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Han, Bae, Kim, and Choi: Origins and Evolution of Social Medicine and Contemporary Social Medicine in Korea

ABSTRACT

Social medicine is recognized as one of medical specialties in many countries. However, social medicine has never been formally introduced to Korea, presumably because the term and its principles were not accepted for some years in the past in American medicine, which has strongly influenced Korean medicine. This paper describes the origins and evolution of social medicine and briefly discusses contemporary social medicine in Korea. Social medicine was initiated in France and Germany in 1848. Since then, it has expanded globally and developed in diverse ways. Included in core principles of social medicine is that social and economic conditions have important effects on health and disease, and that these relationships must be subjected to scientific investigation. The term ‘social medicine’ is rarely used in Korea, but many of its subject matters are incorporated into preventive medicine which, besides prevention, deals with population health that is inescapably social. However, the Korean preventive medicine directs little attention to the basic concepts and principles of social medicine, upon which systematic development of social medicine can be based. Thus, it is necessary to supplement the social medicine contents of preventive medicine through formalizing the linkages between the two fields. One way of doing so would be to change the title of ‘preventive medicine’ course in medical colleges to ‘preventive and social medicine,’ as in many other countries, and to adjust the course contents accordingly.

INTRODUCTION

Social medicine course is offered at many medical schools in European countries [1]. Some medical schools in the US have an academic department named social medicine or social medicine in combination with another discipline, such as the Department of Global Health and Social Medicine at Harvard University Medical School, the Department of Family and Social Medicine at the Albert Einstein College of Medicine, and the Department of Social Medicine at the University of North Carolina at Chapel Hill Medical School. And there are medical schools that have the Department of Preventive and Social Medicine in numerous countries, including New Zealand, Malaysia, Thailand, Myanmar and India. The first edition of The Social Medicine Reader, edited by the faculty members of the Department of Social Medicine at the University of North Carolina at Chapel Hill Medical School, was published in 1997 [2], and the second edition, published in 2005, was expanded into three volumes [3-5]. These facts indicate that social medicine is recognized as a specialty of medicine in many countries.
In Korea, however, the medical community seems to be hardly aware of that there is a medical specialty named social medicine. A paper on an overview of the historical development of social medicine in the 19th-century Germany is the only published material about social medicine written in Korean [6]. The fact that the Korean medical community is not aware of social medicine does not imply that nothing about social medicine is dealt with in the medical schools or none of the approaches based on social medicine is employed in the health care system. The evolution of social medicine has been internationally diverse, so that its concerns and subject matters may vary to some extent among different national contexts [7]. Based upon these observations, this paper will discuss the state of social medicine in Korea following a review of the literature on the origins and evolution of social medicine. In doing so, this study is aimed at the objectives as follows: 1) To improve the understanding of the medical profession about social medicine in Korea by providing the description of its origins and development; 2) To assess the current state of social medicine in Korea and suggest agendas for its future development.

