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M EDICINE AND P UBLIC H EALTH
AT THE E ND OF E MPIRE

H OWARD WAITZKIN
 To the memory of my parents, Ed and Dorothy Waitzkin, who
disagreed with me about nearly everything and therefore helped
me clarify what I really wanted to say, and of Edmundo Granda,
inspirational leader of Latin American social medicine.

First published 2011 by Paradigm Publishers

Published 2016 by Routledge

2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright © 2011 Howard Waitzkin

All rights reserved. No part of this book may be reprinted or reproduced or utilised in
any form or by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Waitzkin, Howard.
Medicine and public health at the end of empire / Howard Waitzkin.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-59451-950-5 (hc : alk. paper) — ISBN 978-1-59451-952-9 (pb : alk.
paper)
1. Social medicine. 2. Imperialism—Health aspects. 3. Public health—Political
aspects. I. Title.
[DNLM: 1. Public Health—history. 2. Public Health—trends. 3. Health Services
Accessibility—history. 4. Health Services Accessibility—trends. 5. History, 20th
Century. 6. History, 21st Century. WA 11.1]
R A418.W345 2011
362.1—dc22
2010036757

Designed and Typeset by Straight Creek Bookmakers.

ISBN 13: 978-1-59451-951-2 (hbk)

ISBN 13: 978-1-59451-952-9 (pbk)
 CONTENTS

Preface vii

Part One: Empire Past

Chapter 1 Empire’s Historical Health Component 2
Philanthropic Foundations 2
International Financial Institutions
and Trade Agreements 4
International Health Organizations 5
A Countervailing Viewpoint 8

Chapter 2 Illness-Generating Conditions of Capitalism and Empire 9

How This Viewpoint Emerged 9
Friedrich Engels 10
Rudolf Virchow 13
Salvador Allende 16
Capitalism, Empire, Illness, and Early Death 21

Chapter 3 The International Market for Health Products

and Services 25
Methods to Address the Falling Rate of Profit 25
The Political Economy of Coronary Care 26
Early History of Coronary Care Units 26
Explaining the Diffusion of Coronary Care Units 29
The Corporate Connection 29
The Academic Medical Center Connection 33
Private Philanthropies 35
The Role of the State 37
Changes in the Health-Care Labor Force 39
Technological Innovation and the International
Capitalist System 40

III
IV C ONTENTS

Chapter 4 Paths of Resistance to Empire in Public Health

and Health Services 43
Chile: A Transformation Thwarted by Empire 44
Cuba: A Transformation Thwarting the Advance
of Empire 52
Comparative Changes in the Context of Empire 59

Part Two: Empire Present

Chapter 5 Neoliberalism and Health 64
Neoliberalism and the Dismantling of the
Public Sector 65
The Transnational Capitalist Class and
Multinational Corporations 66
The Nation-State, Sovereignty, and Health 68

Chapter 6 International Trade Agreements, Medicine,

and Public Health 72
Trade Rules 72
Trade Enforcement and National Sovereignty 73
Trade Agreements and Health 74
NAFTA 75
Free Trade Area of the Americas (FTAA) 77
General Agreement on Trade in Services (GATS) 78
Agreement on Trade-Related Aspects of Intellectual
Property Rights (TRIPS) 80
Overview of International Trade Agreements and Health 81
Actions by Health Professionals and Advocates 81

Chapter 7 Macroeconomics and Health 86

Enhancing Empire by Enhancing Health 86
An Influential Example of “Investing in Health”:
The Report on Macroeconomics and Health 87
The Meanings of “Investing in Health” 88
Financing Versus Reform 90
“Close-to-Client” Systems: Public Funding
for Private Providers 91
The Meanings of Prepayment 92
Donor Financing: Unspoken Options 93
The Value of Life: Disability-Adjusted
Life Years (DALYs) 94
Trade Agreements Versus Corporate Responsibility 95
Recycling Public Health Interventions
to Facilitate Investment 96
 CONTENTS V

Chapter 8 The Exportation of Managed Care 99

Economic Conditions That Fostered Exportation 100
The Managed Care Market and Social Security
Funds in Latin America 102
The Rising Trajectory of Managed Care
in Latin America 105
The Falling Trajectory That Followed 108
Challenges to Public Health and Medical Services 109
Resistance to Managed Care and the Emergence
of Alternative Proposals 110

Chapter 9 Corporations, International Financial Institutions,

and Health Services 113
“Reform” in Mexico 114
“Reform” in Brazil 116
Penetration by Multinational Corporations 117
Effects of Reform in Mexico 118
Effects of Reform in Brazil 120
Vicissitudes of Privatization and Corporatization 121

Chapter 10 The “Common Sense” of Health Reform 123

Ideological Underpinnings of Health Reform 124
Ideological Assumptions in a Silent Process of Reform 125
A Transformation of Common Sense 126
Ideology and the Reconstruction of Common Sense 127

Chapter 11 Stakeholders’ Constructions of Global Trade,

Public Health, and Health Services 131
Government Agencies 131
International Financial Institutions 134
International Health Organizations 136
Multinational Corporations 137
Advocacy Groups 140
Social Constructions of Trade and Health 142

Chapter 12 Militarism, Empire, and Health 145

The Physical and Psychic Impact of War
on Military Personnel 146
Civilian Services for Military Personnel 147
GIs’ Physical and Mental Health Problems 148
Themes from Encounters Between Military
Personnel and Civilian Clinicians 150
The Economic Draft 150
VI C ONTENTS

Deception 150
Ethical Dilemmas and Violence Without Meaning 151
Barriers to Care 151
Privatization of Services 151
Torture and Human Rights Abuses 151
The Changing Health Effects of Militarism 152

Part Three: Empire Future

Chapter 13 Health and Praxis: Social Medicine in Latin America 156
Productivity and Danger 156
History of Latin American Social Medicine 159
The “Golden Age” of Social Medicine in Chile
and the Role of Salvador Allende 159
Social Medicine Versus Public Health Elsewhere
in Latin America 161
The 1960s and Later 163
Political Repression and Work Challenges 164
Theory, Method, and Debate 165
Emerging Themes 167
Social Policies, Empire, and Health 167
Social and Cultural Determinants of Health and Illness 168
Relations Among Work, Reproduction, the
Environment, and Health 168
Violence, Trauma, and Health 169
The Future of Social Medicine 169

Chapter 14 Resistance and Building an Alternative Future 171

The Struggle Against Privatization of Health
Services in El Salvador 172
Resistance to Privatization of Water in Bolivia 174
Social Medicine’s Coming to Power in Mexico City 177
Other Examples of a New Vision: Venezuela,
Uruguay, and Brazil 180
Struggles for National Health Programs
in the Heart of Empire 182
The End of Empire? 186
Sociomedical Activism in the Post-Empire Era 188

