By Sarah Eilers ~
A host emerges from the shadows of a video production set. In measured tones, he introduces the viewer to a series of energetic but respectful debates on medical topics.
Welcome to the exploration of Concepts and Controversies in Modern Medicine, one of a series of programs dedicated to examining the uncertain, candidly recognizing that much of today’s teaching is necessarily based upon opinion, and that the opinions of eminent physicians in a given field vary widely. The National Medical Audiovisual Center [NMAC] believes that openly airing such opposing views is a basic responsibility of medical communications.
The NMAC became part of NLM in 1967, having been transferred from the Communicable Disease Center (now the Centers for Disease Control). The center was predecessor to the library’s current Audiovisual Production and Development Branch. Concepts and Controversies in Modern Medicine, produced in 1969–70, comprised a set of moderated, videotaped discussions on health and medical concerns about which reasonable people could disagree. And did.
Face-Off
Live debates with broadcast audiences were relatively new to the political and cultural landscape at the time. The 1960 Kennedy-Nixon debate was the first televised presidential one, and its optics were thought to have resulted in votes for Kennedy; he looked calmer, taller, handsomer than his opponent. In 1965, James Baldwin debated William F. Buckley at Cambridge University on the topic of whether or not “The American dream is at the expense of the Negro.” Besides the 700 students in the debate hall, another 500 watched via closed-circuit TV, and the recorded debate was eventually released in both the U.K. and the U.S. Other televised political debates followed in the latter half of the 1960s.
In this environment, the National Library of Medicine developed Concepts and Controversies in Modern Medicine. The historical audiovisual collection includes nine Concepts titles, five of which are available in NLM Digital Collections.
Presenting a mix of data, clinical observation, anecdote, and opinion to support their conclusions, each Concepts panel of doctors is guided by a moderator who is usually a physician as well. The participants argue issues including vaccination policies, narcotic addiction treatments, women’s use of oral contraceptives, and involuntary hospitalization of people with psychiatric illnesses. Designed for a professional medical audience, the series featured a plain set—a few chairs, a small coffee table, and a backdrop of life-sized anatomical drawings.
The videos were available for loan to medical educators for many years, but we don’t know how often they were requested or in what context they were used. We do know that some segments were cited in later research. For example, The Psychiatrist in the Courtroom: Selected Papers of Bernard L. Diamond, 1994, cites the Concepts episode titled “Psychiatry and Law: How are they Related?”
The Sharpest Minds on Opposite Sides
One of the panelists in the “Psychiatry and Law” episode, Dr. Thomas Szasz, also appears in “Involuntary Hospitalization of the Psychiatric Patient: Should it be Abolished?” Dr. Szasz, who died in 2012, was deeply influential in the field of mental health, though his foundational arguments sound extreme today. Szasz never wavered in his belief that mental illness is a myth, and that a medical, neuro-diagnostic model is not useful for understanding the human struggle. In the early years of his career, Dr. Szasz stated that the psychiatric discipline, of which he was a member, belonged “in the company of alchemy and astrology.” Opposing Dr. Szasz in the “Psychiatry and Law” debate was Dr. Bernard Diamond, mentioned above, who developed the “diminished capacity” legal defense. Diamond testified on behalf of Sirhan Sirhan during his trial for the assassination of Senator Robert F. Kennedy.
Evidence and opinion on…
Heart disease
The debates clearly illustrate that people, even experts in their fields, can take the same set of data or circumstances and reach different conclusions about what it all means, or which elements should receive the most attention.
Here’s how a typical discussion begins—in this case, about the causes of heart disease.
[Dr. Jeremiah Stamler, Associate Professor, Department of Medicine, Northwestern University Medical School:] I’m convinced that a mass of evidence exists demonstrating that diet is one of the key factors responsible for the current epidemic of severe premature atherosclerotic disease
in the United States population, and accounting for the very high incidence of heart attacks
in the middle decades of life…
[Dr. Mark Altschule, Assistant Professor, Harvard Medical School:] I’m convinced that diet cannot have a primary role in…atherosclerosis.
