And most importantly, why it means we should be dreaming bigger about new models for care

Much of our conversation since the pandemic on either side of the political aisle have cast medicine and public health as suffering a fall from grace from the height of their successes. Once upon a time, medicine was trustworthy, but not longer.

In this telling, American medicine was once the envy of the world, but it has been pulled apart by Big Pharma, for-profit health systems, venture capitalists, and money-hungry health insurers. Doubts have been cast on its efficacy by conspiracy theorists, it’s intentions by anti-vaccination activists, and it’s basic operating model by campaigners agitating for nationalized healthcare. But … once upon a time, things were good. Medicine, supposedly, had a Golden Age.

Doctors, for their part, also remember a past where things were simply better. In his sweeping critique Uncaring, Robert Perl points to the 60s and 70s, when local doctors enjoyed the respect of patients, slow pace of practice, and community in physicians-only cafeterias as being something of a high point. Similarly, when I spoke with my own GP, they indicated that medicine was not the same as when their father practiced in the field. The line that suck with me: “People used to trust what we were doing.”

But in addition to living in the minds of health care providers, you can sometimes run across it’s trace elements among Baby Boomers.  If you talk to an older (white) relative and you’ll find it: a sense of faith and trust in the goodness of healthcare that seems foreign to many of Gen Xers, Millennials, or Zoomers.

So what exactly was this?

Medicine’s Golden Age

Ask one historian or another when it began and ended, and you’ll probably get different answers.  I pin this period from 1935 to 1968, essentially from introduction of antibiotic agents to the crescendo of the thalidomide scandal that conclusively shook confidence in medicine. Historians label these decades “golden” because advancements in medicine produced sensational changes in longevity and quality of life. For Americans who had access to quality care, this resulted in deepening trust in the medical profession and medical institutions.

Compared to the years preceding it, the Golden Age produced magical antidotes to our ills. Doctor-scientists did away with nineteenth century killers like tuberculosis. They began to cure or prevent childhood killers like leukemias, rubella, and mumps. Sulfanilamide, penicillin, and their successors wiped away bacterial infections. Blood could be transfused, plasma stored for emergencies. Surgery became safer, less painful, and more technically complex. Hearts were transplanted. Hormonal birth control reordered family planning and gave women new freedoms. And an avalanche of new drugs protected and cured what ailed us – and unlike the unregulated concoctions from the nineteenth century, they did so with scientifically-backed efficacy. 

Not so Golden

The so-called Golden Age, however, wasn’t always so wonderful. In many ways, increasing life expectancy and trust in the healthcare system among (mostly white) Americans obscured many underlying problems.

Cost of Care: Costs increased at an alarming rate from 1935 to 1970, causing problems for those on low or fixed incomes. This problem persisted from the professionalization of medicine in the 1910s. With the elderly facing escalating costs while living longer on fixed pensions, Congress acted. The 1965 Social Security Amendment Act and 1973 Health Maintenance Organization Act hoped to address these issues. As we can see today, while seniors now can rely on Medicare, costs continue to outpace inflation when insurance costs are included. Seeking medical attention has been cost prohibitive from the outset, with Charles Mayo noting in the 1910s that by 1940, the average working man or woman could never afford care.

Medical Experimentation: Generally, we have high expectations for ethics in medicine today, and these expectations are preyed upon by conspiracy theorists. In the Golden Age, scientific studies were not subject to rigorous review, leading to the era’s dark undercurrent: medical experimentation on vulnerable populations.  Prisoners and minorities, particularly African Americans, were often victims of medical experimentation, including the practice of intentionally infecting men and women with bacteria or viruses and performing procedures without consent. The constellation of exploitative practices became so problematic that in 1964 the Declaration of Helsinki outlined ethical guidelines for experiments to the international medical community.

Unequal Access: Beyond the horror of experimentation, minority populations simply struggled to access care. In 1940, about 10% of the US population was black and only 3% of physicians were Black, a ratio that severely limited the access to care in segregated areas. (And it’s a ratio that has changed little today).  Lest anyone hope this could be remedied by graduating more black doctors, the Flexner Report of 1910 had closed many underfunded programs, which included most historically black medical schools. Many public schools in the south remained closed to black students into the 1950s.  The first African American woman wouldn’t be accepted to the American College of Physicians until 1950, right in the middle of the Golden Age.

Unnecessary Testing and Fee-Splitting: The prohibitions on fee-splitting, where one physician pays another for referring a patient to them, was abandoned during the Golden Age. While the AMA had stood against the practice since the 1890s, by 1955, the AMA redefined fee-splitting to be so narrow as to allow numerous work arounds. In the Golden Age, physicians performed tremendous numbers of unnecessary tests, doctor’s visits, and, as Dr. Paul Hawley pointed out in 1953, surgeries in pursuit of financial gain. Trust may have been high, but behavior often lagged.

So What?

Just as medicine offered miracles in the mid-twentieth century, advances continue to provide near miraculous answers to our most pressing concerns. The near instant deployment of monoclonal antibody treatments and mRNA vaccines for CVOID during the COVID-19 Pandemic are great examples.

As we continue to debate the future of healthcare in America, the idea that the past offered a more wholesome version of healthcare remains as seductive as it is false. Poor access, high cost, racism, and ethical concerns should be viewed as a continuity not a break with the past. American healthcare might be failing today, but it’s hard to know precisely when it succeeded for all Americans. 

This is a realization should be both freeing and empowering. Without the weight of a truly successful past – or at least one replete with severe imperfections – we should be thinking bigger and stretching arguments for innovative delivery models further.  It means that we should be thinking more radically about how we locate, access, and envision care in the future.

We’re not going back to anything but should be dreaming of newer, bigger solutions.