THE ORIGINS, CONCEPTS AND INTERNATIONAL DIFFUSION OF SOCIAL MEDICINE

With the rapid industrialization and urbanization at the turn of the 19th century, European countries faced many of the social problems, including increased low-wage workers, poor working conditions, lack of housing and sanitation facility. Diseases and deteriorating health conditions among industrial workers and in the low-income population were also serious. Under these circumstances, a group of reformist French physicians and hygienists conducted surveys and statistical studies about the relationships between health problems and social conditions [8]. Furthermore, the first 30 years of the 1800s mark the development of modern clinical medicine to replace classical medicine. French physicians realized that many traditional therapeutic techniques were ineffective and, as an alternative, directed attention to hygiene and the influence of social factors on health and disease [9]. Presumably, in addition to such health problems and state of medicine, the zeitgeist in the time of social revolution had made reformist physicians conceive of social medicine.
The term ‘social medicine’ was first used in 1848, when French Revolution took place in February. In March of the same year, when revolutionary hopes were still running high, Dr. Jules Guérin used the term writing in Gazette Médicale de Paris. In that writing, he appealed to the French medical profession to act for the public good and to help create new society expected from the revolution [10,11]. Guérin argued that the goal could be effectively achieved if knowledge and information regarding the relationships among medical issues, social factors and public affairs were systematically integrated into the framework of social medicine.
In Germany, a group of medical doctors and others led by Salomon Neumann, Rudolf Virchow and Rudolf Leubuscher promoted health care reform after the revolution in March 1848 [12]. They fully understood the effect of social factors on health problems. Virchow was a pathologist who provided empirical data supporting the argument that social conditions are important factors in the outbreak of an epidemic. His report, produced in 1848, on the typhus epidemic in the Upper Silesia region of Prussia is considered as a classic in the history of social medicine [13,14].
People are simultaneously biological and social organisms, and thus human health and disease are affected by social factors as well as by biological factors. Included in the basic idea and concept of social medicine is that the interdisciplinary program between medicine and social science would provide medicine with knowledge and skills needed to analyze the social causes of health and illness in the same way as the alliance between medicine and laboratory sciences had provided new insights into the biological, chemical and physical bases of disease [7].
Rudolf Virchow and his colleagues proposed three basic principles regarding the academic and practical aspects of social medicine that were summarized by Rosen [12] as follows: 1) the health of the population is a matter of direct social concern; 2) social and economic conditions have an important effect on health, disease and the practice of medicine, and these relations must be subjected to scientific investigation; and 3) steps must be taken to promote health and to combat disease, and the measures involved in such action must be social as well as medical. These principles are retained until now, without fundamental changes, even while being adapted to different societies and conditions over an extended period of time [15].
Although social medicine was initiated in France and Germany around the same period, its theory was more actively developed in Germany. The literature on social medicine appeared during the period from 1900 to 1920 in Germany is extensive [12]. Probably, for this reason, Rudolf Virchow is commonly considered as the founder of social medicine [14]. The theory of social medicine developed in Germany had a wide influence on the development of this field in many other European countries [12]. Many medical schools in these countries have retained a commitment to its foundational ideas from the early stage to the present day. For example, a study of the curricula of 32 medical schools in 18 European countries conducted in 2002 revealed that over half of the schools were offering social medicine courses [1].
Social medicine was introduced to Latin America and the US in the 20th century. Social medicine in Latin America was at its prime in the 1930s when Salvador Allende, who later became the president of Chile, was central in promoting the field [16]. In the US, interest grew in social medicine, and discussion of the topic was popular during the period after the end of World War II [8]. For instance, the New York Academy of Medicine hosted an academic conference on social medicine in the spring of 1947 and published the report of the proceedings [17]. In November of the same year, the Milbank Memorial Fund held a roundtable discussion on social medicine [18]. Thereafter, the American medical community avoided using the term social medicine for a substantial period of time. The reason for the avoidance was that the phrase ‘social medicine’ sounded very much like ‘socialized medicine’ and the concept incorporated the politically suspect idea of national health system. By the early 1950s, the American social medicine movement lost its momentum during the red scare of what is known as the era of McCarthyism [19,20].
It seems that the term social medicine was no longer considered taboo in mid-1960s. In a survey of American scholars in the fields of preventive medicine, community medicine and public health, conducted during the period from August 1965 to March 1966, it was found that the majority of respondents preferred social medicine as the name of their field of study [20]. Papers on social medicine continued to be published, although not many, discussions on social medicine education began, and practical changes took place as well [21-23]. Recently, on April 30, 2016, the Social Medicine Consortium composed of individuals, universities and organizations striving for equity in health held a symposium on social medicine at the University of Minnesota, exemplifying the current perception of and interest in social medicine in the US [24].

