warriors”) and outlines their training, research, and interactions.  

It isn’t until page 91 that he takes us to the rural Kansas county in which the story of the pandemic begins. For although it was called the “Spanish Flu,” that was actually an eponym of convenience; in fact, the first cases of pandemic flu seem to have arisen on the American prairie. However, newspaper reporting on the new pandemic was felt by the Allies and Central Powers alike to be contrary to the public interest (the war was still raging), so it was left to neutral Spain, whose king had come down with the disease, to publish the early reports. In this section, “The Swarm”, Barry also briefly reviews the basic (not to worry, very basic) microbiology of viruses and the history of some prior pandemics. He follows this with the section called “The Tinderbox,” in which he traces the events leading up to the entry of the United States into World War I, and the importance of that war and the political and social conditions surrounding it in the history of the pandemic. From here on in the influenza itself takes center stage; in sections called “It Begins,” “Explosion,” “Pestilence,” “The Race,” and “The Tolling of the Bell,” the rapid and lethal course of the pandemic is described in gripping (no pun intended) detail. The last two sections discuss the scientific advances (and some false starts) brought about by the cadre of researchers working day and night to tame the outbreak, and then Barry finally turns to the retreat of the virus and ultimate end of the pandemic. The book ends as it began, returning to the stories of the individual men and women of science who engaged in the battle to beat the disease of which it had initially been said by many that “[t]his was, after all, only influenza.”  

For anyone seeking to understand the 1918 influenza pandemic not only from a scientific and medical historical standpoint, but also with an appreciation of the political and sociocultural milieu in which it took place, you can’t do much better than Barry’s work. It is not short—it clocks in at 461 pages, with another nearly 40 pages of endnotes and a 20 page bibliography—but it is well-paced and reads smoothly; the narrative carries you along, a testament to the author’s writing style. Barry succeeds in putting a human face on the pandemic and creates a mental image of the horror of pandemic disease which can stand up alongside those we have of the Black Death of the mid-fourteenth century, with which it is often compared. For those of us who know the flu as a seasonal visitor, (for most of us a major annoyance, but nonetheless a disease that kills tens of thousands each year), the images of massive and rapid death—villages abandoned except for piles of corpses, trains that “left one station with the living…[and]…arrived with the dead and dying”—seem surreal. Barry paces the book in such a way that one can almost hear the stopwatch ticking in the background; The Great Influenza is scientific and historical reporting done with great attention to detail and to getting the medical facts right, but it is reporting done with a novelist’s flair.  

Even as the pandemic begins to recede, leaving in its wake not only the dead but those living with its sequelae, such as post-encephalitic syndromes (the Woodrow Wilson/Treaty of Versailles anecdote is particularly striking), the helplessness of medical science is reaffirmed; the pandemic recedes of its own accord, because the virus mutates to less virulent forms, and the very large number of those who have survived helps to create herd immunity.   

In the book’s Afterword, added in 2018, the author discusses and compares influenza pandemics which followed the 1918 experience, talks about some of the antiviral drugs introduced over the years and how they work, and speculates about what the next great influenza pandemic might look like and how it might be prepared for. His concern was prescient, although it would be a coronavirus, rather than influenza, that would cause widespread death and societal disruption. In fact, one of the most jarring aspects of this story is the fact that, if one changes the dates and the names, the tale bears an uncanny resemblance to the COVID-19 story, right down to the attempts at minimization by the government and even the isolation and victimization of an ethnic group (in 1918 the Germans, who were the enemy in the world war, rather than Asian-Americans, as it would be during COVID).  

The Great Influenza is a detailed, highly readable, and sobering account of an episode which demonstrated once again that despite what we may think, we are not the masters of the world in which we live, and that a microbe could rapidly kill on a devastating scale and upend society—again—and there was initially little that could be done to stop it.  

THE GREAT INFLUENZA: A Story of the Deadliest Pandemic in History
John Barry 
Penguin Books, New York, 2004 (reissued with new afterword, 2018)
461 pages 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image by Medhum.org

The modern world is full of inexplicable conflicts. As one who has spent my life developing vaccines against infectious diseases it is puzzling to see the growing opposition to vaccination, which in the United States and other developed countries have eliminated or limited diseases that once decimated populations. I am old enough to remember as a child the deaths of other children, and indeed as a child I suffered three serious infectious diseases, one of which caused temporary paralysis of my face. 

Later in life, I graduated medical school and became an intern at a large metropolitan hospital in Cleveland. One of the common infections I saw in children was due to a bacterium called Hemophilus influenzae type B, which causes meningitis and epiglottitis (swelling of the structure at the top of the trachea that leads to the lungs). I treated those infections with antibiotics, but that succeeded best if the illnesses were in early stages. I remember one night on duty when a 3-year-old gasping for air was brought in to the Emergency Room by his father. The child had been put to bed that evening appearing to be healthy, but became ill hours later. I rushed into the room ready to help but in seconds, before I could do anything, the child died before my eyes. I will not forget the anguish of his father, or the anguish of other parents I saw whose children were ill with infections. Owing to the later development and employment of a vaccine against H. influenzae type B, the disease has disappeared from the United States. 

In part, the current opposition to vaccines can be attributed to the absence of these diseases they cause, which makes people feel invincible, and in part to a society in which communication of lies and fabrications is easy and rife. Modern communication allows dissemination of arguments based on fabrications to masquerade as facts, and to allow some to profit from those fabrications. Another example of a foolish approach to the issue of vaccination is the attempt by the current administration to break up the measles-mumps-rubella vaccine into three separate injections, despite years and years of safe use of the MMR vaccine that has dramatically controlled those diseases. The effects on public health will be awful. 

Although there is no easy way to deal with this situation, I have long thought that including education in statistics for all school children would be one useful step, so that they understand the relations between risk and benefit when they become adults. The fact of the matter is there is no choice in life that is without risk. The question is what is the ratio of risk to benefits in making that choice? All statistical analyses show that vaccination has little risk and great benefit, so why should we let lies about vaccination prevail? 

All licensed vaccines go through a process involving 5 Phases: Phase 1 involves testing a vaccine in a small number of people. Phase 2 involves increasing the number to several hundred. Phase 3 involves thousands of vaccinees, compared to a group of placebo recipients, checking for safety and efficacy of the vaccine. Phase 4 is after licensure, when observations are accumulated in millions of vaccinees. Phase 5 involves collection and analysis by CDC and potentially other organizations of reports by physicians about safety and efficacy of the vaccine. 

Obviously, if a reaction to a vaccine is frequent, that will be detected in the first three phases. If a reaction is uncommon but significant, it will be detected in phase 4. (Actually, a vaccine against rotavirus, an important cause of infantile diarrhea, dehydration, and death, was taken off the market because of phase 4 findings, to be replaced by a safer vaccine developed in my lab.) The problem is that when millions are being vaccinated, bad things are certain to happen by chance. The question then is are they caused by the vaccine? The answer to that question can only be ascertained by careful study, not by jumping to conclusions. 

Web image from Wikicommons.

The artist depicts Chekhov as he was in the early 1890’s, soon after he had purchased a small, dilapidated estate and moved there from Moscow with his family. In addition to serving as country doctor and public health official in Melikhovo, Chekhov at that time was composing many of the stories and plays that made him one of Russia’s most well-loved writers and a major influence on 20^th century literature. How was he able to pursue two such different and demanding careers? Several years earlier, at the height of Chekhov’s early literary success, his friend Alexi Suvorin had urged the young writer to give up medicine. Don’t spread yourself too thin, he said. You’ll never reach your potential unless you concentrate on writing. In response, Chekhov wrote, “You advise me not to chase after two hares at once and to forget about practicing medicine. Well, I don’t see what’s so impossible about chasing two hares at once… Medicine is my lawful wedded wife and literature my mistress. When one gets on my nerves, I spend the night with the other. This may be somewhat disorganized, but then again, it’s not boring, and anyway, neither loses anything by my duplicity.” (1) In this famous passage, the 28-year-old writer dances lightly over a fundamental truth of his life and identity. In fact, Chekhov’s career was not so much a matter of jumping from one bedroom to another, as was the case perhaps with the poets Wallace Stevens and T. S. Eliot, or the composer Charles Ives. Rather, Chekhov thrived on the effective, if not always seamless, integration of the arts of medicine and writing, which reinforced one another throughout his creative life. This essay explores that integration, and the manner in which Chekhov’s cold eye (objectivity) and warm heart (compassion) reveal themselves in his medical and literary lives. 

