How a British painting helped thwart universal health care in U.S.

The Lancet ran a fascinating essay last month on how the American Medical Association (AMA) used the iconic 19th-century painting “The Doctor” to successfully keep the United States from duplicating the United Kingdom’s implementation of universal government health insurance after World War II.

First exhibited by its British painter, Sir Luke Fildes, in 1891 at the Royal Academy in London, “The Doctor” is a sentimental depiction of a Victorian-era doctor attending to a sick child in a laborer’s cottage. The scene was apparently inspired by the actions of a doctor who took care of Fildes’ own young son as he died from tuberculosis.

As John Harley Warner, a professor of the history of medicine at Yale University, points out in the Lancet essay, “The Doctor” was an immediate hit with the public on both sides of the Atlantic. In the United States, engravings of the painting were soon found hanging in doctors’ waiting rooms, and the image was used frequently in the popular media during the Great Depression to decry the passing of the family doctor.

But the painting became best known during the late 1940s and early 1950s when it played a central role in what was at the time, says Warner, “the most expensive lobbying effort in American history”: the blocking of a U.S. version of the U.K.’s National Health Service (NHS).

Writes Warner (note: British spelling and punctuation):

Between 1943 and 1950, a series of national health insurance bills were debated in the US Congress. In 1947, The Doctor appeared on a postage stamp commemorating the AMA’s centenary. And AMA activists went on to deploy the painting as emblematic of all that would be lost if the state were to impose what they called “socialized” medicine, and, in the same breath, “fascist” health care. The Doctor appeared in pamphlets, print advertisements, and, at medical conventions, on gigantic banners, all with the slogan, “Keep politics out of this picture”.

This is a surprising choice, not least because it flew in the face of the reigning imagery of the Golden Age of American medicine — reductionist high-tech medical science, pursued by researchers in laboratories and practiced by specialists in the modern hospital.

‘A comforting fiction’

In fact, writes Warner, “Fildes’ painting was an enticing fantasy, a comforting fiction that bore little resemblance to the relationship between most doctors and patients. But it captured yearnings many Americans shared, just as it played upon anxieties about the depersonalization of modern medicine and replacement of the general practitioner by teams of anonymous specialists.”

A small number of physicians “protested against this nostalgic celebration of the doctor-patient relationship that masked over the social and technological realities of modern medicine and the economic problems of health-care distribution,” notes Warner, but those voices did not prevail.

In fact, the AMA’s response at the time to those and all other critics of nationalized health care was all too familiar for that Cold War period, as Warner explains:

The AMA’s main rejoinder was red-baiting — accusing all who opposed them of socialism. These years marked the heyday of McCarthyism and the height of fears about communist influence on American institutions. “American medicine has become the blazing focal point in a fundamental struggle which may determine whether America remains free, or whether we are to become a Socialist State, under the yoke of a Government bureaucracy”, the new AMA President asserted in his 1950 inaugural radio broadcast. Congressional debate was to be “The Battle of Armageddon — the decisive struggle which may determine not only medicine’s fate, but whether State Socialism is to engulf all America.”

Inflating expectations

The AMA won its battle against universal health care, but in the process “it had also set up dangerously inflated expectations of the doctor-patient relationship,” says Warner. “… Popular disaffection incited by the promises implicit in [the AMA] campaign was already evident by the early 1950s. Americans wanted the devoted, personal attention they saw in the ubiquitous posters, pamphlets, and billboards displaying The Doctor, but that was not what they experienced.”

In addition, writes Warner, “the politicized language attached to the ideal of a holistic doctor-patient relationship in the 1940s with the call to ‘keep politics out of this picture’ was infused into the fabric of American culture, blocking moves for any profound government-led organisation of health care and leaving a legacy that continues today to shape US health-care politics.”

And here’s what may be the ultimate irony: In 1998, when the U.K.’s National Health Service turned 50, the British government used “The Doctor” to visually embody what universal health care has meant to the British public. And it means a lot to them. One recent poll found that the NHS, despite all its flaws and problems, is the institution that the British are most proud of. It’s even, as one newspaper headline put it, “more cherished than the monarchy and the army.”

You can read Warner’s essay at the Lancet’s website.