Lecture Eight: The AMA's Progressive Pivot

Born in Republican America, with its emphasis on democratic decentralization, the AMA was floundering in the late 1800's, with few doctors latching their sails to its agenda.  Most orthodox doctors remained fully independent, many graduated from poorly regulated schools without any firm curriculum, and the medical landscape was dominated by non-orthodox providers.  In this vein, the AMA shifted course in the late 1800's, increasing its funding stream, starting a journal, and gravitating towards a more top-down Progressive model of care.  Part of its shift required certain compromises and a restructuring of its code of ethics, enabling stronger relationships with the growing pharmaceutical industry that led to more ads and increased revenue, and permitting the inclusion of homeopaths into its orbit if they adhered to certain orthodox precepts.  Where the AMA did not bend is in its medical racial script, as it turned its back on the growing orthodox African American medical profession.

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As we move into the 1900s, uh we see an AMA uh in disarray at the end of the eighteen hundreds, uh with the proliferation of alternative medical societies, with a complete non-cohesion of orthodox doctors, the extensive diploma mill doctoring that's going on. In other words, that so many medical schools claiming to be orthodox were spitting out students who were unqualified, who did not understand orthodoxy. And certainly all these doctors, these orthodox doctors who were fighting for their lives against alternative providers, and also for status and salary and any claim to being true professionals. Remember, at this time, doctors were considered uh among the lowest professionals, certainly below clergy, below lawyers, uh below even bureaucrats in the government in terms of their status and salary. Um they had a fight against this, they had a pushback. Uh by 1900, uh, out of what was estimated to be a hundred thousand Orthodox doctors in America, eight thousand belonged to the AMA, and most of those were not active. Most uh national uh national meetings uh just sported uh a few thousand, if anything. Even the historians who are largely writing through the context of being pro-AMA, having been AMA members, um suggest that the feckless and ineffectual state of the AMA at this point needed to change. Uh James Burrow writes, quote, after more than 50 years of painful growth, the position of the American Medical Association was still insecure. It could speak neither for the entire healing profession nor for the practitioners of conventional medicine in any section of the country, noting that, quote, throughout the 19th century, the association struggled along with the constitution to discourage the development of skilled and experienced executives conducting its affairs. That was due to the federalized nature of the AMA's constitution that put all the power in the state societies. And at this point, too, as we mentioned, it was having its own problems with the state societies. Uh, it it's battle with the New York Medical Society over its alleged embrace of homeopathy severed that group from the AMA for almost two decades. The AMA actually tried to create an alternative group in New York State that was completely rejected by the doctors in New York State. And while the New York City group, the New York Academy of Medicine, remained loyal, many of those people too started to falter because they had to also deal with homeopaths, especially in the uh in the bureaucracy of New York. There was also a huge fight with the Massachusetts Medical Society. In fact, the 1870 convention, which is most remembered because of the attempt of African American doctors to join, was if you read through the records of that convention, if you read letters written to Davis for the 10 to 20 years after the convention, no one mentions race. They all talk about this huge fight with the Massachusetts Medical Society because they the AMA attempted to censor it again for some of its members talking with homeopaths. And the Massachusetts Medical Society, which was stronger than the AMA, had more authority among Orthodox doctors, simply said, okay, we're not going to be part of the AMA anymore. And the AMA had to deal with this basically, its own civil war, in addition to fighting against alternative doctors. And so there was no true central organization for doctors. I mean, the NMA was for African Americans, the Homeopathic Society, the AMA, all these local societies. And then most doctors didn't join anything. You didn't have to. There was no advantage to being a member of any organization, any society, other than for convenience of conferring with other doctors, getting specialized referrals, those kind of things. But it cost money, and most doctors simply didn't do that. At the 1876 convention, none other than AMA president Mariam Sims implored the organization to start looking inward to fix itself. Now, if you don't remember Marion Sims, he was a physician in the South who conducted significant research on African American women