DOCTOR CHEKHOV  

“Medicine Is My Lawful Wife” 

When he graduated from the Moscow State University School of Medicine in June 1884, Chekhov was already earning his living as a professional writer. The grandson of serfs, Anton was the third of six children in a poor merchant family from Taganrog, a southern provincial town on the shore of Sea of Azov. His father had moved the family to Moscow after going bankrupt in 1877. By the time Anton entered medical school on a scholarship in 1879, the Chekhovs were living in squalor. His father had a dead-end job. His older brothers were alcoholics and generally unemployed. Anton soon discovered that he could ameliorate the situation by selling comic sketches to local magazines for eight kopecks per line. This was a type of moonlighting he loved. He wrote obsessively, often knocking off a story or two each night, after spending the day listening to lectures or working in the hospital. Chekhov ultimately published more than 200 pieces while a medical student, most of them under his preferred pseudonym, Antosha Chekhonte. 

Chekhov was a natural storyteller. Thus, it wasn’t surprising that the newly minted Doctor Chekhov continued to write, even after he opened his office and patients began to arrive. “Continued to write” is an understatement. Chekhov published 54 stories in 1885, 76 in 1886, and 57 in 1887. His work evolved from humorous sketches to longer, more serious stories for leading literary journals. In 1888 Chekhov won the prestigious Pushkin Prize and published “The Steppe,” his longest and most innovative story to date. Ivanov, his first full-length play, had a successful premiere in St. Petersburg in January 1889. By that time the young doctor had become one of the best known writers in Russia. 

Yet Chekhov always saw himself as a physician, even though in 1889 he did, in fact, retire from a normal paying practice; after that, he offered his medical services at no charge, even though the generous Chekhov often found himself financially strapped. He took care of the peasants near Melikhovo (as depicted in the painting), donated his services to the government as a district physician, and engaged regularly in public health initiatives. In less than five months in 1891, Chekhov reported seeing 453 patients at a district health center and making 576 house calls, in addition to his home practice. (2) Throughout his life, Chekhov also was heavily involved in grass roots activism, building schools for peasants, raising funds to help famine victims, and, later, near the end of his life, supporting the establishment of a sanitarium for tuberculosis victims at Yalta.  

“My Debt To Medicine” 

One of the best known of these public health efforts was his 1890 epidemiological survey of health and social conditions in the prison colonies on Sakhalin Island. Traveling by himself, Chekhov journeyed six weeks by train, steamboat, and horse-drawn carriage across Siberia to reach the 1000-km long Pacific island on which the Czarist government had recently established a notorious gulag. There, he embarked on a one-man, three-month survey of the population, tenaciously picking his way from settlement to settlement and from house to house, often by foot.  

Biographers have long tried to pinpoint his motivation for this perilous journey. During the year prior to the trip, Chekhov had undergone a crisis of confidence. In a letter to Suvorin, he opined, “I don’t love money enough for medicine, and I lack the necessary passion—and therefore talent—for literature. The fire in me burns with an even, lethargic flame; it never flares up or roars… I have very little passion. Add to that the following psychopathic trait: for two years now, seeing my works in print has for some reason given me no pleasure.” (3) He reported symptoms suggestive of clinical depression, perhaps precipitated by grief over the death of his brother Nicholas from tuberculosis. There was also a literary issue. The master of the short story had promised himself that he would create a Tolstoy-like novel that would confirm his status as a serious writer. But he was unable to do so.  

Undoubtedly a major factor for choosing Sakhalin was Chekhov’s desire to pay his debt to medicine. He had recently developed a scientific interest in penology and had read about the dismal conditions in the Siberian gulag. He saw an opportunity to influence this situation by obtaining accurate data on the health status of Sakhalin convicts. He had never completed the research thesis (the equivalent of a Ph.D.) that would make him eligible to be a medical specialist or professor. Hence, his notion of “my debt to medicine”—he would perform a survey, write his thesis, and become a teacher. 

Ultimately, Chekhov claimed to visit every settlement and survey every household on Sakhalin Island, using a 12-item data collection form. He said he completed over 10,000 of these forms in three months, a feat that (if true) qualifies Chekhov as the speediest shoe-leather epidemiologist of all time. After his return to European Russia, the author found it difficult to organize his data into a coherent study. While he had planned to write a strictly scientific monograph, his creative spirit struggled with the limitations of science. What about his personal experience? What about the interesting stories? After struggling for years, in 1895 Chekhov published The Island of Sakhalin, a curious (but engrossing) mixture of journal, geography, history, medicine, statistics, and travelogue. (4) Unfortunately, the faculty of the University of Moscow was unimpressed.  

“As I Grow Older, the Pulse of Life in Me Beats Faster” 

Picture the mature Chekhov—a middle-aged bachelor, longish face, rather neatly trimmed beard, a prince-nez clipped to the bridge of his nose. His household included his aging parents and his sister Masha, an unmarried schoolteacher who had become his confidant and secretary. His three surviving brothers looked to him for guidance and financial help. Anton was popular, witty, and generous. Among the guests at Melikhovo, there were frequently female admirers. Chekhov’s encounters with women were flirtatious and obviously enjoyable. He had teasing, sexually charged relationships with several women, but whether any of these liaisons are actually “affairs” is uncertain.  

The doctor in the painting already suffered from the tuberculosis from which he would die at the age of 44 years. In fact, he first coughed blood as a medical student. Yet, Chekhov dismissed that episode and each subsequent episode that occurred with disheartening regularity as “influenza” or “bronchitis,” steadfastly refusing to label himself consumptive. As a physician Chekhov must surely have understood the meaning of his symptoms. Was his denial simply a face to show others? Or was his denial so great that it made him unaware? The cat finally came out of the bag in early 1897. While dining at a restaurant in Moscow, Chekhov had a violent spell of hemoptysis that left him critically ill. For the first time, he sought medical treatment and entered the clinic run by Dr. Ostropov, one of his medical school professors. Chekhov’s chronic illness progressively worsened. At the insistence of his doctors, Chekhov left his beloved Melikhovo after 1898 and lived mostly at a new home in the sunny Black Sea resort of Yalta. 

It was also during these last years that the bachelor writer courted and married Olga Knipper, an actress with the Moscow Theater Arts Company. Even after their marriage in 1901, Olga remained at work in Moscow during much of the year, while the invalid Chekhov lived in Yalta, theirs being perhaps one of the earliest examples of the modern two-career commuter marriage. Chekhov found himself able to devote less and less of his waning energy to writing, especially since he refused to give up his social and philanthropic activities. Nonetheless, between 1898 and his death in 1904 Chekhov completed some of his greatest work, including several stories, two novellas (“Peasants” and “In the Ravine”), and his last plays, The Three Sisters (1900) and The Cherry Orchard (1903).  

COLD EYE, WARM HEART 

Chekhov’s Doctors 

Several characteristics of Chekhov’s work reveal the influence of medical training and practice. He used clinical knowledge to lend accuracy to his descriptions of disease and medical situations. This characteristic is perhaps most clearly seen in the characterization of mental disorders. For example, the title character in Ivanov is a subtle portrait of a man suffering from clinical depression, who eventually commits suicide. The young heiress in “A Doctor’s Visit” presents symptoms we would now label as generalized anxiety or panic disorder. The title character in Uncle Vanya appears to have a neurotic depression, a condition that meets today’s DSM 5 criteria for Persistent Depressive Disorder. In the peculiar story called “The Black Monk,” Chekhov describes a psychotic condition, presumably schizophrenia.  

Chekhov also drew from his medical experience in creating a multitude of physician characters. Doctors play significant roles in nearly 30 stories and in all of his major plays, except The Cherry Orchard. The author’s sensibility as a medical insider gives insight and poignancy to these characters, who range from committed altruists to lazy bureaucrats to burned out cases. Chekhov knew too much about the contemporary state of medical science to portray his doctors as curing many people. Thus, they often appear impotent. Yet, at their best Chekhov’s doctors convey the seamless fabric of tenderness (compassion) and steadiness (detachment) that lies at the heart of good medical practice. They also demonstrate courage, altruism, and self-effacement. For example, in “The Grasshopper” (1892) Dr. Dymov dies as a result of contracting diphtheria from a patient. Dr. Kirilov in “Enemies” (1887) demonstrates extraordinary devotion to duty by leaving his distraught wife and dead son in order to make an emergency house call.  

Perhaps Chekhov’s most textured portrait of a good physician appears in “A Doctor’s Visit” (1898). The protagonist, Korolyov, is a young doctor substituting for his boss, the professor of medicine. During the course of the story he moves from being a careful observer (detached concern) who ascertains that his young patient has nothing wrong but a “case of nerves,” to making an imaginative leap by which he connects more deeply with her. This empathic connection allows him to relieve some of her suffering by re-framing her illness. While he cannot solve her existential problems, his demonstration of solidarity leads her to trust him and to gain insight. Korolyov is like Chekhov himself. Dr. Pavel Archangelsky, who supervised Chekhov’s first job as a physician, captured the author’s ability to listen carefully when he later commented: “… he did everything with attention and a manifest love of what he was doing, especially toward the patients who passed through his hands. He listened quietly to them, never raising his voice, however tired he was and even if the patient was talking about things quite irrelevant to his illness.” (5)  

At the other end of the spectrum, some of Chekhov’s doctors are insensitive, incompetent, or impaired. Mayer, the callous medical student in “A Nervous Breakdown” (1889) is a disaster. Mayer can rattle off statistics on the number of whores in London and Moscow, but he is unable to “see” (empathize with) the suffering of the living-and-breathing whores he encounters. Shelestov in “Intrigues” (1883) and the public health doctor in “Darkness” (1887) are examples of self-centered physicians a little further along in their professional lives. The former is superficial and pompous; the latter is narrow-minded and detached.  