INSTITUTIONALIZATION OF SOCIAL MEDICINE AS AN ACADEMIC DISCIPLINE

Most of established academic disciplines have some common institutional arrangements, such as courses on the disciplinary subject offered by an autonomous organizational unit at colleges or universities and an academic society for the discipline. From early in the 20th century, social medicine began to become institutionalized as an academic discipline, and the institutionalization had been expedited around the end of World War II [12,25,26].
The University of Vienna began to offer a social medicine course in 1909, and the University of Zagreb in Croatia appointed a faculty member of social medicine in 1931. In the UK, the appointment of the first chair of social medicine by Oxford University in 1943 provided a great stimulus to social medicine as an academic discipline. Some two years later, the University of Edinburgh, the University of Birmingham and Trinity College Dublin appointed a faculty member of social medicine [8,25]. The Interim Report of The Royal College of Physicians of London, 1943, recommended that every medical school should establish a Department of Social and Preventive Medicine and made recommendations on how the subject should be taught [25]. In 1956, the Society for Social Medicine was established [25,26].
According to Rosen [8], at least until the early 1970s, the content of courses offered by a Department of Preventive Medicine in American medical schools were essentially the same as that offered by a Department of Social Medicine in British medical schools. The history of the Department of Social Medicine at the medical school of the University of North Carolina at Chapel Hill exemplifies the traditional relationship between social medicine and preventive medicine. The Department, originated from the Department of Preventive Medicine in 1952, has kept its current name since 1980 after going through a few instances of reorganization and renaming. Furthermore, the department is responsible for the resident training program for preventive medicine now [27].
The majority of the medical schools in India have the Department of Preventive and Social Medicine upon the recommendation made at a medical education conference in 1955 [28]. In addition, as mentioned earlier, many medical schools across the world, including those in New Zealand, Malaysia, Thailand and Myanmar, have the Department of Preventive and Social Medicine.

