From the State of the Field column of the November 2010 issue of Perspectives on History
The History of Medicine: Challenges and Futures
Robert Peckham, November 2010
The recently announced closure over the next two years of the Wellcome Trust Centre for the History of Medicine at University College London (UCL)—an institution associated with leading scholars such as Roy Porter—has given those in the field pause for thought. Beyond the particular funding issues at Wellcome-UCL, the disbandment of a major center of research in the history of medicine raises critical issues about the constitution of academic and subdisciplinary fields. Today, as history enjoys a resurgent popularity with TV programs and museum exhibitions devoted to the subject, many historians are pondering the future of the history of medicine.
In this article, I address a number of interrelated questions: Where should the history of medicine be situated? How should the history of medicine be constituted? And what is its purpose, particularly given the explosive evolution of contemporary medicine and its expanding linkages with a huge diversity of fields including biology, physics, and the social sciences?
It could be argued that the history of modern medicine that impacts and makes increasing demands upon health policy and national economies has a relatively brief trajectory. Although the antecedents of modern genetics stretch back to the 19th century, major technological developments cluster, for the most part, over the past few decades. Anti-cancer drugs and other costly modern medicines are of recent origin, as are transplant surgery, stem cell technologies, and assisted reproduction. This recent history raises two important questions for the field. First, how likely are efforts preoccupied with the protracted prehistories of these and other areas of rapid growth likely to yield practical benefits? Second, does the fact that these growth areas are complex and require considerable technical and scientific knowledge on the part of the historian change the meaning and scope of history as it applies to modern technology-driven medicine?
Answering these questions in any depth lies beyond the purview of this brief article. Instead, my aim is to survey a number of approaches which have sought to situate medical history in different ways by arguing for its relative usefulness. By way of a conclusion, I draw upon the recent experience of the University of Hong Kong (HKU), which last year established the Centre for the Humanities and Medicine, a joint initiative of the Faculty of Arts and the Faculty of Medicine, with history as one key research focus. In founding the new center, HKU has demonstrated its commitment to a field that openly celebrates its diversity and eschews a narrow, programmatic agenda.
As a global financial hub, a former British crown colony and, since 1997, a Special Administrative Region of the People’s Republic of China, Hong Kong provides a particular vantage point for rethinking the scope and value of the history of medicine as a field. The University of Hong Kong’s Faculty of Medicine originated with the establishment of the Hong Kong College of Medicine for Chinese in 1887 by Sir Patrick Manson, one of the founders of tropical medicine. At the same time, Western medical science has coexisted in Hong Kong with other healing practices, highlighting issues of imported technology and local contexts. This background and Hong Kong’s frequently evoked collective memory of epidemics—from the 1894 discovery of the plague bacillus in Hong Kong by Alexandre Yersin and Kitasato Shibasaburo to 21st-century zoonotic diseases such as SARS and Avian Flu—all of this, together with the ongoing overhaul of the health care system in mainland China, grounds the new center at HKU in contexts that are local as well as global; that are historical, as well as urgently contemporary.
The Uses of History
Talk of a crisis over the history of medicine’s possible “de-institutionalization” is nothing new: it has stalked the field for at least the last decade. In part, the vision of breakup has reflected concerns over the lack of any clearly delineated identity as the vigor of the new social history, which had developed from the 1960s, dispersed into a multitude of approaches by the late 1980s leaving no apparent unifying purpose.1
Different approaches within the field have emphasized history’s different uses. For example, the history of medicine has been construed as an account of the past that bolsters the institution of medicine and the status of health care professionals. It has been envisaged as an interpretation of the present that draws upon an understanding of past trends. From the 1960s historians such as Charles E. Rosenberg, for example, explored medical history in relation to broad social and political currents. Rosenberg subsequently articulated ways in which history might be used as a resource, contributing to public debates about the crises of contemporary medicine.2
History has also been conceived as a means of developing possible future scenarios based on evidence from the past. Thus, Richard E. Neustadt and Ernest R. May argued that history, and in particular the management of public health events such as the disastrous mass-vaccination debacle in the United States following the Swine flu scare of 1976, furnished insightful evidence for decision-makers formulating future health policy. Needless to say, Neustadt and May were both evoked during the 2009 H1N1 pandemic.3
The emphasis on the utility of history in the 1980s and 1990s was further fueled by a need to assert the field’s legitimacy, especially at a time when the consequences of neoliberal economic reforms associated with Reagan and Thatcher were reshaping education, and when AIDS was raising fundamental issues about the prerogatives of the state. It was also, undoubtedly, a strategy of accommodation, given that medical schools were, and remain, the best-funded and most powerful institutions on campus.
In recent years, the pressure to demonstrate the history of medicine’s practical value has intensified, over and above the pressures felt by many other academic fields. At a time of avowed crisis in health care systems around the world—and in the face of emergent and re-emergent diseases, biosecurity threats, and rapid technological advances—historians of medicine are increasingly required to display their field’s efficacy as a tool for furthering understanding, shaping policy, and contributing to the management of illness.
Other pressures have affected the field, challenging its coherence. Medicine’s encroachment into areas hitherto deemed cultural and social, for example, has drastically extended the field’s scope. The globalization of disease transmission, medicine and health care, together with increasingly multi-ethnic societies in the West and the rise of new non-Western focused academic centers in Asia and elsewhere are also reconfiguring the history of medicine in significant ways. As the field broadens its base from a predominantly Western oriented science-driven medicine to encompass East Asia and global history, more generally, questions about the scope of the field have come to the fore: Where should its limits be drawn? How does medicine relate to other healing traditions?