Chekhov’s most complete insensitive and acquisitive social climber is found in “Ionych” (1898). Dr. Startsev, when the reader first meets him, is a young physician setting up practice in a provincial town. After surviving an unrequited infatuation with the daughter of a wealthy townsman, Startsev devotes himself entirely to work. His practice prospers and he branches out into real estate. As he grows corpulent and wealthy, Startsev loses touch with his patients (and his own humanity): 

“Probably because his throat is covered with rolls of fat, his voice has changed; it has become thin and sharp. His temper has changed, too; he has become ill humored and irritable. When he sees his patients, he is usually out of temper; he impatiently taps the floor with his stick, and shouts in his disagreeable voice: ‘Be so good as to confine yourself to answering my questions! Don’t talk so much!’” (6) 

“Ionych” traces the progressive destruction of a medical practitioner who finds that medical affluence is more to his liking than the emotionally and physically difficult path of medical virtue.  

Some of Chekhov’s most interesting doctors are tortured by existential or spiritual conflict. Chekhov accurately depicted professional burnout, a syndrome characterized by depletion, detachment, depersonalization, denial, and depression. (7) Dr. Kirilov, who chooses to “go to the office” instead of mourning with his wife, may illustrate the relatively early phase of emotional detachment. Dr. Ovchinnikov in “An Awkward Business” (1888) demonstrates the more advanced symptom of depersonalization when he slugs his assistant in response to the man’s incompetence. The overworked Ovchinnikov reacts to his personal depletion by objectifying and dehumanizing his assistant, a response that compromises the medical care he is trying to protect. Chebutykin in The Three Sisters (1900) illustrates the extreme of alcoholism. Though still employed as a military physician, Chebutykin convincingly asserts that he has forgotten all the medicine he ever learned.   

Ragin in “Ward #6” (1892) and Nikolai Stepanovich in “A Dreary Story” (1889) are complex characters in whom depression and burnout are superimposed on a deep sense of existential failure. Like many of Chekhov’s characters, these physicians suffer from a lack of self-knowledge; they move through life relying on one form of self-deception or another. When they were younger, they committed themselves to noble ideals—Stepanovich to teaching and Ragin to practice in a provincial hospital. But in the long run they never “found” themselves. Professor Stepanovich yearns for a unifying moral principle that would knit together the fragments of his life. Dr. Ragin experiences his failure as emotional numbness. He yearns to suffer, assuming that if he experienced pain, he would be freed from his inability to feel. Thus, the academic physician pines for salvation in the cognitive sphere; the practitioner yearns for emotional redemption. In each case the focus remains inward, rather than turning outward to others, in whom salvation might actually be found.  

Medical Sensibility 

Medical attitudes and methodology play a larger role in Chekhov’s work than does medical knowledge. He believed that his duty as a writer was to present his observations clearly and accurately; in other words, to lay out the data in an objective fashion and allow readers to reach their own conclusions, rather than providing an author’s interpretation. He wrote, “The artist should not be a judge of his characters and what they say, but only an objective observer.” (8) 

This objective attitude put him in conflict with most other Russian writers of the time. It was a major source of conflict with Tolstoy, who was widely revered at the time as a living saint. The two men enjoyed a close personal bond but approached writing with radically different philosophies. After his mid-life religious conversion, Tolstoy viewed literature as a way to communicate his moral vision. He preached the gospel of a radical Christianity, in which all men work together to achieve economic and social equality. However, he rejected the concept of material progress and was particularly skeptical of medicine and doctors. Chekhov, on the other hand, strove to be objective, to present people as they are and the world as it is. His medical training taught him to be a careful observer; his medical attitude made him leery of judging others.  

Other Russian writers and intellectuals spoke out against the czarist government’s repressive social institutions. While this protest was disguised in various ways in order to satisfy the state censors, late 19^th century Russians (like their 20^th century counterparts) learned to speak and understand a subtle code of insurrection. The intellectuals addressed “big issues”—democracy, education, social revolution. They wrote articles, organized meetings, and gave speeches. Here again, Chekhov found himself on a different wavelength. He rarely engaged in theoretical discussion and did not advocate radical social change. Rather, he preferred a pragmatic, case-based approach. His goals were relatively limited, but achievable. Treat the sick patient. Document and publicize the abysmal condition of prisoners. Contain the cholera epidemic. Provide financial assistance to keep farmers afloat during the famine. Raise money for a new school. On and on, but always specific and personal.  

In “About Love” (1898), the narrator speculates on the essence of love. Are there universal characteristics that identify love wherever it occurs? “What seems to fit one instance doesn’t fit a dozen others,” the narrator concludes. “It’s best to interpret each instance separately in my view, without trying to generalize. We must isolate each individual case, as doctors say.” (9) Indeed, Chekhov’s stories and plays rigorously follow this dictum. While many of his Russian contemporaries used fiction to advance moral or social theories, Dr. Chekhov focused on the complexities of human interaction. In Chekhov’s world, biology and circumstance constrain freedom. People often do not listen. Acts performed with good intentions frequently result in hurtful outcomes. And yet occasionally and in unexpected places, one finds a glimmer of love, courage, spirituality, or healing. “Never generalize,” Chekhov tells his readers. “Never theorize. Pay attention to the particulars. Focus on the concrete.” In this respect, the 19^th century physician-storyteller presages the 20^th century physician-poet, William Carlos Williams, who coined the aphorism, “No ideas but in things.”  

In the long run, Chekhov’s objectivity and aversion to theory played a major role in the development of modern literature, as 20^th century writers followed Chekhov in attempting to describe the world of human character and relationship objectively, and allowing that world to speak for itself. To the extent that Chekhov’s “lawful wedded wife” contributed to his sensitivity, skills, and attitudes, perhaps medical education and practice played an unanticipated role in the history of literature, his delightful “mistress.” 

Adapted in part from Coulehan J. (Ed.) Chekhov’s Doctors, Kent State University Press,  2003

Sir Luke Fildes’ “The Doctor,” is in the Tate: File:The Doctor Luke Fildes crop.jpg – Wikimedia Commons 

Portrait of Chekhov: File: Chekhov 1898 by Osip Braz.jpg – Wikimedia Commons 

REFERENCES 
1, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p.  
2, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p.  
3, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 81. 
4, Chekhov A. A Journey to Sakhalin, translated by Brian Reeve, Cambridge, Ian Faulkner Publishing, 1993.  
5, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p. 27. 
6, Chekhov A. Ionych. In: The Tales of Chekhov. Volume 3, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 91. 
7, Coulehan JL. Being a Physician. In: Mengel MB, Holleman WL (Eds.) Fundamentals of Clinical Practice. A Textbook on the Patient, Doctor, and Society, New York, Plenum Medical Books Company, 1997, pp. 73-101. 
8, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 54. 
9, Chekhov A. About love. In: The Tales of Chekhov. Volume 5, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 290.

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Aug 6, 2025 6286

An Awkward Business by Anton Chekhov 

Jun 11, 2025 1431

The Grasshopper by Anton Chekhov

May 11, 2025 1252

Ionych by Anton Chekhov 

Mar 11, 2025 2065

A Doctor’s Visit  by Anton Chekhov 

Mar 11, 2025 1730

Ward No. 6 by Anton Chekhov

Mar 11, 2025 3245

A Nervous Breakdown by Anton Chekhov 

Feb 11, 2025 1477

Enemies by Anton Chekhov

Jan 11, 2025 1566

Painting an Ideal: Luke Fildes’ The Doctor with Hannah Darvin

Dec 28, 2024 1228

The Knick portrays all that goes on in and around a hospital struggling to provide care for the poorer classes in lower Manhattan during the early 1900s. It shows that many of what were then considered important advances in medicine, technology, society, and culture were later considered dangerous, unethical, barbaric, inhumane, and racist. The series asks whether health care of any era, along with associated social and cultural factors at work, are destined to be seen sometime in the future in similar ways. 

Storylines of the Poor and the Famous 

The Knick was inspired by the Knickerbocker Hospital, founded in Harlem in 1862 to serve the poor. In this twenty-part television series spread over two seasons, the fictional Knick is located somewhere in the lower half of Manhattan around 1900. The time covered during the series is not marked in any distinct way. The characters do not age much, and although fashion and customs remain static during the series, the scope and significance of advancements that come into play were actually adopted over a longer time than the episodes cover.  