DEVELOPMENT OF MEDICINE AND SOCIAL MEDICINE

The main medical interventions in modern health care are based on biomedical sciences and technologies that have been developed with advances in human biology, other natural sciences and engineering. New effective biomedical interventions are continuously developed, so that increasingly more diseases can be prevented and treated. However, the fundamental limitations of biomedical interventions should not be overlooked.
As described before, health and disease are affected by social factors as well as by biological factors. For example, people may suffer from preventable communicable diseases due to unsanitary living conditions of slum area and people may die from curable diseases because of delay in seeking adequate medical services due to financial burden. Although the direct cause of their suffering and death was disease, the underlying cause was poverty which is not a biomedical problem. Generally speaking, the social causes of, experiences of and response to diseases and other health problems do not belong to the domain of biomedical science or intervention. Furthermore, many problems in health care associated with the increasing effectiveness and value of medical services, changes in the pattern of illnesses, aging of population and continuous increase in health expenditure are more social than medical.
Advancements in medicine and the development of modern health care changed major causes of morbidity and mortality from infectious to chronic and degenerative diseases. In response to such changes in patterns of disease, health policy focused on changing health behavior and promoting healthy lifestyle. From the 1960s, social medicine also increasingly concentrated on relations between health, illness and social behavior [29]. But empirical studies revealed the limitation of a model of prevention that primarily focused on changing individual behavior [7], and therefore policy and research interest was shifted to addressing the social structural determinants of health and disease. Recently, policy efforts give added emphasis on developing approaches directed to social determinants of health as concern with health inequalities is increased [30-35].
Social medicine explicitly investigates social determinants of health and disease, rather than treating such determinants as mere background to biomedical phenomena [36]. In line with this perspective of social medicine, Link and Phelan [37] argued that epidemiological studies should pay greater attention to basic social conditions questioning the emphasis on such individually-based risk factors as diet, cholesterol level, exercise and the like. They indicated two reasons for this claim. One of their argument is that individually-based factors must be contextualized to craft effective interventions to improve population health. The other is that social factors such as socioeconomic status and social support are likely fundamental causes of disease.
Eisenberg [38] more specifically argued that the distribution of health and disease in human populations reflects where people live, what they eat, the work they do, the air and the water they consume, their activity, their interconnectedness with others and the status they occupy in the social order. Holtz et al. [39] also indicated that each of the risk of exposure, host susceptibility, course of disease and disease outcome is shaped by the social matrix, whether the disease is labeled infectious, genetic, metabolic, malignant, or degenerative. Both of the papers provided illustrations of the social roots of diseases.
Although infectious diseases are clearly caused by biological factors, the patterns and duration of the infection vary according to the characteristics of population, such as size, structure, density, their utilization of health care services and living conditions [38]. By definition, an infectious agent is a necessary cause of the disease. Eliminating the agent eliminates the disease. But it is not a sufficient cause, for not every person exposed to the agent develops clinical disease. The resistance of the host is as decisive as the virulence of the agent. Moreover, the epidemiology of infectious diseases is affected by human organizations as well as by the characteristics of the infectious agent. For example, the penetration of an infectious agent, which is virulent and infectious only in acute phase, into a small community would rapidly kill or immunize so high a proportion of the population that the agent is no longer able to propagate itself. On the other hand, in big cities, such agents have a large enough reservoir to maintain the chain of transmission. And social stratification is to be made in large communities, and disease epidemiology begins to correspond to the stratification.
The change in the prevalence of type 2 diabetes (NIDDM) among the people of Nauru, a small island in the South Pacific, is a good example of the relationship between socioeconomic factors and diabetes [38]. Until World War II, the main job of Nauruans was fishing and farming for subsistence which required high energy expenditure. After the war, introduction of phosphate mining by foreign companies yielded rental income for Nauruans that rapidly transformed them into wealthy and sedentary people. Virtually all foodstuffs were imported, and most had a high calorie content; obesity became ubiquitous. NIDDM, previously minimal, began to reach epidemic proportions in the 1950s, and in the late 1990s, afflicted almost two-thirds of 55-year-old to 64-year-old adults. The distribution of the disease among Nauruans has continued to change during the past 50 years. Health surveys revealed that the age standardized prevalence of impaired glucose tolerance rose to 21% in the mid-1970s and then declined to half that value by the late 1980s; yet, the risk factors persisted. According to Eisenberg [38], the plausible explanation for the rise and subsequent fall is that NIDDM resulting from the affluent lifestyle has already afflicted most of the genetically susceptible Nauruans, leaving a residual population of relatively resistant individuals.
Neel [40] has proposed the “thrifty genotype” hypothesis to explain the epidemiological changes in diabetes, like those observed in Nauru. In a situation where there is a fluctuating food supply and frequent famines, greater fat stores would be helpful for surviving subsequent periods of starvation. Individuals with thrifty adaptations (i.e., those able to release insulin rapidly when a temporary food glut becomes available) can convert most of their ingested calories into fat. The very same genotype becomes a handicap in the presence of abundant highcalorie foodstuffs and reduced physical activity. This hypothesis indicates that social conditions, through interaction with genotype, can influence the distribution of diseases in a population.
The prevalence of heart disease and diabetes is two to three times higher in African Americans than in whites, but representative surveys of Caribbean populations of African origin have revealed prevalence rates two to five times lower than those of blacks in America or Britain. This suggests that racial disparities in health status observed in the US are associated with social contexts rather than with biological attributes including genotype [41].
The Center for Interdisciplinary Health Disparities Research at the University of Chicago (CIHDR) proposed a downward causal model or a multilevel causal model of the mechanism through which social factors cause diseases and influence health outcomes [33]. According to the model, upstream determinants at the social and environmental levels influence and regulate events at lower levels, that is, from individual behavior and physiology to the cellular and genetic interactions with health and disease. And feedback also occurs from lower to higher levels, with genetic and biological factors, influencing phenomena above them. In the US, despite the fact that white women are more likely to develop breast cancer, black women are more likely to die from it. Through the study of this disparity, CIHDR illustrated the applicability of the model for understanding the causal role of certain social factors in developing diseases.
Several empirical studies on the effects of social factors on health and disease were briefly reviewed. These studies indicate the inherent social basis of disease causation that is part of the basic concept and theory of social medicine. And they provide some rationale for Einsenberg’s claim that all medicine is inescapably social [38].