Dr. Stamler argues his position first, citing numerous and varied datasets.
Now, study after study of these international differences, both analyses of United Nations data, World Health Organization data, the very important International Autopsy Study done by our colleagues at the Louisiana State University Medical School, together with the very important field studies of Dr. Keys and his group in 12 different populations of Europe plus the Japanese, all show a very close correlation among the pattern of a diet, particularly the saturated fat intake, the dietary cholesterol intake, the serum lipids of the populations under study, and the incidence and mortality rates as well as the prevalence rates of coronary heart disease.
Dr. Altschule counters.
The authors of the report of the Helsinki study and the Los Angeles study, in their own reports, said that their groups were not matched. The one from Los Angeles, in particular, referred to the fact that one of their groups smoked more than the other and they hadn’t taken that into account before starting it. They said they didn’t think it made any difference, I don’t know on what basis.
Smallpox
In another session, debating the utility of continued routine smallpox vaccination, Dr. John M. Neff, Assistant Professor of Pediatrics at Johns Hopkins University, and Dr. Samuel Lawrence Katz, Professor and Chairman of the Department of Pediatrics at Duke University, cite national and international vaccination statistics and mortality figures as they argue their cases. Neff describes the smallpox shot as “a very poor vaccine,” whose effectiveness is short in duration, with “a significant amount of mortality.” Katz is squarely on the other side. “I believe that our nation’s freedom from smallpox rests upon the widespread use of smallpox vaccine.” They agreed, at least, on this graphic that shows regions of the world where smallpox was endemic in 1955.
In other presentations, doctors considered the most effective treatment for narcotic addicts (intensive inpatient therapies vs. reliance on methadone), as well as access to birth control pills. In “The Oral Contraceptives,” the debate was mostly about side effects, and how tightly access to the pill should be controlled by the medical establishment. Just four years before, in 1965’s Griswold vs Connecticut, the U.S. Supreme Court had struck down a state law banning the use of contraceptives by married women. Individual states could still prevent unmarried females’ access to contraception, and many did. In the Concepts segments, the question of who should have access and under what circumstances arises. Dr. Louis Lasagna argued that many women don’t want or need 100 percent effectiveness in birth control, and the possible complications are therefore not worth the health risks when safer, almost as effective methods are available.
Preserving Data
The Concepts debates, informed and thought-provoking, were possible because data were collected, disseminated, and analyzed. Continued interpretations and criticisms of those studies are possible today because, just as critically, the data were preserved. A PubMed search reveals 41 articles that interpret or re-interpret data from Ancel Keys’ Seven Countries Study (cited by Dr. Stamler), including this one from 2015 about the impact of the study on the Mediterranean diet concept.
We hear about data every day. In historical medical collections, data abounds, both quantitative and qualitative. In its format, scope, and biases, data inherently contains more information than its face value. This series, Revealing Data, explores how, by preserving the research data of the past and making it publicly available, the National Library of Medicine (NLM) helps to ensure that generations of researchers can reexamine it, reveal new stories, and make new discoveries. As the NLM becomes the new home of data science at the National Institutes of Health (NIH), Circulating Now explores what researchers from a variety of disciplines are learning from centuries of preserved data, and how their work can help us think about the future preservation and uses of the data we collect today.
Learn more about NLM’s world-renowned historical audiovisual collections.
Sarah Eilers is the Manager of Historical Audiovisuals in the History of Medicine Division at the National Library of Medicine.
Dr. Szasz’s views don’t sound at all extreme. The hazards of what he dubbed the “therapeutic state” are apparent in many aspects of life, from the War on Drugs to the drugging of millions of children for behavioral reasons. Szasz was prescient and heroic in the clarion warning bells he rang for 50 years.