The series builds on some known history. The central character, the chief surgeon Dr. John Thackery, is modeled on a famous surgeon of the time, Dr. William Halsted, in both his surgical adventurism and in his drug addictions. The character, Dr. Algernon Edwards, who is an African-American, Harvard-educated, and European-trained surgeon, is based in part on Dr. Louis T. Wright, who became the first African-American surgeon at Harlem Hospital during the first half of the twentieth century.   

Storylines of human drama and folly run through the series. Among them are medical cases both ordinary and bizarre, heroic successes and catastrophic failures, loves won and lost, gilded lives and wretched existences, honor and corruption, racism and more racism. Within these storylines are the scientific, medical, and industrial advances of the period, as well as the social frameworks that form fin de siècle hospital care and medical research in New York City.   

Some of the industrial advances adopted by the hospital include electrification, telephone service, and electric-powered ambulances. We see that transitions to these new technologies are not without risks and catastrophes: patients and hospital staff are electrocuted, and when the ambulance batteries died — a frequent occurrence– many of the patients they carried died, too. 

Medical advances integrated into various episodes include x-rays, electric-powered suction devices, and an inflatable balloon for intrauterine compression to stop hemorrhages. Thackery is a driven researcher taking on some of the big problems of the day, such as making blood transfusions safe, curing syphilis, and discovering the physiologic mechanisms of drug addiction. We see how he learns at the cost of his patients, or rather his subjects. We also get a glimpse of movements directed at population health. For example, epidemiological methods are applied to find the source of a typhoid outbreak, which drew from the actual case of Mary Mallon (aka, Typhoid Mary). Shown juxtaposed to the advances in epidemiology is the concurrent interest that was rising in eugenics and its broad application to control for unwanted individual traits and particular groups of people. Research ethics and regulations were a long way off.  

Time Tells 

Each era possesses its own hubris based on the technological advances and social progress made over those of previous eras, and on the certainty that the mistakes made before have not been repeated. Time reveals whether those attitudes and positions were justified. For Soderbergh, the director of the series, this idea was top of mind, and he stated as much in an interview published in the August 1, 2014 New York Times:  

There are so many treatments on the show that make you gasp because they’re so wrong…It just makes you wonder what treatments we’re all taking at face value that 10 or 15 years from now we’re going to be told, ‘Well, that didn’t work, and in fact that makes it worse.’  

Early twenty-first-century medical care has benefited from advances in molecular biology, medical devices, surgical procedures, data analytics, and epidemiological methods among others. People only participate in experimental protocols with their informed consent, and health care workforces are highly diverse. Impressive indeed, but none that in any way dwarf some of the advances shown during the series, and many that make twenty-first-century medical care possible. And, while The Knick shows how patients were often victims of bad science, bad technique, unproven technology, and malfeasance, the current era of health care is rife with risks for its own harms. Based on a complex analysis from several sources, the U.S. Institute of Medicine estimated in 1999 that between 44,000 and 98,000 people die from preventable medical errors each year in the US (To Err is Human). In 2016, researchers from The Johns Hopkins University reported in the May 3, 2016 issue of The BMJ (The British Medical Journal), that at the time The Knick was running in 2014–2015, medical errors were the third leading cause of death in the U.S. While the the accuracy of these estimates could be challenged, we can take from them with some amount of certainty that medical error exists today to a significant degree.  

The Knick pushes us to consider and to beware of what we may see resulting from modern-day biomedical and technological advances as time passes. To the medical drama and personal drama of most television medical serious, The Knick adds the drama of time. 

—————————- 

The Knick
Steven Soderberg, director 
Cinemax 
Twenty episodes, 2014-2015 
Running time: 42–57 minute episodes 

Awards
Peabody Award 
Six Primetime Emmys 
Three Critics Choice Television awards 

The Knick began streaming on HBO Max on February 20, 2021 

A child of unconventional, British-born parents, raised in the bucolic countryside of Vancouver Island, British Columbia, her relentless pursuit of science began in a love of animals, carrying her through two Canadian universities to a University of Chicago PhD in pharmacology and tenuous postdoctoral positions investigating the pituitaries of whales and armadillos. The research sent her to sea with grudging whalers and to inhospitable deserts by night. She married fellow pharmacologist Ellis Kelsey, followed him for his work, and became a mother of two daughters. Lack of paid opportunities for a woman scientist sent her commuting to medical school in Chicago where she obtained an MD degree in 1950 at age 36, while her husband kept the home and family together. She was working as a G.P. locum tenens and as an editor for JAMA. After a stint in South Dakota, the family relocated to Washington in 1960 where she began her lengthy career in the FDA, rising through the ranks to positions of prominence. Not long after the move, her stance on thalidomide earned her the Distinguished Federal Service Award of 1962, presented by President J​ohn​​ ​F. Kennedy. It also brought widespread admiration, mountains of fan mail, several other honours, and the resentment of male colleagues. Ellis died suddenly in 1966, but she kept working into her 90s, taking on the public-health challenges of other notorious “remedies” seeking approval. Kelsey’s fame eventually subsided but rose again in 2015 with late honours and her death at 101 years of age.  

Cheryl Krasnick Warsh​,​ who lives and works on Kelsey’s parental home of Vancouver Island, has given us a wonderful biography. With many previous publications in gender history and the history of alcohol and other drugs, Warsh is well placed to handle this vast and ​multifaceted​​ ​topic, sensitive to the misogyny of Kelsey’s century and with expertise on the nature and fortunes of licit and illicit substances.  

In twenty short chapters, Warsh divides this long life into three ​​segments– before​,​ during, and after thalidomide– and identifies her subject in three different ways. She describes “Frankie’s” early years in simple prose, reminiscent perhaps of Gertrude Stein or Emily Carr. Quirks and disputes in the Oldham home become evidence of a high-functioning, dysfunctional family. As a young woman, “Frances Oldham” delved into science studies at what would become University of Victoria and McG​i​ll in Montreal but made the ​trip ​back home every summer. She slipped into the laboratory of distinguished pharmacologist E.M.K. Geiling at the University of Chicago, when he believed the applicant was male. Despite his initial skepticism, Geiling fostered her career and supervised her doctorate. In 1937, she worked on the lethal side-effects of elixir sulfanilamide and determined that the solvent was responsible. At that time, she also became interested in researching harmful effects of pharmaceuticals on pregnancy and explored the legal protections (or lack thereof) for their consumers. With Geiling and Ellis Kelsey, Frances Oldham wrote a pharmacology textbook, one of the first in America, that went into four editions. These experiences, her medical degree and the work with JAMA were excellent preparations for her concerns about thalidomide. Now she was “Dr Kelsey,” one of two in the same home. 

Kelsey first doubted the value of this new drug when the side effect of peripheral nerve damage seemed to have been excluded from the incomplete applications and their inadequate trials. Further delay allowed for the early reports of fetal damage (coming from newspapers rather than manufacturers) to add to the concerns. While she succeeded in blocking the approval of thalidomide, it had managed to make its way into the US anyway, in the form of free samples given to practitioners sloppily engaged as researchers in shoddy “clinical trials.” Warsh carefully tracks the resultant American harm through reports of at least 56 damaged or dead infants documented in a survey of city health officers in 1962—probably merely the tip of an iceberg. She also probed the tragedy’s impact on attitudes to abortion, respect for the disabled, and increasing caution over medications. 

Beyond the thalidomide story, this biography provides a good sense of the evolving field of pharmacology and interesting chapters on the thorny history of several famous drugs–Krebiozen, laetrile, dimethyl sulfoxide (DMSO), artificial sweeteners, and diethylstilbestrol (DES)–and the harmful impact of Xrays on the pregnant belly. Kelsey found support from other women scientists, in particular Barbara Moulton and Helen Taussig​,​ who became her friends. 

Warsh has tapped into a wealth of sources—extending well beyond the numerous publications, FDA documents, and newspaper reports. She interviewed Kelsey, aged 99, in 2014 and spoke with her colleagues, daughters and other family members. She made excellent use of the personal papers, sorted by the pharmacologist herself with the help of FDA historian John Swann; they contain more than 78,000 items and occupy more than 100 feet of shelving in the Library of Congress. Moreover, Warsh follows the court decisions, changing legislation and rules governing not only drug approvals but ​also ​the ordering of female lives in terms of employment and reproductive freedoms. Yet she handles all this information with a deft light touch, accessible language and playful humour.  

A great read about a great scientist and a fascinating era in biomedical science. 