SOCIAL MEDICINE IN KOREA

Since Japanese medicine was influenced by German medicine, it is probable that social medicine was known in Korea during the period of Japanese rule. Hong-Jong Yoo, a Korean physician, used the term social medicine in an essay titled “Two major harms from the viewpoint of hygiene,” printed in the first issue of Gaebyuk published in 1920 [42], and the term appeared in newspapers around the time. But the extent to which social medicine was established as an academic discipline or as a specialty of medicine in Korea is not known.
The term social medicine has been rarely used in Korea after the liberation from Japanese rule either. Exchange with American medicine, which became active from around the 1950s, was the driving force for the development of Korean medicine. But social medicine was not introduced, presumably because American medicine avoided using the term for a substantial period of time, especially for some years from the era of McCarthyism in early 1950s. However, some research papers, which considered social factors as part of study variables, used the term social medicine in the title like ‘socio-medical study.’ (There are papers titled “Social medicine” [43] and “A study on the development of social medicine curriculum” [44], but their content is not about social medicine but about medical education.)
The establishment of Institute of Social Medicine, Hallym University (The Institute is now named Health Services Research Center.) in 1984 was the first formal use of the term in Korea. In 1985, Hallym University College of Medicine established the Department of Social Medicine (literal translation of Korean name) instead of the Department of Preventive Medicine which is the common name used in Korean medical colleges. A few years later, two more newly founded colleges of medicine established the Department of Social Medicine. Their English name is the Department of Social and Preventive Medicine. As the reasons for using social medicine instead of or in combination with preventive medicine in those medical colleges, two points are indicated. First, fundamental knowledge and technologies for prevention are developed by all the medical specialties and most of preventive services for individuals are performed at the departments of clinical medicine, so that prevention cannot be monopolized by a certain specialty. In fact, prevention is the concern of all the medical specialties including basic medical sciences [45]. Second, preventive medicine, as the title of specialty, does not reflect the fact that Korean preventive medicine deals with much broader content than prevention. At this point, we may ask a couple of questions. What is the relationship between social medicine and preventive medicine? Can the use of the term ‘social medicine’ help resolve the problems faced with the use of the term ‘preventive medicine’?
In the textbook edited and published by the Korean Society for Preventive Medicine [46], preventive medicine is defined as one of medical specialties aimed to protect, maintain and promote health and well-being of individuals and groups of people, and to prevent disease, disability, and premature death. This definition implies that preventive medicine is distinguished from other medical specialties by its two characteristics, focus on prevention and concern with groups of people as well as individuals. Understanding of patterns of health and illness in groups of people and making interventions at the population level to improve their health require consideration of the effects of various social factors on health and health care delivery system. Therefore, the biomedical model of health and disease is not appropriate for dealing with many of the problems and issues involved in the research and practice of preventive medicine [47,48]. These concepts of preventive medicine associated with its population perspective to health and disease are the very basic ideas and concepts of social medicine and the term ‘social medicine’ apparently reflects such concepts better than the term ‘preventive medicine’. In fact, once the two terms were often used interchangeably in America [49], perhaps on the basis of such commonality. In the light of the conceptual commonality, it is understandable that Korean preventive medicine deals with many of the subject matters of social medicine.
A quick observation of the subjects of the aforementioned textbook published by the Korean Society for Preventive Medicine is made to confirm that they include those of social medicine. The subjects of the book are grouped into four parts: ‘Health and Disease’ (part I); ‘Epidemiology and Its Applications’ (part II); ‘Environment and Health’ (part III); and ‘Health Care Services and Management’ (part IV). In describing the concepts related to preventive medicine and public health in part I, socioeconomic, cultural and political factors are considered as part of the determinants of health. This perspective to health is in agreement with the concepts of social medicine. Epidemiology, discussed in part II, is used as a methodology in social medicine as well. Besides, epidemiology of most of diseases are affected by social factors as well as by biological factors. The subjects of part III, environmental pollution, environmental contamination and occupational diseases are also closely associated with social and economic conditions. Health care delivery system, health insurance and health behavior included as the subjects of part IV are also important issues for social medicine. Even through a quick fragmentary observation, it is found that Korean preventive medicine incorporates a great deal of social medicine contents.
In Korea, the term social medicine is rarely used but many of its subject matters are incorporated into preventive medicine as reflected in a text book. But the implicit incorporation of fragmentary contents of social medicine without any discussion of its concepts and theory may be of little help for understanding even the basics of social medicine, such as the need for and the significance of investigating the effects of social conditions on health, disease and health care. Therefore, efforts should be made to supplement social medicine contents of preventive medicine through formalizing linkages between the two fields. One way of doing so is to change the title of ‘preventive medicine’ course in medical colleges to ‘preventive and social medicine,’ as in many other countries and adjust the contents of teaching and textbook. It is believed that this change will be also helpful for clearly defining the academic and practical identity of preventive medicine.