without anesthesia, who created the discipline of gynecology in America, is known as the father of gynecology, through research on these women who at the time were slaves, to learn new surgical techniques that he then, once he mastered them on them, once he caused whatever damage was going to be caused, he then moved over to the white community. And these became some standard procedures that are still used today. And he became head of the American Academy of the New York Academy of Medicine. His statue's still in Central Park. And then in 1876, the president of the AMA. And he brought up race. Again, this was never brought up in AMA after 1870 and 1872. He wrote, quote, who can forget the last meeting held in this city? It was Philadelphia in 1872, when so much time was wasted in discussing the woman question and the Negro question. And he said, Fortunately, for us, these vex questions are now all settled quietly and in the most natural way. Gentlemen, I congratulate you with all my heart on having eliminated these troublesome questions so as to vote your time hereafter wholly to matters of scientific and professional interest. He and all the AMA members did not want to discuss race, and it was never discussed. Other than these couple sentences, no one brought up race at all. But his speech was much more about we have to organize as a group. We have to work on our own internal power. And he gave a few ways to do that, many of which related to having a more centralized uh executive council that could have more control instead of this very democratic constitution that allowed anyone to say anything and to give incredible power to the state societies, which he believed was not going to allow them to move forward in the world. At the same convention, 1876, Dr. E. R. Squibb of New York, who is a member, uh, proposed that the AMA focus its lens on regulating and helping to advance pharmaceuticals. He even suggested an amendment stating, quote, resolved that the American Medical Association take the whole subject of the national pharmacopia into consideration for review and management. He wanted the AMA to run the pharmaceutical industry. He wanted them to have a strong relationship with the pharmaceutical industry. And by the way, at this point, the pharmaceutical industry was growing, and pharmaceuticals were often herbal medicines put into pills, but they had what were called proprietary drugs. Proprietary drugs were created by companies, and they were pills with a mix of secret ingredients that the companies would not reveal. So Squibb said, let's let's do this. Let's regulate this industry, let's be part of it, let's uh work with them. Uh the AMA was not interested in the time. Uh part of it was due to its own code of ethics, but it was still so disorganized that all the, when you read the transactions, it just was fighting, people just fighting about this, and nothing happened. Squibb, of course, went on to found one of the nation's largest pharmaceutical firms and wrote his own textbook of drugs when the AMA didn't act and tried to regulate it himself, tried to be in charge of it himself. The AMA wasn't quite ready at this time. But they they both struck cords, Sims and Squibb, and the AMA's liberal constitution and enabling all members to partake in debates about policy while at the same time allowing local society to script their own agendas was preventing the AMA from establishing an efficient and effective uh management apparatus. Um just just reading through the transactions, you could feel just the chaos that was going on in the AMA at this time. Um but things started to change uh at the end of the 1800s, and part of that was due to the efforts of the AMA's founder, Dr. Davis. Davis realized that the AMA needed both to consolidate its power in a small group and also to increase its financial coffers. It could not um at this time hire lobbyists or spread its tentacles into mainstream medicine or even offer doctors anything beyond a meeting place. It needed money. And um, where was it going to get this money? Well, uh Davis was very um positive about working with the pharmaceutical industries, but he also, along with uh other AMA members such as Lewis Sayre, who was president in 1880, uh, looked across the sea to England, where the British Medical Journal had saved the British Medical Association from insolvency. How did it do that? By creating this journal, it created massive amounts of advertising. And who advertised in the journal but drug companies? And in Britain, that led to tens of thousands of dollars saving the British Medical Association and making it very powerful. But if you're gonna advertise drugs, that created a dilemma that challenged the AMA's code of ethics, which condemned, even forbade the use of these proprietary drugs. And the proprietary drug makers are the ones who wanted to advertise. Um, between 1880 and 1900, the transactions are filled with just contentious discussions about clean advertising amendments that sought to eliminate all proprietary drug ads from the journal, which was finally created in 1880. So that the journal came, but the