Frances Oldham Kelsey, the FDA, and the Battle Against Thalidomide
Warsh, Cheryl Krasnick
Oxford University Press. 
New York, 2024-03-15

Photos of Frances Oldham Kelsey from Wikicommons

Cheryl Krasnick Warsh Interviewed at Library of Congress

In Dangerous Medicine: the Story behind Human Experiments with Hepatitis, Sidney A. Halpern tells the story of America’s decades-long investment in hepatitis inoculation experiments, of which the infamous Willowbrook study was only the final and perhaps most egregious example. The experiments began in 1943 in response to an epidemic of “serum” hepatitis among military draftees who had received yellow fever vaccine. The initial idea was to characterize the infectious agent that caused the disease and to examine its clinical features under controlled conditions. In later years, studies involved testing various preventive measures, both for serum (B) and infectious (A) hepatitis.  

During World War II, the Armed Forces Epidemiology Board (AFEB) initiated a series of inoculation studies among conscientious objectors, prisoners, and mental patients. Most of the subjects were conscientious objectors who volunteered, despite having a wide variety of service options. “Virtually all the men serving as hepatitis subjects spoke of a desire to engage in meaningful and consequential humanitarian service.” (p. 63) Investigators told the volunteers, “It is our judgment that the possibility of permanent or even protracted or severe impairment of liver function following participation in the jaundice experiment is very slight.” (p. 48) At that time, of course, long-term consequences of hepatitis B infection—chronic infection, cirrhosis, and hepatocellular carcinoma—were unknown. However, many of the subjects did develop clinical disease and at least one subject developed fulminant liver failure and died.  

After the war, hepatitis researchers relied almost exclusively on institutionalized subjects. For example, Joseph Stokes Jr. of the AFEB “not only drew subjects from a mental hospital and multiple institutions for children, but he also enlisted inmates from five state correctional facilities… in New Jersey.” (p. 101) Stokes claimed the research was “beneficial for both the facility and its residents.” (p. 96) Later, researchers at Johns Hopkins, Yale, and the NIH conducted studies at other institutions. For prisoners, participation offered multiple benefits, including the possibility of early release. Among the objectives of studies during the 1950s were attempts to eradicate the infectious agent by sterilizing the infected serum, which were unsuccessful. During these studies, four subjects died of fulminant hepatitis, two at McNeil Island Penitentiary in Washington and two at Lewisburg Penitentiary in Pennsylvania.  

Willowbrook was one of two long-term hepatitis inoculation programs begun in 1956. At the time, Willowbrook State Hospital on Staten Island had one of the largest populations of the cognitively impaired in the USA. It was the overcrowded home to some of the state’s most disabled patients – 39% were non-ambulatory, and 64% unable to feed themselves. A New York University team, later headed by Saul Krugman, professor of pediatrics, established a hepatitis unit which each year admitted approximately forty-eight children between three and ten years of age. Many of the experiments involved injecting subjects with serum containing live infectious (A) or serum (B) hepatitis virus. Major study findings included clearly distinguishing between the natural history and characteristics of hepatitis A and B, and discovering that gamma globulin was an effective means of preventing clinical illness in hepatitis A. 

This decades-long sequence of inoculation studies occurred despite post-war developments in research ethics. The Nuremberg Code was promulgated in 1947, followed in 1964 by the Helsinki Declaration. These documents established principles designed to protect the rights and welfare of research subjects, including respect for individuals, voluntary participation, informed consent, risk/benefit analysis, confidentiality, and scientific integrity. However, at least in the United States, hepatitis investigators, among others (e.g. Tuskegee syphilis study), ignored or evaded these principles.

Except for wartime experiments on conscientious objectors, hepatitis inoculation studies violated almost every ethical principle set forth in the Nuremberg Code and Helsinki Declaration. The vast majority were conducted in closed institutions among subjects who either lacked the ability to consent, or whose participation was not necessarily voluntary (i.e. prisoners). Where consent was obtained (e.g., from a prisoner or surrogate), the investigators provided incomplete or false information (e.g. stating that risk was minimal), despite several deaths from fulminant liver failure. Yet, Joseph Stokes claimed that virus inoculation could “in our opinion be of benefit to the individual himself.” (p. 98) In addition, coercive tactics were used (e.g., quicker admission to an institution, or earlier release from prison).  

Dangerous Medicine highlights unethical practices in American hepatitis research throughout the mid-20^th century. While contemporary ethical standards had yet to be established, broad ethical principles articulated by the Nuremberg Code and Helsinki Declaration and reiterated (at least, in part) by the American Medical Association, were ignored. Public outcry in 1972 against Willowbrook, Tuskegee and other unethical research led in 1974 to the establishment of the National Commission for Protection of Human Subjects of Biomedical and Behavioral Research and, subsequently, to the Belmont Report, the Common Rule, Institutional Review Boards, and contemporary standards in human subjects research. Interestingly, as far as Dr. Halperin is aware, no follow-up studies have ever been done to ascertain the long-term health consequences of these hepatitis study subjects.  

Dangerous Medicine tells a sobering story, well-worth reading. And, given the prevalence of academic incentives and multiple conflicts of interest, I’m afraid the story of unethical research is far from over 

1. Beecher HK. The Ethics of Clinical Research. New England Journal of Medicine. 1966; 274: 1354-1360. 

Dangerous Medicine: The Story behind Human Experiments with Hepatitis
Sydney A. Halpern
Yale University Press, 2021
304 pages 

Web image of Hepatitis B from Wiki Commons

JC: Well, it’s great to see you, Alan, and thank you for agreeing to this interview. It’s been a long time since I saw you in person. I remember when we first met in 1992 at the Society of Teachers of Family Medicine meeting in San Diego. It was at a poetry reading, and we were both presenting our work there.

I’d like to begin by quoting an article that I saw in the Amherst student magazine from 2008. You had just received an honorary doctorate of science there. It goes like this, “AB’s combination of his education, his love of art, his passion for medicine and his wonderful sense of humor have made him a great warrior in the fight against smoking. Dr SmokeBuster offers an alternate view in the seemingly strict discipline of medicine. He embodies the philosophy of the liberal arts, using a variety of disciplines to communicate his message. Most importantly, AB brings poetry and artistic splendor to the often overly calculated role of science.”

I think that really describes your ability to merge your love of the arts and humanities with humor and your passion for medicine, as well as your public health activism and your career-long campaign against cigarette smoking. So how do you look at that? How do you view those interdigitating components?

AB: First of all, this is so unbelievable. If you told me that when I was struggling to figure out what to do in life, that I’d be interviewed by Jack Coulehan, I’m just really appreciative that you would take the time to do this.

I had great fortune in my upbringing and growing up on the periphery of New York City.

It was really a marvelous time. I thought New York City was where moms took their kids to go to see plays and museums on weekends. I didn’t realize people actually live there. Where I was born, at Rockaway Beach Hospital in New York, you could see the ocean from the hospital. My father, Leon Blum, MD, was an intern there and then a member of the medical staff. He was a general practitioner for 37 years in the very town in which he’d been raised, Rockaway Beach. And that’s where Jonas Salk spent his summers. And Burrill Crohn was from there, of Crohn’s disease fame. So it has a rich heritage. I grew up in a low middle income community, nearby Far Rockaway, where my father, Leon Blum, MD, knew everybody.

My dad was very literary. He would do the Sunday New York Times crossword puzzle, which I could never do. And I had great opportunities to experience culture. Of course, I thought museums were mostly about dinosaurs. I never realized that there were art museums. That was the awakening I got when I went to my first National Conference of Family Practice Residents meeting in Kansas City.

It was pretty boring. So I started walking around Alameda Plaza, and I came across this beautiful building that looked like a Greek temple, and it turned out to be the Nelson Gallery. And that was really my awakening in art.

JC: And you also had an early commitment to activism. It’s remarkable that even as a resident in the late 1970s at the University of Miami, you had already begun, kind of this dual career as a regular practicing physician and as a family practice resident, you organized a campaign against smoking and other unhealthy habits among adolescents. What was the origin of the idea for the Doctors Ought to Care movement?

AB: I think everything I’ve ever done is irony and humor, and even the title of my undergraduate thesis on Robert Frost was called “The Way of Understanding is Partly Mirth” (from a line of one of his poems). I don’t think I would have been able to get through being fired a couple of times, not getting into this or that school, not getting this or that job, missing the deadlines for exams that I had to take, and so forth had I not had a sense of humor.