SUMMARY AND CONCLUSION

It was observed that social medicine is recognized as a specialty of medicine in many countries. The Korean medical community, however, does not seem to be aware of that social medicine is one of medical specialties, but it does not mean that nothing about social medicine is dealt with in medical colleges or none of social medicine approaches is employed in health care services. Since social medicine has evolved in diverse ways in different countries, the main concerns and subject matters of teaching and research may differ to some extent among countries. Based upon these observations, this paper is intended: 1) to improve medical profession’s understanding of social medicine in Korea through providing the description of its origins and development; and 2) to assess the current state of social medicine in Korea and suggest agendas for its future development.
Included in the core principles of social medicine are: 1) that social and economic conditions have an important effect on health, disease and the practice of medicine, and these relations must be subjected to scientific investigation; and 2) that the measures to promote health and combat disease must be social as well as medical. Interests in the relationships between health and social factors began in the 18th century, but the term ‘social medicine’ was first used in 1848 by a French doctor, Jules Guérin in the year of the February Revolution in France. In the same year, Rudolf Virchow and his colleagues initiated social medicine in Germany.
Social medicine initiated in France and Germany had a wide influence on the development of this field in many other European countries. Interest in social medicine grew and discussion of the topic was popular in the US for some time after World War II. However, the American medical profession avoided using the term for a substantial period of time. The reason for the avoidance was that the phrase ‘social medicine’ sounded very much like ‘socialized medicine’ and the concept incorporated the politically suspect idea of national health system. By the early 1950s, the American social medicine movement lost its momentum during the red scare of what is known as the era of McCarthyism. Presumably because of the avoidance of the term by American medicine, which has widely influenced Korean medicine, social medicine has not been introduced to Korea.
Korean preventive medicine is distinguished from other medical specialties by its two characteristics, focus on prevention and concern with groups of people as well as individuals. Understanding of patterns of health and illness in groups of people and making interventions at the population level to improve their health require consideration of the effects of various social factors on health, disease, and health care delivery system. In other words, Korean preventive medicine deals with, besides prevention, health problems at the population level that are inescapably social. These concepts of preventive medicine associated with its population perspective to health and disease are the very basic ideas and concepts of social medicine.
In Korea, the term social medicine is rarely used but many of its subject matters are included in preventive medicine as reflected in a textbook. But it is not likely that further systematic development of social medicine would be made because there has never been any academic discussion of the concepts and theory of social medicine, upon which such development can be based. Indication is that efforts should be made to supplement social medicine contents of preventive medicine through formalizing the linkages between preventive medicine and social medicine. One way of doing so is to change the title of ‘preventive medicine’ course in medical colleges to ‘preventive and social medicine’ like in many other countries, and adjust the course contents in accordance with the new title.

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

SUPPLEMENTAL MATERIAL

Supplemental material (Korean version) is available at http://www.jpmph.org/
jpmph-50-3-141-suppl.pdf

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49. The distinction between public health and community/social/preventive medicine. J Public Health Policy 1985;6(4):435-439.
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