Notes 190

Index 220

About the Author 228

 8
PREFACE

My work for this book sprang from activism and research, as a medical doctor and
social scientist, in international health. During my years working as a primary care
practitioner with the clinic system of the United Farm Workers (UFW) Union in
the 1970s, I gradually became aware that one does not need to travel outside the
United States to fi nd the “Third World.” Instead, areas quite close to home manifest
problems and challenges that resemble those of countries usually labeled as economi-
cally less developed.
At about the same time, I learned that advances in Latin American social medicine,
originating in countries considered less developed than the United States, offered
illuminating insights into our own “more developed” country. My discovery contra-
dicted the underlying assumptions in my prior education that superior research and
intellectual work took place mainly in the United States and similar economically
advanced nations.
Specifically, I discovered Latin American social medicine shortly after the military
coup d’état that, on September 11, 1973, ended Chile’s three-year, democratically
elected, socialist government (called Unidad Popular, or Popular Unity), led by
President Salvador Allende, a physician and leader in social medicine. In the UFW,
organizers and members quickly began to talk about the dictatorship that followed
and especially the deaths and political repression that the dictatorship perpetrated.
Although I had hoped to spend part of the following year in Chile, contributing to
the advances in medicine and public health that were occurring under the Unidad
Popular government, the coup intervened. So instead of going to work in Chile, I
became active in the international solidarity movement that tried to assist Chilean
health workers and other citizens whom the military dictatorship had tortured,
imprisoned, or otherwise threatened. Later, the solidarity movement extended
to Argentina, Brazil, Uruguay, and several other countries in South and Central
America—all of which were ruled during that period by dictatorships supported by
the U.S. government and partly funded by the tax dollars of U.S. citizens.
As part of this solidarity effort, I collaborated with a colleague, Hilary Modell,
who had worked during the previous two years with the Unidad Popular government

VII
VIII P R EFACE

in a community-based health program. After the coup, Hilary had escaped in one of
the last Red Cross evacuation planes to leave Chile. Because North American health
professionals knew little about the efforts of the Unidad Popular or the repression
that followed the coup, we decided to write an article to spread knowledge about the
situation in Chile. A Chilean colleague also collaborated on the article but chose to
remain anonymous, due to the danger that he feared if his identity were to become
known to the dictatorship. Eventually we were able to publish an influential article
in the New England Journal of Medicine, which received worldwide attention.1 Al-
though the article mobilized further solidarity work in the United States, Canada,
and Western Europe, our writing also incensed members of the Chilean dictatorship,
which officially condemned Hilary and me. As a result, neither of us could travel to
Chile for many years.
While carrying out research for this article in the Stanford University library, I
made an astonishing discovery. In the library’s card catalog I found a reference to a
book written by Allende in 1939: La Realidad Medico-Social Chilena (The Chilean
Medico-Social Reality).2 I obtained a copy from the library of the Hoover Institute
at Stanford, whose collection the U.S. Central Intelligence Agency funded as a re-
source for counterinsurgency research. As the Hoover Institute acknowledged, the
intended purpose of this collection was to provide information useful for suppressing
revolutionary movements in Latin America, Africa, and Asia.
Reading Allende’s book was a transformative experience, in which I began to
appreciate the importance and relevance of Latin American social medicine. Al-
lende, who trained as a pathologist, wrote the book as minister of health for a newly
elected popular-front government. Supported by his team at the ministry, Allende
presented an analysis of the relationships among social structure, disease, and suf-
fering. La Realidad conceptualized illness as a disturbance of the individual fostered
by deprived social conditions. Breaking new ground in Latin America at the time,
Allende described the “living conditions of the working classes” that generated ill-
ness. Allende emphasized the social conditions of underdevelopment, international
dependency, and the effects of foreign debt and the work process. In La Realidad,
Allende focused on several specific health problems, including maternal and infant
mortality, tuberculosis, sexually transmitted and other communicable diseases, emo-
tional disturbances, and occupational illnesses. Describing issues that had not been
studied previously, he analyzed illegal abortion, the responsiveness of tuberculosis
to economic advances rather than treatment innovations, the role of housing density
in the causation of infectious diseases, and differences between generic and brand-
name pricing in the pharmaceutical industry.
Seeing the relevance of Allende’s book to many issues that we were facing in the
United States, I began a long-term effort to study Latin American social medicine.
Eventually this effort involved visits to several countries in Latin America where social
medicine groups were working actively. During 1994–1995, I spent nine months in
Latin America, fortunately sponsored by fellowships from the U.S. Fulbright Program
and the Fogarty International Center of the U.S. National Institutes of Health, to
 PREFACE IX

conduct a more in-depth study of the field. This project allowed lengthy visits with
social medicine groups in Chile, Argentina, Uruguay, Brazil, Mexico, Ecuador, and
Cuba. In addition to providing me with further reading, colleagues generously shared
their time with me for in-depth interviews.
Every two years, with rare exceptions, I also have attended the congresses of the
Latin American Association of Social Medicine (Asociación Latinoamericana de
Medicina Social, ALAMES). These meetings have helped me to keep up with cur-
rent developments in Latin American social medicine and to maintain long-lasting
friendships with Latin American colleagues. ALAMES congresses have facilitated
my ongoing efforts to understand the changes in health services and public health
policies spearheaded by colleagues who recently, with the advent of progressive
governments in various countries (especially Brazil, Ecuador, Argentina, Uruguay,
Chile, Venezuela, and Bolivia), have risen to prominent positions in those countries’
ministries of health.

* * *
Guided by collaborations with Latin American colleagues, I began to study more
deeply the overt and subtle relationships between health and empire. The examples
of committed scholarship that Allende and more recent leaders of Latin American
social medicine provided inspired a series of investigations into how health services
and public health have intertwined with empire building, historically and in the
present. These studies led to a perspective that public health and health services
contributed not only to historical imperialism but also to the “neo-imperialist”
patterns seen during more recent years. As military conquest and colonialism trans-
formed into the somewhat more subtle forms of economic exploitation and political
coercion (the latter always reinforced by the threat of military intervention), public
health and health services have contributed to the maintenance of empire in new
and sometimes surprising ways.
Yet, alongside worldwide economic crisis, resistance to empire has consolidated
worldwide. Especially in Latin America, regimes that previously complied with the
dictates and corporate interests of the United States and Western Europe have grown
weak and have largely disappeared. Replacing these colonies and neo-colonies, new
governments emerging through electoral, democratic procedures have resisted the
historical patterns of empire. These new regimes increasingly have refused to accept
the historical patterns of empire that fostered exploitation and poverty around the
world. National and local leaders have entered into novel coalitions that have trans-
formed previous patterns of political and economic dominance. Coinciding with a
critical weakening of the international capitalist system during recurrent fi nancial
crises, the emergence of these new governments and coalitions during the early years
of the twenty-fi rst century has changed the fundamental nature of empire.
U.S. capitalism has become something different, with the socialization of wide
sectors of the economy under government ownership, more and more resembling
the “mixed” economic systems of Europe. Capitalism has not exactly ended, but it
X P R EFACE

has become a system riddled with contradictions that no longer can sustain previous
patterns of international domination. Now that U.S. capitalism as we have known it
has ended, and empire in its previous form has ended as well, we need to understand
more fully the relationships between empire and health and how these relationships
are transforming.