I was about a 7-year-old watching Brooklyn Dodgers games on TV with my father in the afternoons when he would rest after his 9 am-to-noon and 1 pm-to-4 pm clinic before his after-dinner office hours in our house, where the living room became the waiting room. We loved the Dodgers, and one day he said, “Look at that Lucky Strike commercial. Why don’t you take out our tape recorder and record it, because one day nobody’s going to believe that they would associate sports and cigarettes.” And sure enough, it only got worse as the decades went by. Meanwhile, I had begun an interest in smoking because my father had had a heart attack in his 40s, when I was 5 years old. He started smoking Chesterfields as a medical student and continued through his service in the Army in World War II in New Guinea. It just stuck with me that when and if I ever got to medical school, I’d learn a lot more about that. I never did. Only about 30 minutes of education at Emory was devoted to smoking, and it was a part of a lecture on lung diseases by Dr Brigitte Nahmias. She juxtaposed ads for cigarettes next to pictures of her patients with occupational lung disease and some who smoked. I thought that was a good way to demonstrate the contrast between the macho men in the cigarette ads and the wrecks that she cared for. So with the help of a pathology professor at Emory, I decided to create my own slide presentation of all the smoking-related diseases. By the time I was in my residency, I began speaking in elementary, middle schools, and high schools to try to talk to kids about not taking up smoking and other killer lifestyles that were being promoted to them in the mass media.

At a meeting of the National Conference of Family Practice Residents in Kansas City in 1977, I tried to share this work with the other attendees but was initially rebuffed. I was finally given a room after the main proceedings ended. It was filled to overflowing. Over 50 people came, and one of them was Rick Richards from South Carolina, who told me “You know, I’m going to go back to Spartanburg and do the same thing you do, and I’ll see you next year.” Well, by that next year, we’d organized several chapters, and we were asked to give the main talk at the conference. So DOC, or Doctors Ought to Care, became known for not just lecturing on the dangers of smoking, but also for ridiculing, satirizing and parodying cigarette advertising and the way in which the tobacco companies were getting away with murder. We were the first and only physician organization to confront the tobacco industry itself, and not just angrily, but using humor and MAD Magazine-style satire such as the Barfboro Man and the Emphysema Slims tennis team. These were some of the things that we created when the American Cancer Society was saying, “Oh no, no, you can’t do that. You’re going to get sued.” Well, we were sued, and that only brought more attention to us. We did a t-shirt parody of Miller Lite Beer, whose original slogan was, “Miller Lite. We’re having a party.” Our slogan had a guy with his arm around a toilet saying, “Killer Lite. I’m grabbing a potty.” Miller Brewing, which was owned by Philip Morris at the time, sued us in state and federal court. We won the case, but it was no fun being involved in litigation with the world’s largest cigarette company.

JC: That makes me want to jump ahead to some of the exhibitions in the Center for the Study of Tobacco and Society. I was reviewing the website last week and the whole thing is so impressive, but the humor and the irony in the titles and the text of some of your exhibitions is amazing.

So to get into that, let’s move to the beginning. I believe it was 1997 when you began the Institute for the Study of Tobacco and Society at the University of Alabama, let’s go back to Doctor Ought to Care.

Alan: DOC was started in 1977. I was in internal medicine after my graduation from Emory, and I loved my internship at McGill’s Royal Victoria Hospital in Montreal, but I kept on running into family practice residents at Montreal Jewish Hospital who seemed to be loving their experiences even more than I was. So when I was on vacation in Miami, I thought why not look up family medicine?

I walked into the Department of Family Medicine at Jackson Memorial Hospital of the University of Miami, and there was Irwin Redlener, who was actually a pediatrician. Irwin was filling in at the request of the chairman Lynn Carmichael. It turns out that this was the first family medicine residency in the United States. Lynn also helped found the Society of Teachers of Family Medicine and became the first editor of its journal Family Medicine. The residency had features found in few other training programs of that era such as sports medicine, podiatry, integrative medicine, pastoral care, an annual symposium on sexuality, extensive community outreach, a resident-run evening clinic, and a monthly book group to discuss The Person: His and Her Development Through the Life Cycle by Theodore Lidz. It was just amazing timing for me, and I never looked back.

Lynn tolerated me pretty well for my activism on tobacco after initially chastising me for trying to convince his secretary to stop smoking. He eventually admired what I was trying to do, which was to bring our knowledge about health into the community to try to make up for the health and socioeconomic disparities in the neighborhoods around the inner-city hospital.

Dr. Richards and I were soon joined by another family physician, Dr. Tom Houston, and through the National Conference of Family Medicine Residents we were able to disseminate our activist approach to tackling the killer habits. In the 1980s we wound up having close to 100 chapters of

DOC in medical schools and family medicine residency programs, some of which still exist. Our approach was to use humor and satire, as opposed to all the staid organizations like the American Cancer Society, the American Heart Association, and the American Lung Association, which still relied on pamphlets, posters, and unpaid public service ads on TV that usually aired at 3 in the morning. DOC was the first health group to purchase counter-advertising space on billboards, bus benches, TV, and radio. No one else had ever done that. We were also the first to involve teenagers in our work and to tap the highest level of creativity and commitment of every family physician we could find. In 1978, I co-hosted a conference with a junior high school student that was attended by 150 students from 30 schools in South Florida to train them to help raise the awareness of their peers about the targeting of young people by the purveyors of cigarettes, alcohol, and junk food.

Flash forward to 1997 when I was on the faculty at Baylor College of Medicine. I was invited to give the family medicine residency graduation address at Tuscaloosa. I shared my sketches and stories of patients and also gave a grand rounds on the physician’s role in ending the tobacco pandemic.

Afterwards, the chairman, Jerry McKnight, asked me if I wanted to stick around. I thought he meant going for a beer, but he wanted me to apply for a new endowed chair position in family medicine.

When I moved to Alabama two years later, I started the Center for the Study of Tobacco and Society. DOC was still going, but I also wanted to do something different such as researching the history of smoking and efforts to counteract it.

I began to organize the vast amount of material that I had amassed over the years through what I called a daily biopsy of the smoking pandemic – the largest collection on the tobacco industry, cigarette marketing, and anti-smoking advocacy at any university. This was all pre-internet and pre-ebay. I had tens of thousands of items, and the University of Alabama was kind enough to provide some space. I thought of this as both a museum and an archive, and for the next 15 years I hired graduate students from the School of Library and Information Studies to start cataloguing the collection.

The main work product of the Center is exhibitions. We began with an exhibition at the annual convention of the Association of American Editorial Cartoonists called “Cartoonists Take Up Smoking!” It took ten years to research and involved acquiring over 300 original artworks from the nation’s newspaper editorial cartoonists. The exhibition then went to the National Museum of Health and Medicine in Washington for a year and traveled to ten other venues. So we had a great opportunity to share our work, but then it dawned on me in 2015 to do online exhibitions to reach a much larger audience. We’ve now done nearly 40 exhibitions, and I’ve never looked back.

JC: And I think that that those online exhibitions, each of them, seems to be a massive enterprise with so much richness in the visual material, in your text, comments and so forth. It’s remarkable that you have been able to collect this much essentially social history and curate it in such innovative ways.

Alan: Well, here comes the trigger warning, because I do this mostly for me, partly because. I don’t think most people understand the smoking issue. I really don’t. I don’t think there’s much to cheer about, in spite of the progress that we’ve made in reducing adult smoking from over 40% in 1964 to less than 15% today. Just this year, an investigative report was released about how low-tar cigarettes are bigger than ever in China, because they’re still pushing the absurdly fraudulent notion that there can be a safer cigarette. Even the Journal of the American Medical Association bought into this for awhile back in the 1970s. It’s such a tragic history in this country that I cringe whenever I hear public health people saying that the reduction in cigarette smoking is the greatest public health triumph of the 20th century. Not at all. In my opinion, it’s just the opposite. 

We learned everything we needed to know about smoking by 1964 when the Surgeon General’s report came out. My dad taught me everything I think I needed to know when I was much younger than that. I wrote my first article on smoking when I was editor of my high school newspaper, The Woodmere Academy ECHO. And I think I’m the longest running individual on this issue, because I’ve been doing this with a passion for over 60 years – – fortunately, I haven’t had to earn my living from my anti-smoking work. And that’s where my trigger warning comes in, because it’s hard to imagine how thoroughly the field has been professionalized. You have to have a Master of Public Health or a Doctor of Public Health degree to get a job in it, as compared to the hundreds of grassroots activists from all walks of life across the country who led the way for decades in passing local clean indoor air laws. And guess what it’s called now: “Tobacco Control.” Of course, it’s not about controlling tobacco. It’s about curbing smoking and its promotion. This issue is something that medicine hadn’t addressed before, because unlike an infectious disease it’s a human behavior that’s taught to us by an industry that’s making an enormous profit. So I believe my contribution was to shift the focus away from lung cancer and smokers and instead onto Marlboro and the people in the tobacco industry who promote it. I think that was an exponential leap from where we were before then.