drug ads didn't follow. It's interesting because these drug companies themselves decided just to circumvent the AMA and ignore its journal. And these drug companies are growing fast since the Civil War. The laws of the land allowed the um uh creation of corporations uh much more nimbly than prior to the Civil War. And a lot of these companies just blossomed and exploded. People wanted drugs. It was wild that you know at this time the drug craving in in our country was so high that people like these promises. And these drug manufacturers made wild promises. They also created their own journals. Um so Park Davis, for instance, which was a new company, created several journals with wide circulation, basically journals that pretended to be scientific journals but were just advertising drugs. And and who were the authors uh in these journals? They were Orthodox doctors who were paid to write these um proprietary articles that were advertising drugs allegedly under a scientific guise, that they were proven to work, and these orthodox doctors, who were often hand-fed articles that they were gonna sign and put in these journals, were paid enough money that they were willing to do it. Welcome to the modern world, which started in the late 1800s. And against this and everything else, the journal of the American Medical Association was not doing well. Even by 1900, um, it was costing more to print and disseminate the journal than it was receiving because it had scant ads, it cost about $25,000 a year to produce the journal, and at most the journal was making uh $10,000 to $15,000, looking again at the archives which spell all this out. And so the journal was doing not what Nathan Davis was saying. Now, so if the journal was making $14,000 a year and spending $25,000 a year in production in 1890, by 1903, the revenue went up to $88,000. By 1909, it went up to $150,000. So what happened? Well, the AMA started, at least its small cadre, led by people like Davis, started to transcend the democratic structure and hire experts, alleged experts, to change course. It's ironic that it when you read about the guy who truly altered the AMA's scope, especially during this time, a guy named George Simmons, who became the AMA's pharmacy czar through the 1920s. Um he was a former homeopath. He actually was a practicing homeopath at the time. Um, but it became uh uh important to use him because he knew uh how to do this. So what did he do? Him and Davis, among other of the leading members, first pushed for um a revised uh code of ethics that allowed proprietary drug advertising under the stipulation that the AMA would control which proprietary drugs were used and would have some type of um regulatory role over looking at those drugs. So the deal was, you know, the whole thing about proprietary drugs is there were secret ingredients. The deal they made with these drug companies is we'll advertise your drugs if you tell us the secret ingredients, and we're also gonna create a pharmacopia, just what Squib had suggested, that lists the drugs that we approve. Well, guess what? The drugs they approve are the drugs that they advertise. That's just the way it works out. And so they started advertising more and more proprietary drugs. This was not without contention in the AMA, but again, they pushed it through despite clear opposition among many of its members. Um other changes also occurred in the code of ethics at this time, including allowing some consultation with homeopaths, which is a big change because theoretically the AMA was created specifically uh in its because of its war on quote unquote quacks, which were the homeopaths. So now they were allowed to speak with the homeopaths. I think you know the AMA leaders, although it's not spelled out, realized that they could not fight on all fronts at once. And if the homeopaths could help them, people like Simmons, then God bless them. So with with um with this action of creating a pharmacopoeia, it hoped to make itself relevant. And and well, as we'll see, the um the reasons for this were very self-centered, but also um it saw that the drug industry was growing, and if it could work with that industry, it could get a lot of money. Rather than having the industry siphon off its own doctors to create these other journals, it could do this in its own journal and make a lot of money, which is exactly what happened. And ironically, and we'll talk a lot about this later, um, this was the era of progressivism in America, and progressives wanted to regulate the drug industry, and the AMA stood up and said, we're the guys to do it. And a lot of progressives um jumped on that train, and a lot of reformers looked to the uh AMA to start regulating the drug industry. Again, the regulation of the drug industry was we're gonna advertise, but we're gonna pretend to look the other way with proprietary drugs. As Paul Starr states, quote, the logic of the AMA's regulatory system was to withhold information from consumers and rechannel drug purchasing through physicians, which gave physicians a larger share of the purchasing power of their patients. In other words, um, not