* * *
The book’s three parts focus on the past (referring to the period until approximately
1980), the present (including the more recent past, from 1980 to 2010), and the
future. In explaining the historical patterns that have linked empire and health,
Part 1 presents an overall conceptual approach that guides the analyses that follow.
This framework places medicine and public health in the broader social context of
capitalism and imperialism and argues that the transformations that have occurred
in medicine and public health during the past two centuries gain clarity when this
political-economic context receives close attention. In Chapter 1 I consider the key
role that philanthropic organizations promoting public health have played in empire,
the economic considerations that motivated the formation of our principal inter-
national health organizations, and how international trade agreements have linked
public health to the strengthening of empire. The illness-generating conditions of
historical capitalism and imperialism form the focus of Chapter 2, which clarifies the
emergence of social epidemiology with its emphasis on the social determinants of
illness and suffering. Chapter 3 details the international market for health products
and services and the role this market has played in strengthening the worldwide
operations of multinational corporations. In Chapter 4 I analyze some of the early
resistance to imperialist domination that occurred in Chile and Cuba and how that
resistance implied a transformation of public health and health services.
Part 2 addresses the relationships between empire and health during the current
period of history, operationally defi ned as beginning in about 1980 and continuing
until approximately 2010. Initially, this part of the book focuses on the broad poli-
cies during recent history that have strengthened empire and have weakened public
health and health services. Chapter 5 explains the impact of neoliberal political-
economic policies on public-sector health and mental health services, the process of
privatizing these services, the emergence of a transnational capitalist class linked to
the penetration of international markets for health products and insurance by multi-
national corporations, the impact of economic globalization on the nation state, and
the resulting loss of nations’ sovereignty in managing public health. In Chapter 6 I
extend this analysis to the specific impacts of international trade agreements in public
health and medicine, including the effects of trade rules and their enforcement, as
well as the responses by health professionals and advocates. Chapter 7 untangles the
relationships between macroeconomic policies and health, especially policies based on
the assumption that enhancing health will lead to enhanced economic development
through private investment.
 PREFACE XI

The following chapters in Part 2 focus on the roles of multinational corporations

and international fi nancial institutions, as well as the ideologies and constructions
of reality that provide a rationale for the actions of key stakeholders. Chapter 8 ex-
amines multinational managed care organizations and their attempts to export their
for-profit operations from the United States to other countries, including countries
whose national health programs aim to ensure universal access to care. International
fi nancial institutions and their efforts to foster “reforms” that encourage reduction
of public-sector services and privatization of programs receive attention in Chapter
9; Mexico and Brazil serve as case examples. In Chapter 10, I examine the ideologi-
cal underpinnings that justify such reforms, under the rubric of a new “common
sense” that socially constructs a rationale for erosion of public services and expan-
sion of the private sector. Chapter 11 explores in more detail the differing social
constructions of key stakeholders in current struggles linking global trade, public
health, and health services: government agencies, international fi nancial institutions,
international health organizations, multinational corporations, and advocacy groups.
Militarism and ideologies supporting military intervention, which reinforce empire
through actual or threatened intervention in countries that do not readily accede
to the goals of the politically powerful and economically dominant, compose the
theme of Chapter 12; the impact of war on the health and mental health of military
personnel, as well as the emergence of civilian services for military personnel that
aim to foster peace and a reduction in militarism, emerges as a key focus.
In Part 3, I examine the apparent end of empire as we have known it and the
changes in medicine and public health that are occurring as empire slowly dies.
Chapter 13 describes the flowering of social medicine in Latin America and argues
that the accomplishments and insights of this field provide an inspirational model
for future intellectual work and praxis in medicine and public health. In Chapter 14,
which concludes the book, I present examples of key struggles toward more humane
medical and public health systems that illustrate the conditions of the predictable
future; based on path-breaking efforts in El Salvador, Bolivia, Mexico City, and Ven-
ezuela, I describe the contours of sociomedical activism in the post-empire era.

* * *
On the material front, colleagues and I have benefited from grants that have partially
supported this work, from the National Library of Medicine (1G08 LM06688), the
New Century Scholars Program of the U.S. Fulbright Commission, the John Simon
Guggenheim Memorial Foundation, the Roothbert Fund, the U.S. Agency for
Healthcare Research and Quality (1R03 HS13251), the National Institute of Mental
Health (1R03 MH067012 and 1 R25 MH60288), the United Nations Research
Institute for Social Development, RESIST, the Research Allocations Committee at
the University of New Mexico, and the Robert Wood Johnson Foundation Center
for Health Policy at the University of New Mexico. The views expressed in this book
of course do not necessarily represent those of the funding agencies.
XII P R EFACE

I feel indebted to many people for providing collegial input and moral support at
several key junctures. This note provides inadequate acknowledgment, and I take full
responsibility for any errors and problems in the manuscript. Rebeca Jasso-Aguilar
made critical contributions to this work through collaboration over many years; she
is a co-author of chapters 5 and 14 and provided assistance for several other chapters
as well. Sofía Borges, my highly esteemed daughter, offered expert editorial advice
and contributed with sensitivity to the book’s design at a reasonable price. Jean Ellis-
Sankari, Hilary Modell, Felipe Cabello, Lori Wallach, Carolyn Mountain, and Ron
Voorhees provided helpful suggestions at several key points. I am very grateful to
colleagues, comrades, and friends in Latin America—Jaime Breih, Arturo Campaña,
Kenneth Camargo Jr., Alfredo Estrada, Celia Iriart, Silvia Lamadrid, Cristina Lau-
rell, Francisco Mercado, Emerson Merhy, Jaime Sepúlveda, Mario Testa, Carolina
Tetelbaum, Adriana Vega, and particularly Edmundo Granda, to whose memory I
have dedicated the book. They and many other colleagues working in Latin American
social medicine offered inspiring examples of committed intellectual work, praxis,
and personal strength under sometimes quite severe adversity and danger. I acknowl-
edge some other key contributions of colleagues and friends within the notes of the
chapters that follow. Dean Birkenkamp provided very helpful guidance in his roles
of editor and publisher, as he has done also in prior projects.
 PART O NE

E MPIRE PAST
 8
C HAPTER 1

EMPIRE’S HISTORICAL HEALTH COMPONENT

Although it is a complex, multifaceted phenomenon, I defi ne “empire” in simple

terms as expansion of economic activities—especially investment, sales, extrac-
tion of raw materials, and use of labor to produce commodities and services—
beyond national boundaries, as well as the social, political, and economic effects
of this expansion. Empire achieved many advantages for economically dominant
countries. During the 1500s, a “world system” emerged in which a core group
of nations came to control a worldwide network of economic exchange relation-
ships.1 For centuries, empire included military conquest and the maintenance of
colonies under direct political control. The decline of colonialism in the twentieth
century led to the emergence of political and economic “neocolonialism,” by
which poorer countries provided similar advantages to richer countries as they
had under the earlier, more formal versions of colonialism.
Public health and health services played important roles in several phases of
empire past. The connections among empire, public health, and health services
operated through specific institutions, including philanthropic foundations,
international fi nancial institutions, organizations enforcing trade agreements,
and international health organizations. Now I turn to each of these institutions
and focus mainly on their early histories. Later in the book, I consider their
more recent operations.