There were quite a few health care professionals who were opposed to smoking. Thoracic surgeons Alton Ochsner and Michael DeBakey were warning that cigarette smoking caused lung cancer beginning in the late-1930s. For their trouble, they were ridiculed by the medical profession. Organized medicine didn’t want anything to do with fighting smoking. (For one thing, their medical journals accepted lucrative cigarette advertising revenue until well into the 1950s; for another, two-thirds of physicians in the 1940s smoked.) So what I think we did in DOC was to shift the focus to monitoring the tactics of the tobacco industry. Our strategy gave permission for everybody else to point the finger at the industry as the source of the problem. But the federal government never devoted any funding to fight smoking, and there was relatively little effort. So leading the way was that band of people who hated going into restaurants or getting on airplanes and breathing tobacco smoke. It was that activist group of people– – not the public health people, not the physicians – – who started the nonsmokers’ rights movement. And then there was a guy like me who was looking at the advertising and promotion of tobacco products. But most of those working in this field today are focused on regulation and legislation, even in this non-legislative era. Then there are the full-time smoking cessation researchers, who are practically studying nicotine receptors on toenails rather than looking at the larger picture. They’ve medicalized and “pharmacologicalized” smoking cessation. As a result, physicians no longer take an extra minute or so to encourage their patients to stop smoking. They just prescribe a drug. And I don’t think that most people in tobacco control are looking at the fact that we could have done so much more in these 60 years. For example, the first time the government ever spent a penny on paid advertising to fight smoking was in 2012.

In 1998, the state attorneys general forged a $206 billion settlement with the tobacco industry which sounded great. But although most of that money was supposed to go to fight smoking, only 2% of that has been allocated by state legislatures for tobacco use prevention and cessation. It’s all about the money.

JC: It’s all about the money.

Alan: An internist colleague, Ed Anselm, made this marvelous comment, “The most addictive thing about tobacco is money.” And he wasn’t just talking about the tobacco industry, but also about the people who say they’re fighting smoking but are really just fighting over the grants to write policy papers telling legislators what to do about smoking.

It’s a dark field.

JC: It sounds, from what you’re saying, you know, the image I have is Socrates, as a gadfly in Athens talking about the gods and so forth, and his questions threatening the status quo. One thing has improved though, you haven’t been convicted. You haven’t had to take the hemlock.

Alan: No, I was arrested, though. I’ve been arrested a couple of times for demonstrating (but never charged), once with a city councilman in Houston when we went to the Astrodome to protest a Cinco de Mayo festival sponsored by RJ Reynolds’ Camel cigarettes. Let me just give you an example of the absurdities I’ve experienced: I was fired as editor of the New York State Journal of Medicine after three years, having produced the first theme issues on smoking at any medical journal, and which brought national attention to the Journal. As editor, I had to attend the monthly board meetings of the of the Medical Society of the State of New York (MSSNY), which published the Journal. To paraphrase the Borscht Belt comedian Henny Youngman, the average age of the board members was deceased. I was about 20 years younger than the next youngest person in the room, and all they were talking about were economic matters like the high cost of malpractice insurance. It was not at all about health and medicine and helping people, in my opinion. But I’m grateful to MSSNY for having had the opportunity to do these theme issues on tobacco problems. Following the second one, though, I was fired for having spent too much time on smoking.

JC: I think we can agree that that money talks, and we lived in the mid-20th century in a culture in which smoking was not only acceptable, but it was really highly touted. For example, most doctors smoked Camels, but on the other hand, don’t you feel that that your campaigning, and your creativity has contributed to cultural change, even though it’s been at a slow pace?

Alan: I did a teaching fellowship in family medicine at the University of Miami after graduating from the residency program. And what I learned was how to give a good presentation and how to write learning objectives. These skills may seem simple, but that’s deceptive. First, there is the cognitive objective (imparting information), which 99% of lecturers think is the entire lesson they are supposed to teach. Then there’s the behavioral objective, which can teach learners how to do a procedure or demonstrate a skill. But what they’re missing, I think, is the attitudinal objective. I came away from that fellowship understanding that every presentation, every paper, every research poster I would ever do would have the reader, viewer, or the listener going away saying, “Gee, I never thought about it like that before.” That’s an attitudinal objective. I wanted to change the way people looked at an issue.

It’s something that stays with me every time I advise a resident on giving a presentation. I also do this in my exhibitions on tobacco in the hope that the viewer can see the ironies and learn the lessons from decades of foot-dragging by organized medicine, the public health community, and academia – and their fear of confronting the tobacco industry – that can be applied to tackling other challenging health problems such as gun violence, obesity, emerging and re-emerging viral diseases, and digital media addiction. There are many ways we can look at the smoking issue. Our failure to address it for so many decades is a metaphor for how we’re dealing with the wired epidemic of kids having the attention span of a fig.

JC: In 1964 when the Surgeon General came out with his first report, I believe 45% of adults in the US smoked, and now it’s approximately 11%, and the images that you have in your in your exhibitions show how trendy and culturally appropriate smoking was at that time. Now, you have to admit that there is a significant cultural awareness that smoking isn’t the thing to do, and that at least if you do smoke, you have to go out to the back, and you can’t smoke here or there, and there’s a certain kind of negativity against it. I consider that a cultural change. And of course, all of the tobacco corporations have had the time over those 60 years or so, to adapt to these new conditions and to spread their tentacles elsewhere. But it seems to me, it does constitute a change.

Alan: Jack, we look at our time now as an age of disinformation and regression, and dare I say, the word “retribution,” because we have willful ignorance that I haven’t seen in my lifetime. I lined up at my school in Woodmere, Long Island, to get my polio vaccine as a five-year-old. I was in the original Polio Pioneer trials. We have people today who are saying they’re “doing their own research” as to why they won’t get a Covid vaccination that has saved millions of lives even though these vaccines were developed in record time, thanks to our knowledge of previous epidemics, especially SARS in the early 2000s. Most of the time developing the vaccine for Covid was taken up with the trial, not with the development of the vaccine.

I think the missing element today in countering this horror is humor, and that’s why I like to think that MAD Magazine was my leading medical journal for many decades. I actually got to meet the editors and the publishers of MAD because I wrote a letter to publisher Bill Gaines and editor Al Feldstein when I was editor of the New York State Journal of Medicine. I asked, “Why don’t you resurrect those great parodies of Marlboro and other cigarette brands?” And they invited me to have lunch with them in New York City? It was fun. And they then resumed doing those parodies.

I had a lot of other influences growing up. On the radio, Jean Shepherd (best known as the author and narrator of “A Christmas Story”) was kind of every adolescent’s hero. Every night, he would tell stories of his time growing up in Indiana, and I think that’s how I got a lot of my storytelling ability.

And reading newspapers. I would often buy all nine New York dailies on a Saturday just to see the different sportswriters’ take on the Dodger games and to see the sports cartoons by Willard Mullen in the World-Telegram & Sun. Some of these were resurrected in my exhibition, “Cartoonists Take Up Smoking!” .Also, I was a magician growing up doing birthday parties and school assemblies, inspired by my father who would do little tricks for his patients. I really loved that. Once I even got to open for pianist Peter Nero at the Rheingold Music Festival in Central Park. I wasn’t very good that night, but I still get to say I performed for 3000 people.

JC: Well, it’s clear that we take ourselves too seriously. We’ve lost the ability to look at ourselves and our culture with that kind of ironic distance. And in addition to that, when you were talking about the development of the Covid vaccine, the disinformation, to me, seems to be a malignant outgrowth of some of the technologies that we’ve developed and we’ve made accessible to the world, and the ability of people to spread disinformation with such great facility and power.

Alan: I think that we need to match the reality of the society that we’re living in with the strategies to counteract it, and I don’t think we’re doing that. We’re too ideologically split, and I don’t know where common sense has gone. I don’t think the media have risen to the occasion. Our newspapers are gone. I don’t do social media. But I just am horrified. I used to think I wasn’t very literate because I looked at all my fellow English majors, like you, Jack. They were omnivorous. I did pretty well, but I just never felt that I was that knowledgeable about poetry and literature. And I see now that I was pretty good compared to what people are spending their time doing today. There are no humanities to speak of in medical schools, except for the honors courses for the self- selected students who are already interested in humanities, and you and I have spoken about the fact that out of 22,000 entering medical students today only around 500 majored in a non-STEM field. It’s mind-boggling. It’s terrible.

JC: That brings up a point I’ve been meaning to take up in this interview, and that is, we’re both medical school professors. I’m emeritus. You’re still active. In my career, I have tried to imbue in students a love of humanities, the use of the arts and humanities to develop empathy, to develop reflectiveness and resilience. And of course, I’ve gotten a lot of feedback on that, or blowback, I guess I should say, because people say, well, that’s not going to work. It doesn’t matter. These guys are going out into a different medical world in which they are going to be subjected to stresses, to constraints and so forth. So even if they go into this with that kind of humanistic perspective, they won’t be able to effectuate it in their practice. And of course, having looked back on my career, it’s kind of difficult to hear that. I’m not sure that I believe it, but I wonder what your thoughts are on that matter.

