Institutionalizing Plague Doctors

The patterns of civic and medical response to epidemics established between the fourteenth and nineteenth centuries persisted, though in modified form, into the twentieth. These patterns were institutionalized as the nature of the threat changed. Civic authority was vested in permanent agencies of government rather than in temporary committees of influential businessmen and physicians. Since the late nineteenth century, state, county, and city public health departments have had responsibility for disease surveillance and prevention and, very often, for hiring physicians to work in public hospitals and clinics. During the twentieth century, the diseases of the sick poor became first a responsibility of graduate medical education and then an important source of income for medical faculty themselves. Foreign medical graduates remained the most conspicuous group explicitly seeking opportunities by caring for diseases among the poor.

Moreover, as a result of medical advances, general economic conditions, and changes in the natural history of infectious disease, devastating epidemics seemed to many people to be a matter only of historical interest, except in non-Western countries. In the twentieth century, epidemics in the United States have generally been perceived as manageable and likely to be resolved in short course by the application of modern scientific methods. I have seen no evidence that access to physicians was considered a problem during the influenza and polio epidemics earlier in the century.^[18] Most physicians seem to have regarded risks to themselves from treating patients with communicable diseases as manage-

able, often as negligible, if proper procedures were used. An exception to this generalization, until the late 1940s, was the risk to every medical student and house officer of contracting tuberculosis.

The common law, medical practice acts, and codes of ethics seemed adequate to regulate physicians' behavior in choosing patients. This body of precedent and exhortation permitted physicians to select their patients, except in emergencies. Once having chosen a patient, in the AMA's formulation earlier in this decade, "a physician has a duty to do all he can for the benefit of his individual patient" without concern for the "allocation of scarce resources."^[19]