Philanthropic Foundations

Although notions about beneficent contributions by wealthy people to the

needy date back in Western civilization to the Greek practice of “philanthropy,”
modern practices that included the formation of foundations with their own

2
 EMPIRE’S HISTORICAL HEALTH COMPONENT 3

legal status began in the early twentieth century, largely through the efforts of
Andrew Carnegie. After he amassed a fortune in the steel industry and initiated
philanthropic ventures such as the Carnegie Libraries in towns throughout the
United States, Carnegie offered his opinions about the social responsibilities of
wealth in writings such as The Gospel of Wealth, published in 1901.2
Carnegie’s book developed the principle that contributing to the needs of
society was consistent with good business practices, partly to achieve favorable
popular opinion about capitalist enterprises and individual entrepreneurs. By
contributing intelligently to address social needs rather than squandering one’s
wealth, Carnegie argued, the businessperson also could ensure personal entry into
the heavenly realm (thus, the framework of “gospel”). Among the book’s other
notable features, Carnegie distinguished between “imperialism” and the more
virtuous “Americanism”: “Imperialism implies naval and military force behind.
Moral force, education, civilization are not the backbone of Imperialism. These
are the moral forces which make for the higher civilization, for Americanism.”3
By creating interconnected philanthropic foundations, Carnegie acted to ensure
that his beliefs achieved the fruits he preferred in the disposal of his earthly
wealth and in his own heavenly future.
The most cogent early extension of philanthropic foundations to public health
and health services involved John D. Rockefeller and the Rockefeller Foundation.
With his fortune based in oil, Rockefeller emulated Carnegie’s philanthropic
activities, despite their confl icts in the realm of monopolistic business practices.
However, Rockefeller and his associates moved more specifically to support public
health activities and health services that would benefit the economic interests of
Rockefeller-controlled corporations throughout the world.
In particular, the Rockefeller Foundation initiated international campaigns
against infectious diseases such as hookworm, malaria, and yellow fever. Be-
tween 1913, the year of its founding, and 1920, the foundation supported the
development of research institutes and disease eradication programs on every
continent except Antarctica. Infectious diseases proved inconvenient for ex-
panding capitalist enterprises due to several reasons, which became clear from
the writings of Rockefeller and the managers of the Rockefeller Foundation.4
First, these infections reduced the productivity of labor by diminishing the ef-
fort that workers could devote to the job (thus the designation of hookworm,
for instance, as the “lazy disease”). Second, endemic infections in areas of the
world designated for such efforts as mining, oil extraction, agriculture, and
the opening of new markets for the sale of commodities made those areas
unattractive for investors and for managerial personnel. Third, to the extent
that corporations assumed responsibility for the care of workers, especially
when workers were in short supply within remote geographical areas, the costs
4 C HAPTER 1

of care escalated when infectious diseases could not be prevented or easily

treated.
To address these three problems—labor productivity, safety for investors and
managers, and the costs of care—the Rockefeller Foundation’s massive cam-
paigns throughout the world fostered research and efficient delivery of services.
These programs took on certain characteristics that persist to this day in some
of Rockefeller’s activities as well as in those of other foundations, international
health organizations, and nongovernmental organizations. Rather than organiz-
ing “horizontal” programs to provide a full spectrum of preventive and curative
health services, the foundation emphasized “vertical” programs initiated by the
donor that focused on a small number of specific diseases, such as hookworm
or malaria. In addition, rather than broad public health initiatives to improve
economic and health conditions of disadvantaged populations, the foundation
favored the development of vaccines and medications that could prevent and
treat the infectious diseases designated as most problematic—an approach some
referred to as the “magic bullet.” Later in the book, I show how these orienta-
tions have persisted in even the most recent, large-scale efforts by foundations
to address public health problems in less developed countries.5

International Financial Institutions and Trade Agreements

Although trade across nations and continents dates back centuries, the framework
for modern international fi nancial institutions and trade agreements began after
World War II with the Bretton Woods accords. These accords, which gradually
emerged as an important mechanism to protect the political-economic empires
of the United States and Western European countries, grew from meetings in
Bretton Woods, New Hampshire, that involved representatives of countries
victorious in World War II. The agreements initially focused on the economic
reconstruction of Europe. Between 1944 and 1947, the Bretton Woods nego-
tiations led to the creation of the International Monetary Fund (IMF) and the
World Bank, as well as the establishment of the General Agreement on Tariffs
and Trade (GATT).6
By the 1960s, after the recovery of Europe, these institutions and agreements
gradually expanded their focus to the less developed countries. The World Bank,
for instance, adopted as its vision statement “our dream—a world without pov-
erty.”7 However, because the IMF and World Bank provided most of their assis-
tance through loans rather than grants, the debt burden of the poorer countries
increased rapidly. By 1980, many less developed countries, including the poorest
in the world, were spending on average about half their economic productivity, as
 EMPIRE’S HISTORICAL HEALTH COMPONENT 5

measured by gross domestic product, on payment of their debts to international

fi nancial institutions, even though these institutions’ goals usually emphasized
the reduction of poverty. These international fi nancial institutions during the
early 1980s embraced a set of economic policies known as “the Washington
consensus.” Advocated primarily by the United States and the United Kingdom,
these policies involved deregulation and privatization of public services, which
added to the debt crisis by constraining even further the public health efforts
and health services that less developed countries could provide.8
GATT initially aimed to reduce tariffs and quotas for trade among its twenty-
three member nations. Its fairly simple principles included “most favored nation
treatment” (according to which the same trade rules were applied to all participat-
ing nations) and “national treatment” (which required no discrimination in taxes
and regulations between domestic and foreign goods).9 GATT also established
ongoing rounds of negotiations concerning trade agreements.
From their modest origins in GATT, international trade agreements eventu-
ally morphed into a massive structure of trade rules that would exert profound
effects on public health and health services worldwide.10 Although I consider
recent trade agreements further in Chapter 6, the contours of the transition
from GATT to what followed proved quite dramatic. As the pace of interna-
tional economic transactions intensified, facilitated by technological advances
in communications and transportation, the World Trade Organization (WTO)
in 1994 replaced the loose collection of agreements subsumed under GATT.
The WTO and regional trade agreements have sought to remove both tariff and
nontariff barriers to trade.
Growing from the narrow scope of GATT, whose focus involved tariff barriers
alone, the burgeoning array of international trade agreements encompassed under
WTO expanded the purview of trade rules far beyond tariff barriers. Instead,
the new trade agreements interpreted a variety of public health measures, such
as environmental protection, occupational safety and health regulations, qual-
ity assurance for foods and drugs, intellectual property pertaining to patented
medications and equipment, and even health services themselves as potential
nontariff barriers to trade. As I argue later, this perspective in trade agreements
transformed the sovereignty of governments to regulate public health and to
provide health services.