only did the journal advertise these drugs, but through its regulatory apparatus and pharmacopia, the AMA, working with progressive reformers, uh said that the only doctors who could dispense these drugs would be sanctioned Orthodox doctors who were AMA members. Hence, giving doctors some incentive to join the AMA, which is what happened. As we showed that you know, the numbers, uh, the amount of money that JAMA was making increased exponentially, but but so did too the um membership in the AMA, which we'll talk about later because there are a lot of reasons for that. The AMA also, to satisfy its members, played a double game. It it worked with uh the progressives in 1906 to finally pass the Pure Food and Drug Act, um, but it put itself in charge of the regulation. And even in its journal, it continued to invey against a lot of the makers of proprietary drugs. But of course, these were the proprietary drugs not advertising in its journal. It would not bite itself in its tail at this point. It was going to actually push these other companies, these drug companies, to advertise, or else it was going to um assail them, which is what it did. This is the new AMA. What's interesting too um is that we've talked a lot about the biting African-American medical system. Well, a lot of um African-American doctors and even uh a lot of African Americans who did not see doctors used many of the herbal remedies that were um very popular during the slave era. And um, unless those remedies were to be dispensed by Orthodox doctors, by the way, uh African American doctors were able to dispense these drugs too, even though they were not members of the AMA. Unless they were dispensed and approved by the AMA, um, they were considered illegal as more and more states jumped on the progressive train and started regulating drugs. And and going through African-American journals at this time and newspapers, they were really annoyed about this. And they they felt one of them, the Cleveland Gazette, wrote that the uh quote, political activity, the American Medical Association has become so pronounced so as to prevent the sale of so-called patent medicines. This is almost the first time in the history of the United States that any organized class has frankly avowed the purpose of capturing legislatures and dominating legislation in their own selfish interest. And and the rising sun in the late 1800s asserts that if patent medicines, quote, are good enough for physicians to prescribe in seven cases out of ten, because this is what physicians were using, even drugs at that point that were not approved by the AMA, um, if they're if they're good enough for family use in cases of necessity when the symptoms are well known and easily by the people, as by the doctors, basically saying, why are the why is the AMA now saying they're no good? They've been used for decades, if not longer, successfully. Doctors were giving them out constantly, and now the AMA was saying they were forbidden. And they saw this uh for what it was, which was a selfish grab on money. Um, but again, you know, the AMA had its medical racial script, even though it wasn't talking about race, it was certainly not going to allow any herbal treatments approved by African Americans and African American doctors to make it into its pharmacopia, and it didn't. And if you look through some of these drugs, they never made it in. And we don't know if they were rejected because they wouldn't advertise or for other reasons, but uh probably a lot of it had to do with race, uh, which was the the big secret in the AMA's background that it would not really discuss. And again, this is truly um uh a way to make money. AMA needed money, so it was going to use that money uh to hire lobbyists, it hired a lot of lobbyists. Um, it moved its central organization to Chicago and actually bought a building for itself. Um, by using the journal, it grabbed more not only advertising funding, but also uh a lot more Orthodox doctors who were interested in the journal now and who um were uh joining the AMA and the local medical societies. But this was just the tip of the iceberg. It with the money that it achieved by its um self-serving and somewhat nefarious marriage to the growing uh pharmaceutical industry um by changing its code of ethics and by centralizing to some extent and basically ignoring the protests of its members, the AMA now had some power. With money comes power. But the second part of that power um is that the AMA was seen as a progressive. Force that could regulate not only the drug industry but the entire uh medical industry. And progressives looked to the AMA as that organization that was going to be their guys in the medical world. This was the most progressive organization because it wanted to change things and centralize things. Progressives were all about that, which we'll talk about. So this was the first step. From the early 1870s to the end of the century, the AMA made a huge leap in increasing its coffers and its membership and its power. And we will see what other things it did during this time to truly create the medical system we have today.