Alan: Ann Walling has an excellent review article on ageism in the July 2024 issue of American Family Physician. She compiled a checklist of questions to ask an older person. She wrote it because she was struck by many of her older patients telling her how they did not feel respected by some of the younger physicians. But I noticed she didn’t include “How do you spend your time?” or “What was your occupation?” A person’s identity is paramount. I don’t think they consider their identity is being a patient.

I find that students are trained to be good mechanics about diseases, and that they can look up anything about diseases and how to treat them. But that doesn’t involve reading things that aren’t only related to the patient you’re addressing at that moment, and that doesn’t involve pleasure reading.

My point is that we no longer live, if we ever did, in the same neighborhood as our patients. We are in not just an ivory tower, but it’s got a moat around it, and they have to come to us. So I ask every resident, “How did the patient get here today?” And you know, after the first 20 or 30 eyerolls they realize it’s relevant. Or, “Who’s at home?” Many residents initially say, “That’s too personal.” This is family medicine that I’m talking about, and they’re saying to me that just asking who’s at home is too personal, or asking about the father when a newborn is brought in by the mother or grandmother or great-grandmother for a well-child visit is too personal.

You couldn’t get any further from my father’s education at Downstate in the 1930’s (when it was Long Island College of Medicine). He would walk two to three blocks to make house calls or even deliver babies. I may be romanticizing, but I think we’ve moved so far away from them, the patients, that now it’s all about us.

When I was a new faculty member at Baylor I didn’t know anything about Houston, so I started exploring the city. I began in January. By July, I proposed doing a community field trip for the incoming interns and new faculty. I chartered a school bus and took them to a Black radio station, an art museum, the city desk of one of the two daily newspapers, the county health department, the city council, the jail, and the criminal court. I did this for 12 years. I’d change the itinerary a little bit, and the only requirement was that they would write a reflective statement. When the residents were getting their exit interview from residency after three years, the community field trip – – that one day that they had as interns – – was one of the highest rated activities.

I think it’s so important to recognize with humility that we don’t know very much about our patients anymore. I’ll give you one quick example. I was attending in an ICU at Baylor and one of the residents was rattling off endless laboratory results. The patient was intubated, so we couldn’t talk to him. Finally, I just said, “Who is this patient? You’ve told me every laboratory result known to mankind, but you’ve never said a word about who he is.” Tomorrow morning, tell me who he is.” And I walked away, I was so angry.

And the next morning the resident excitedly said, “You wouldn’t believe who this guy is. He’s the architect who designed this hospital!” I mean, he was absolutely incredulous. And it wasn’t anything great that I’d said, other than to stop presenting people as numbers. Stop talking about people as “diabetics.” Just say, “the patient with diabetes.” It doesn’t take that much of a leap to talk about people with a disease, rather than who they are as a disease. And again, I’m not the first to suggest this, but it’s also astounding that we can’t dissuade residents from presenting people by race and gender. Warren Holleman, Marsha Holleman, and Bill Monroe wrote a terrific essay, a critique of how we present and discuss patients, in Literature and Medicine in 1992 called, “Is there a person in this case?”

JC: With regard to the bus trips and the field trips, in 1968 when I was a second year medical student at the University of Pittsburgh, we had a community and preventive medicine course in which weekly or biweekly we would go to nursing homes, to neighborhoods, like the so-called Hill District, which was the African American neighborhood in in Pittsburgh, and so on. What I’m trying to say here is that many of these ideas we’re coming up with and saying this would be something new, were practiced in the past, but have been lost. The other thing has to do with interviewing patients. I wrote an article in the early 1980s in the Annals of Internal Medicine called “Who is the Poor Historian?” And I pointed out that that when you’re interviewing a patient, which of you is the historian? Well, obviously, it’s the doctor who is collecting the data and who is trying to assemble and interpret it as a historian does. So again, this was 30 years ago.

Alan: This is so amazing. We should collect all these. One of my favorites is “well- developed, well-nourished and in no acute distress,” which should only ever be used to describe an infant in the neonatal ICU. Instead, imagine calling a woman “well-developed, well-nourished…” And you see this on every chart. This is what the dopey electronic medical records populate.

We are so beyond reclaiming the medical record. I did a grand rounds a few years ago about scribes. For the past decade, I’ve been privileged to have had an incredible experience with medical scribes. These are mostly pre-med students at the University of Alabama who have been one better than the next. One of them wasn’t even going to go into medicine but I urged her to apply, and she did. It’s a terrific way to help mold their thinking about medicine. I don’t like the idea of shadowing, which is passive, whereas being a medical scribe is a commitment, and it’s not easy. I’ve watched these students closely, and it has been a great joy. I confess that I initially opposed having a scribe, because I thought it was going to violate the patient-physician relationship and confidentiality. But it’s a wonderful experience that I wish we would be able to expand.

It’s absolutely astounding how we’ve become so absorbed in populating medical records with minutiae that very few people read. In auditing records of residents, I look past the templates. I want to read their narrative. I want to see that this was generated by a human being.

JC: My sense is that, as a result of my own experience, what we have done in teaching the human aspects of medicine and providing role models and images of what that could be, is that we have influenced a percentage of young medical students and residents who have been malleable in a way and made them better doctors. And that percentage, I don’t claim that it’s large, but I think it’s a real contribution.

We’ve talked a lot about the difficulties and the disparities and in a sense of atrocities, really, of modern medicine, but I’d like to leave this conversation with a positive note. So I guess I’d like to ask you, Alan, what kind of positive note can we end on from your experience?

Alan: You know, every day I must count my blessings. I give thanks for the opportunity to experience the moments that I get with patients, with residents, with colleagues. I’m

a critic, but I’m also probably the biggest fan of what we do in family medicine. When it was founded as a specialty in 1969, there was a kind of a nostalgia for, and resurrection of, the old general practitioner. So I’m really living at least in some way like my dad lived and appreciating these experiences with people. I don’t think medicine is anything other than that. I admire radiologists, especially those that want to see a picture of the patients that they’re reading the films on. I admire every sub-, sub-, sub- specialist there is, because, gosh, it’s good to know that if you need them, they’ll be there. But what a privilege it is to be able to see people from all generations at any given moment. I never know from one day to the next who I’m going to see, and on a single day about two years ago I actually saw patients of four generations in the same family: great grandmother, grandmother, mother and daughter. So I think that I’m a commercial for family medicine, but I’m not a commercial for making medicine into a disease-oriented, as opposed to a people-oriented, field. I think we can’t get to the diseases until we know who people are.

JC: I agree. I’m not sure we can return to the past or to the more holistic view that we recognize in your father and some of the doctors that I encountered when I was young. But I think we need to keep working and seize any opportunity that presents itself to get our message through. I’d like to thank you for this discussion. We could continue for several hours on these topics, and that would be very interesting, but in the interest of time, we have to conclude now. So thank you.

Alan: And I want to thank you and Lucy for thinking of me in this context. I also would be remiss in not thanking my wife, Doris. We’re going to be celebrating our 49th anniversary (in September 2024) with a few days in the Adirondack Mountains. Also, my three sons, Leon, David, and Sam, my late father and mother, Eric Solberg (my colleague and co-author in DOC for over 25 years), and the many mentors I’ve had: English professor Chick Chickering at Amherst College; cardiologist and poet John Stone at Emory University School of Medicine; Howard Rusk, the pioneering rehabilitation medicine physician in New York; Sam Nixon, a president of the American Academy of Family Physicians; and Bob Rakel, who was the chairman who took a chance on me after I was fired as editor of the New York State Journal of Medicine, even though I hadn’t worked in a hospital or clinic for several years.

I’ve been incredibly fortunate to have all these individuals in my life. There was also Kurt Deuschle, chair of community medicine at Mount Sinai School of Medicine. When I was fired as editor, I called him, looking for a few words of sympathy and encouragement. Instead, Kurt sternly replied, “It’s your own damn fault.” I was crestfallen and speechless. But then he explained, “You got too far away from patients.”

I’ve never forgotten that advice.

Alan Blum, MD, is a family physician and professor of Family Medicine at the College of Community Health Sciences, which also functions as the Tuscaloosa Regional Campus of the University of Alabama School of Medicine. He is the first holder of the Gerald Leon Wallace Endowed Chair in Family Medicine at The University of Alabama College of Community Health Sciences. One of the foremost authorities on tobacco problems, Blum is the director of The University of Alabama Center for the Study of Tobacco and Society, which he established in 1999.

Links
1964 Surgeon General’s Report
University of Alabama Center for the Study of Tobacco and Society
Irwin Redlener’s Bio on Wikipedia
Alan’s stories and sketches of patients 
Alan’s website about an artist who was a patient for over 50 years at the state mental hospital in Tuscaloosa

Intro photos from Covering Cancer? exhibition at Center for the Study of Tobacco and Society