International Health Organizations

The fi rst approach to international public health organization evolved in Europe

during the Middle Ages. At that time, some governments established local,
6 C HAPTER 1

national, and international cordons sanitaires—guarded boundaries that blocked

people from leaving or entering geographical areas affected by epidemics of in-
fectious diseases. In addition, governments imposed maritime quarantines that
prevented ships from entering ports after visiting regions where epidemics were
occurring. “Sanitary” authorities arose mostly on an ad hoc basis and remained
active mainly when epidemics were present or anticipated.11
During the late nineteenth and early twentieth centuries, the rise of export
economies and the expansion of economic interests worldwide triggered the
demise of conventional maritime public health. Instead, the motivation for
international cooperation in public health emerged largely from concerns about
infectious diseases as detrimental to trade among nations that were participating
in the expanding reach of capitalist enterprise. The need to protect ports, invest-
ments, and landholdings such as plantations from infectious diseases provided
incentives for redesigning international public health.
The fi rst formal international health organization arose in the Americas.
Founded in Washington, D.C., during 1902, explicitly as a mechanism to protect
trade and investments from the burden of disease, the International Sanitary
Bureau focused on the prevention and control of epidemics.12 Mosquito eradica-
tion campaigns and the implementation of a vaccine against yellow fever occupied
public health professionals in this organization throughout the early twentieth
century. During that period, plans proceeded for the construction of the Panama
Canal, the development of agricultural enterprises in the “banana republics” of
Central America and northern South America, and the extraction of mineral
resources as raw materials for industrial production from such areas as southern
Mexico, Venezuela, Colombia, and Brazil. Work in the tropics demanded public
health initiatives against mosquito-borne diseases like yellow fever and malaria,
parasitic illnesses like hookworm, and the more common viral and bacterial ill-
nesses like endemic diarrhea.
As the fi rst modern international health organization, the International
Sanitary Bureau devoted much of its early activities to infectious disease surveil-
lance, prevention, and treatment, largely to protect trade and economic activities
throughout the Americas. Later, during the 1950s, the International Sanitary
Bureau became the Regional Office for the Americas of the World Health Or-
ganization (WHO) and in 1958 changed its name to the Pan American Health
Organization (PAHO). Subsequently, PAHO’s public health mission broad-
ened.13 However, PAHO retained a focus on the protection of trade through
the present day, and in general it supported the provisions of international trade
agreements.
WHO emerged in 1948 as one of the component suborganizations of the
United Nations (UN). Although prevention and control of infectious disease
 EMPIRE’S HISTORICAL HEALTH COMPONENT 7

epidemics remained a key objective throughout its history, WHO did not frame
its purpose in controlling infectious diseases as a way to protect trade and inter-
national economic transactions—as PAHO had done during its early history.
Instead, during the 1970s, WHO prioritized the improved distribution of health
services, especially primary health care. This orientation culminated in the famous
WHO declaration on primary health care, issued at an international conference at
Alma-Ata, USSR, in 1978, which provided guidelines for subsequent actions by
WHO and its affi liated organizations.14 As the principle of universal entitlement
to primary care services throughout the world became one of WHO’s priorities,
the organization took a strong position of advocacy on behalf of programs to
improve access to care, especially in the poorest countries.
During the late 1970s and early 1980s, however, WHO entered a chronic
fi nancial crisis produced largely because of the fragile fi nancing provided for
WHO’s parent organization, the UN. Because of ideological opposition to
several programs operated by component organizations of the UN, especially
those of the United Nations Educational, Scientific, and Cultural Organiza-
tion (UNESCO), the Reagan administration withheld from the UN large
portions of the United States’ annual dues. As a result, the UN began to
experience increasing budgetary shortfalls, which it passed on to its compo-
nent organizations, including WHO. Into this fi nancial vacuum moved the
World Bank, which began to contribute a large part of WHO’s budget. (The
precise proportion of WHO’s budget dependent on the World Bank’s fi nanc-
ing remained shielded from public scrutiny.) As its fi nancial base shifted more
toward the World Bank and away from the UN, WHO’s policies also trans-
formed to an orientation that more closely resembled those of international
fi nancial institutions and trade agreements. The fi nancial crisis that originated
in the nonpayment of dues by the United States eventually led within WHO
to a policy perspective regarding international trade that proved similar to
PAHO’s earlier orientation.
In these ways, the history of international health organizations manifested
an ongoing collaboration with institutions that sought to protect commerce
and trade. Constituted in the interest of trade, the organizational predeces-
sor of PAHO devoted half a century of public health initiatives largely to the
prevention and control of infections that threatened the viability of trade and
investment. PAHO and eventually WHO sought improved health conditions in
poor countries partly as a means to strengthen the economic positions of rich
countries by facilitating activities that extracted raw materials and that opened
new markets. The efforts of international health organizations on behalf of em-
pire came to compose a major focus of the public health enterprise that these
organizations fostered.
8 C HAPTER 1

A Countervailing Viewpoint

I return to the above themes in Part 2, where I delve into the recent connections
among empire, public health, and health services in more detail. How these more
recent connections evolved, however, reflected in part the patterns established
as empire emerged during the late nineteenth and early twentieth centuries
and then flourished during the post–World War II era. The historical strands
of empire already considered—extraction of raw materials and human capital,
exploitation of a cheap labor force in less developed countries, the prominence
of an international capitalist class, military conquest or the threat of conquest,
the contributions of foundations to capitalist expansion abroad, the key positions
of international fi nancial organizations and trade agreements, and the major
roles of international health organizations—become recurrent themes later in
the book, as I account for the more recent ways that empire, public health, and
health services have become closely linked.
Alongside the concepts and ideologies that provided rationales for the growth
and maintenance of empire, a countervailing viewpoint emerged historically. The
latter approach proved more critical of empire and uncovered troubling connec-
tions among capitalist enterprises, imperial expansion, ill health, and early death.
This countervailing approach, which culminated in the current concern about
the social determinants of illness, becomes the focus of the next chapter.
 8
C HAPTER 2

ILLNESS-G ENERATING CONDITIONS

OF C APITALISM AND E MPIRE

Conditions of society that generate illness and mortality have become largely
forgotten and rediscovered with each succeeding generation. Now, when disease-
producing features of the environment and workplace threaten the survival of
humanity and other life forms, it is not surprising that such problems would
receive attention. But there is a long history of research and analysis about the
relationships among political economic systems, the social determinants of health,
and the health of populations that has been neglected, despite its relevance to
our current situation.