Whilst the field has a historical interconnection with medical practice, there has also been a critical tradition which has sought to interrogate the deep-rooted assumptions and political interests which underpin medicine. This is a tendency reflected in contemporary scholarship on biopower and biopolitics and in the disparagements of “traditional” medical histories, which are viewed as uncritical celebrations of the field’s progress, written for and by physicians.4 Critical academic approaches found their popular articulation in attacks on the medicalization of society and the arguments promoted by Ivan Illich and others who sought to demonstrate the “radical monopoly” of institutionalized technologies and, in particular, the counter-productivity of medical practices which they claimed were impeding rather than promoting society’s health.5
Particularly in the 1980s and early 1990s historians such as David Arnold examined medicine as a site of contestation between state authorities and colonial subjects.6 This critical focus on an authoritative colonial medical discourse, state interventionism, and the body, was part of a more socially expansive and theoretically informed understanding of medicine in relation to state-sponsored public health.
Today the notion of history as a critique of medicine and history as an extension of medical practice—conceived as a humanistic craft—have to some extent uneasily conjoined in the “medical humanities.” This is a field that has burgeoned over the last decade in the U.S., Europe, and increasingly in Asia, and aims to integrate the humanities with medicine as a way of cultivating critical perspectives on medical practice and in so doing foster more precisely honed skills of observation and analysis. History is here construed as a discipline that promotes self-reflection by elucidating the cultural and social contexts within which our experiences of medicine, illness, and health are shaped.
The University of Hong Kong Initiative
Many academic centers for the history of medicine are multidisciplinary communities that draw upon the expertise of faculty members from across the university. As such, they reflect institutional configurations of research interests aimed not only at amplifying the profile of the field, but also at enhancing research funding mechanisms. Different arrangements in different institutions reflect funding priorities, institutional traditions, personal predilections, and practical staffing exigencies—often a combination of all of these. In some universities the history of medicine is taught in departments of history, as an elective module within medicine, as postgraduate offerings in virtual multi-disciplinary centers, or diffused across area studies.
Given the plurality of methods and aims within the field, and the range of institutional solutions, where—in an ideal world—would one situate a new center, which included the history of medicine as a key research theme? At the University of Hong Kong, it was felt that a partnership between the Faculties of Arts and Medicine would be crucial to the success of any initiative. Yet there were few models here to draw upon as most research centers were situated either in one faculty or another. In a sense, this lack of models had advantages, as well, enabling us to develop a fresh approach without the encumbrance of institutional precedents. The solution was to embody an inter-faculty partnership at all levels, with joint funding and the appointment of two directors with a cross-faculty executive committee.
There were several rationales for the new center. First, it had been clear for some time that there was a growing research focus on medical and health-related issues across the arts, with a core focus on history. At HKU, the arts encompass four schools, including the Humanities, Chinese, English, and Modern Languages and Cultures, and by 2008 these common interests had coalesced in a Forum for the Humanities and Medicine. Meanwhile, a Medical Humanities Group within medicine had for some time been piloting ideas for a reformed clinical curriculum. Indeed, a backdrop to the creation of the new center, which conjoined these two initiatives, was the substantive restructuring of the undergraduate curriculum as part of a major overhaul of Hong Kong’s higher education. As the institution moved to a four year common core curriculum (to be fully implemented by 2012), the university took the opportunity to reflect critically on its goals in the context of an increasingly interconnected world. The new center has been shaped by this self-reflection, as well as by the university’s commitment to promoting cross-disciplinary teaching and research, including the Faculty of Arts Strategic Research Theme on “China-West.”
The Centre for the Humanities and Medicine has already established a number of key research clusters including: histories of infectious disease, health and Asia, urban ecologies, health communication, philosophy and therapy, natural disasters, biotechnology, and humanitarianism. Informing all of the clusters is a conviction that to understand the forces which have shaped and continue to shape medical technology, health care, and experiences of illness and disease in Asia requires a diversity of approaches and methodologies. It requires a flexible framework that can join up thinking from biotechnology to Chinese studies, linguistics, ethics to public health and beyond—with history as a key dimension. And while drawing upon local resources, it must also cultivate global networks to draw upon the expertise of other scholars and institutions further afield.
The priority for the history of medicine now, however tempting in the light of the economic downturn, is not to bestow a new coherence on the field or to rediscover an overarching mission that would banish differences of methodology. On the contrary, it is to promote, in whatever ways possible, historical approaches that draw upon the full range of the field’s multiple pasts, recognizing that diverse methods will be crucial and that the boundaries of medical history must be expanded to include other traditions of health and other varieties of non-Western historiography.
Robert Peckham is co-director of the Centre for the Humanities and Medicine and assistant professor in the Department of History at the University of Hong Kong.
1. Frank Huisman and John Harley Warner, “Medical Histories,” in Frank Huisman and John Harley Warner, eds. Locating Medical History: The Stories and Their Meanings (Baltimore and London: Johns Hopkins University Press, 2004), pp.1–30 (17–19).
3. Richard E. Neustadt and Ernest R. May, Thinking in Time: The Uses of History for Decision-Makers (New York: Free Press, 1986). For a contemporary interpretation, see Virginia Berridge, “Thinking in Time: Does Health Policy Need History as Evidence?,” The Lancet, 375:9717 (6 March 2010), 798–799.
4. As Huisman and Warner argue, this caricaturing of ‘traditional’ medical history is a largely ‘invented tradition’ that belies the plurality of earlier approaches and methodologies. See “Medical Histories,” 4–5.