How This Viewpoint Emerged

Three people—Friedrich Engels, Rudolf Virchow, and Salvador Allende—made

major contributions to understanding the social origins of illness under capitalism
and empire. Although other writers also have examined this topic,1 the works
of Engels, Virchow, and Allende are important in several respects. All three
writers emphasized the importance of political economic systems as causes of
illness-generating social conditions. Engels and Virchow provided analyses of
the impact of political economic conditions2 on health that essentially created
the perspective of social medicine. Both men were active during the tumultuous
years of the 1840s and both took decisive—though divergent—personal actions
to correct the conditions they described through political economic change.
Allende’s key work appeared during a later historical period, the 1930s, and a
different geopolitical context. While Engels and Virchow documented the impact
of early capitalism, largely before the expansion of empire, Allende focused on

9
10 C HAPTER 2

empire and underdevelopment. Although little known in North America and

Western Europe, Allende’s studies in social medicine have influenced efforts
to achieve political economic changes that improve health conditions in Latin
America and elsewhere in the less developed world.
While Engels, Virchow, and Allende conveyed certain unifying themes that
contribute to our understanding of the connections among health, capitalism,
and empire, they also diverged in major ways, especially regarding the political
economic structures of oppression that cause disease, the social contradictions
that inhibit change, and directions of reform in political economic systems that
would foster health rather than illness. A look backward to these prior works
gives a historical perspective to issues that today gain even more urgency. Their
works have influenced a new generation of researchers and activists, who also
focus in large part on political economic systems as social determinants of health
and illness.

Friedrich Engels

Engels wrote his fi rst major book, The Condition of the Working Class, in England,
under circumstances whose ironies now are well known.3 Between 1842 and
1844, Engels was working in Manchester as a middle-level manager in a textile
mill of which his father was co-owner. Engels carried out his managerial duties
in a perfunctory manner while immersing himself in English working-class life.
The richness of Engels’s treatment of working-class existence has attracted much
critical attention, both sympathetic and belligerent.4 His analysis of the politi-
cal economic origins of illness, though central to his account of working-class
conditions, has received relatively little notice.
In this book Engels’s theoretical position was unambiguous. For working-class
people the roots of illness and early death lay in the organization of economic
production and in the social environment.5 British capitalism, Engels argued,
forced working-class people to live and work under circumstances that inevitably
caused sickness; this situation was not hidden but was well known to the capital-
ist class. The contradiction between profit and safety worsened health problems
and stood in the way of necessary improvements.
Engels’s theoretical perspective, however, focused on the profound impacts
of political economic system and class structure, as well as the difficulties of
change while the effects of social class under early industrial capitalism persisted.
Considering the effects of environmental toxins, he claimed that the poorly
planned housing in working-class districts did not permit adequate ventilation
of toxic substances. Workers’ apartments surrounded central courtyards with-
out direct spatial communication to the street. Carbon-containing gases from
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 11

combustion and human respiration gathered and lingered within living quar-
ters. Because disposal systems did not exist for human and animal wastes, these
materials left in courtyards, apartments, or the street resulted in severe air and
water pollution. Such poor housing conditions led to an increase of infectious
diseases, particularly tuberculosis. Engels noted that overcrowding and insuf-
ficient ventilation contributed to high mortality from tuberculosis in London
and other industrial cities. Typhus, carried by lice, also spread due to inadequate
sanitation and ventilation.
Turning to nutrition, Engels drew connections among social conditions,
nutrition, and disease, emphasizing the expense and chronic shortages of food
supplies for urban workers and their families. Lack of proper storage facilities
at markets led to contamination and spoilage. Problems of malnutrition were
especially acute for children. Engels discussed scrofula as a disease related to poor
nutrition; this view antedated the discovery of bovine tuberculosis as the major
cause of scrofula and pasteurization of milk as a preventive measure. He also
described the skeletal deformities of rickets as a nutritional problem, long before
the medical fi nding that dietary deficiency of vitamin D caused rickets.
Engels’s analysis of alcoholism focused on the social forces that fostered exces-
sive drinking. In Engels’s view, alcoholism served as a response to the miseries
of working-class life. Lacking alternative sources of emotional gratification,
workers turned to alcohol. Individual workers could not be held responsible
for alcohol abuse. Instead, alcoholism ultimately was the responsibility of the
capitalist class:

Liquor is their [workers’] only source of pleasure. . . . The working man . . . must
have something to make work worth his trouble, to make the prospect of the next
day endurable. . . . Drunkenness has here ceased to be a vice, for which the vicious
can be held responsible. . . . They who have degraded the working man to a mere
object have the responsibility to bear.6

For Engels, because alcoholism was so fi rmly rooted in social structure, to

attribute responsibility to the individual worker was misguided. If the experi-
ence of deprived social conditions caused alcoholism, the solution involved
basic political economic change rather than treatment programs focusing on
the individual.
Engels also analyzed structures of oppression within the social organization
of medicine. He emphasized the maldistribution of medical personnel. Accord-
ing to Engels, working-class people coped with the “impossibility of employing
skilled physicians in cases of illness.”7 Infi rmaries that offered charitable services
met only a small portion of people’s needs for professional attention. Engels
12 C HAPTER 2

criticized the patent remedies containing opiates that apothecaries provided for
childhood illnesses. High rates of infant mortality in working-class districts,
Engels argued, were explainable partly by lack of medical care and partly by the
promotion of inappropriate medications.
Engels next undertook an epidemiological investigation of mortality rates
and social class, using demographic statistics compiled by public health of-
ficials. He showed that mortality rates were inversely related to social class, not
only for entire cities but also within specific geographic districts of cities. He
noted that in Manchester childhood mortality was substantially greater among
working-class children than among children of the higher classes. In addition,
Engels commented on the cumulative effects of class and urbanism on childhood
mortality. He cited data that demonstrated higher death rates from epidemics
of infectious diseases like smallpox, measles, scarlet fever, and whooping cough
among working-class children. For Engels, crowding, poor housing, inadequate
sanitation, and pollution—all standard features of urban life—combined with
social class position in causing disease and early mortality.
In describing particular types of industrial work, Engels provided early ac-
counts of occupational diseases that did not receive intensive study until well
into the twentieth century. Many orthopedic disorders, in Engels’s view, derived
from the physical demands of industrialism. He discussed curvature of the spine,
deformities of the lower extremities, flat feet, varicose veins, and leg ulcers as
manifestations of work demands that required long periods of time in an upright
posture. Engels commented on the health effects of posture, standing, and re-
petitive movements, noting that:

All these affections are easily explained by the nature of factory work. . . . The
operatives . . . must stand the whole time. And one who sits down, say upon a
window-ledge or a basket, is fi ned, and this perpetual upright position, this con-
stant mechanical pressure of the upper portions of the body upon spinal column,
hips, and legs, inevitably produces the results mentioned. This standing is not
required by the work itself.8

The insight that chronic musculoskeletal disorders could result from unchang-
ing posture or small, repetitive motions seems simple enough. Yet, this source
of illness, which is quite different from a specific accident or exposure to a toxic
substance, entered occupational medicine as a serious topic of concern only
toward the end of the twentieth century.
Engels’s discussions of occupational lung disease were detailed and far-
reaching. His presentation of textile workers’ pulmonary pathology antedated
by many years the medical characterization of byssinosis, or brown lung:
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 13

In many rooms of the cotton and flax-spinning mills, the air is fi lled with fibrous
dust, which produces chest affections, especially among workers in the carding
and combing-rooms. . . . The most common effects of this breathing of dust are
bloodspitting, hard, noisy breathing, pains in the chest, coughs, sleeplessness, in
short, all the symptoms of asthma.9

Engels also offered a parallel description of “grinders’ asthma,” a respiratory

disease caused by inhaling metal dust particles in the manufacture of knife
blades and forks. The pathologic effects of cotton and metal dusts on the lung
were similar; Engels noted the similarities of symptoms experienced by those
two diverse groups of workers.
Engels analyzed the ravages of pulmonary disorder among coal miners. He
reported that unventilated coal dust caused both acute and chronic pulmonary
inflammation that frequently progressed to death. Engels observed that “black
spittle”—the syndrome now called coal miners’ pneumoconiosis, or black lung—
was associated with other gastrointestinal, cardiac, and reproductive complica-
tions. By pointing out that this lung disease was preventable, Engels illustrated
the contradiction between profit and safety as a political economic determinant
of disease in capitalist industry:

Every case of this disease ends fatally. . . . In all the coal-mines which are properly
ventilated this disease is unknown, while it frequently happens that miners who go
from well to ill-ventilated mines are seized by it. The profit-greed of mine owners
which prevents the use of ventilators is therefore responsible for the fact that this
working-men’s disease exists at all.10

After more than a century and a half, the same structural contradiction impedes
the prevention of black lung.
Engels interspersed his remarks about disease with many other perceptions of
class oppression. His argument implied that the solution to these health prob-
lems required basic political economic change; limited medical interventions
would never yield the improvements that were most needed. Although Engels’s
early work on medical issues has eluded many later researchers and activists, his
analysis exerted a major influence, both intellectual and political, on one of the
founders of social medicine, Rudolf Virchow.

Rudolf Virchow

A nineteenth-century physician who made important contributions in social

medicine, anthropology, cellular pathology, and parliamentary activity, Virchow
14 C HAPTER 2

developed a unified explanation of the physical and social forces that caused dis-
ease and human suffering. He used a dialectic approach to both biological and
social problems, perceiving natural and social processes as a series of antitheses.
In 1847, he anticipated the revolutions of 1848 by claiming that the apparent
social tranquility would be “negated” through social confl ict in order to reach
a “higher synthesis.”11 Virchow used a similar dialectic analysis in tracing the
process of scientific knowledge.12
Virchow manifested these orientations—of applied science, dialectics, and
materialism—in his analyses of specific illnesses. He emphasized the concrete
historical and material circumstances in which disease appeared, the contradictory
political economic forces that impeded prevention, and researchers’ role in advo-
cating reform. In the analysis of multifactorial etiology, Virchow claimed that the
most important causative factors were the material conditions of people’s everyday
lives. This view implied that an effective health-care system could not limit itself
to treating the pathophysiological disturbances of individual patients.
Based on study of a typhus epidemic in Upper Silesia, a cholera epidemic
in Berlin, and an outbreak of tuberculosis in Berlin during 1848 and 1849,
Virchow developed a theory of epidemics that emphasized the political eco-
nomic structures that fostered the spread of illness. He argued that defects of
society were a necessary condition for the emergence of epidemics. Virchow
classified certain disease entities as “crowd diseases” or “artificial diseases”;
these included typhus, scurvy, tuberculosis, leprosy, cholera, relapsing fever,
and some mental disorders. According to this analysis, inadequate social con-
ditions increased the population’s susceptibility to climate, infectious agents,
and other specific causal factors—none of which alone was sufficient to pro-
duce an epidemic. For the prevention and eradication of epidemics, political
economic change was as important as medical intervention, if not more so:
“The improvement of medicine would eventually prolong human life, but
improvement of social conditions could achieve this result even more rapidly
and successfully.”13
The social contradictions that Virchow most strongly emphasized were those
of class structure. He described the deprivations that the working class endured
and linked disease patterns to these deprivations. Virchow also noted that morbid-
ity and mortality rates, especially for infants, were much higher in working-class
districts of cities than in wealthier areas. As documentation, he used the statistics
that Engels cited, as well as data that he himself gathered from German cities.
Describing inadequate housing, nutrition, and clothing, Virchow criticized the
apathy of government officials for ignoring these root causes of illness. Virchow
expressed his outrage about class conditions most forcefully in his discussion of
epidemics like the cholera outbreak in Berlin:
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 15

Is it not clear that our struggle is a social one, that our job is not to write instruc-
tions to upset the consumers of melons and salmon, of cakes and ice cream, in
short, the comfortable bourgeoisie, but is to create institutions to protect the poor,
who have no soft bread, no good meat, no warm clothing, and no bed, and who
through their work cannot subsist on rice soup and camomile tea . . . ? May the
rich remember during the winter, when they sit in front of their hot stoves and
give Christmas apples to their little ones, that the shiphands who brought the coal
and the apples died from cholera. It is so sad that thousands always must die in
misery, so that a few hundred may live well.14

For Virchow, the deprivations of working-class life created a susceptibility to

disease. When infectious organisms, climatic changes, famine, or other causal
factors were present, disease spread rapidly through the community.
Because he clarified the social origins of illness, Virchow advocated a broad
scope for public health and the medical scientist. He attacked structures of oppres-
sion within medicine, particularly the policies of hospitals that required payment
by the poor rather than assuming their care as a matter of social responsibility.
Virchow envisioned the creation of a “public health service,” an integrated system
of publicly owned and operated health-care facilities, staffed by health workers
employed by the state. Such a system would defi ne health care as a constitutional
right of citizenship. Included within this right were the political and economic
conditions that contributed to health rather than to illness.15
Two other principles were central to Virchow’s conception of public health:
prevention and the state’s responsibility to ensure material security for citizens.
Virchow’s focus on prevention derived primarily from his observation of epi-
demics, which he believed could be prevented by straightforward changes in
social policies. He found a major cause in several poor potato harvests preced-
ing the epidemics; government officials could have prevented malnutrition by
distributing foodstuffs from other parts of the country. Virchow argued that
prevention was largely a political economic problem: “Our politics were those
of prophylaxis; our opponents preferred those of palliation.”16 Health workers
could never accomplish disease prevention solely through activities within the
medical sphere; material security also was essential. The state’s responsibilities,
Virchow argued, included providing work for “able-bodied” citizens. Only by
conditions of economic production that guaranteed employment could workers
obtain the economic security necessary for good health. Likewise, the physically
disabled should enjoy the right of fi nancial support by the state.17
Virchow’s visions of the social origins of illness pointed out the wide scope
of the medical task: the study of social conditions as part of clinical research
and health workers’ engagement in political action. Virchow frequently drew
16 C HAPTER 2

connections among medicine, social science, and politics: “Medicine is a social

science, and politics is nothing more than medicine in larger scale.”18 Virchow’s
analysis of these issues faded from public discourse largely due to conservative
political forces that shaped the course of scientific medicine during the late
nineteenth and early twentieth centuries. His contributions set a standard for
current attempts to understand and to challenge the political economic condi-
tions that generate illness and suffering.

Salvador Allende

Although Allende’s political endeavors remain better known than his medical
career, his writings and efforts to reform medicine and public health served as one
of several important influences on social medicine, especially in Latin America.
Acknowledging intellectual debts to Engels, Virchow, and others who analyzed
the social roots of illness in nineteenth-century Europe, Allende implemented
a political economic model of medical problems in the context of empire and
economic underdevelopment. This model emphasized societal characteristics
that policy reform could modify.
Allende recognized that the health problems of Chilean people derived largely
from the country’s political and economic conditions. Writing in 1939 as minister
of health for a popular-front government, Allende presented his analysis of the
relationships among political economy, disease, and suffering in his book, La
Realidad Médico-Social Chilena.19 The book conceptualized illness as a distur-
bance of the individual that often was caused by deprived social conditions. The
approach implied that social change was the only potentially therapeutic approach
to many health problems. After an introduction on the connections between the
political economic system and illness, Allende presented some geographic and
demographic “antecedents” to contextualize specific health problems. Sharing
a similar focus with Engels and Virchow, he focused on the “living conditions
of the working classes.”
In his account of working-class life, Allende emphasized capitalist imperi-
alism, particularly the multinational corporations that extracted profit from
Chilean natural resources and inexpensive labor. He claimed that to improve
the health-care system, a popular-front government must change the nature of
empire:

For the capitalist enterprise it is of no concern that there is a population of workers

who live in deplorable conditions, who risk being consumed by diseases or who
vegetate in obscurity. . . . [Without] economic advancement . . . it is impossible to
accomplish anything serious from the viewpoints of hygiene or medicine . . . because
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 17

it is impossible to give health and knowledge to a people who are malnourished,

who wear rags, and who work at a level of unmerciful exploitation.20

His analytic tone and statistical tabulation thinly veiled Allende’s outrage at the
contradictions of class structure and underdevelopment that empire fostered.
Allende focused fi rst on wages, which he viewed as a primary determinant of
workers’ health. Many of his political economic observations anticipated later con-
cerns, including wage differentials for men and women, the impact of inflation, and
the inadequacy of laws purporting to ensure subsistence-level income. He linked
his exposition of wages directly to the problem of nutrition and presented compara-
tive data on food availability, earning power, and economic development. Not only
was the production of milk and other needed foodstuffs less efficient than in more
developed countries, but Chilean workers’ inferior earning power also made food
less accessible. Reviewing the minimum requirement to ensure adequate nutrition,
he found that the majority of Chilean workers could not obtain the elements of this
diet on a regular basis. He argued that high infant mortality, skeletal deformities,
tuberculosis, and other infectious diseases all had roots in inadequate nutrition;
improvements depended on changed political and economic conditions.
With the same focus on concrete, material conditions, Allende then turned
to clothing, housing, and sanitation facilities. He found that working people in
Chile were inadequately clothed, largely because wages were low and the great-
est proportion of income went for food and housing. The effects of insufficient
clothing, Allende observed, were apparent in rates of upper respiratory infec-
tions, pneumonia, and tuberculosis, which were higher than in any economically
developed country.
In his analysis of housing problems, Allende focused on population density,
which largely reflected the geography of economic production. He noted that
Chile had one of the highest rates of inhabitants per residential structure in the
world; overcrowding fostered the spread of infectious diseases and poor hygiene.
Again he cited comparative data that showed a correlation between population
density and overall mortality. In a style similar to that of Engels and Virchow,
Allende presented a concrete description of housing conditions, including details
about insufficient beds, inadequate construction materials, and deficiencies in
apartment buildings. He reviewed the provisions for private initiative in construc-
tion, found them unsatisfactory, and outlined the need for major public-sector
investment in new housing. Allende then presented data on drinking water and
sewerage systems for all provinces of Chile, noting that vast areas of the country
lacked these rudimentary facilities.
His view of working-class conditions laid the groundwork for Allende’s
analysis of concrete medical problems. When he discussed specific diseases, he
18 C HAPTER 2

looked for their sources in the social and material environment. The medical
problems that he considered included maternal and infant mortality, tuberculosis,
sexually transmitted diseases, other infectious diseases, emotional disturbances,
and occupational illnesses. He observed that maternal and infant mortality rates
generally were far lower in developed than in less developed countries. After
reviewing the major causes of death, he concluded that malnutrition and poor
sanitation, both rooted in the political economy of underdevelopment, were
major explanations for this excess mortality.
In the same section, Allende gave one of the fi rst analyses of illegal abortion.
He noted that a large proportion of deaths in gynecologic hospitals, about 30
percent, derived from abortions and their complications. Pointing out the high
incidence of abortion complications among working-class women, he attributed
this problem to economic deprivations of class structure. After a statistical ac-
count of complications, Allende allowed his outrage to surface:

There are hundreds of working mothers who, because of anxiety about the in-
adequacy of their wages, induce abortion in order to prevent a new child from
shrinking their already insignificant resources. Hundreds of working mothers lose
their lives, impelled by the anxieties of economic reality.21

Allende designated tuberculosis as a “social disease” because its incidence dif-

fered so greatly among social classes. Writing before the antibiotic era, Allende
reached conclusions similar to those of modern epidemiology—that is, the ma-
jor decline in tuberculosis followed economic advances rather than therapeutic
medical interventions. From statistics of the fi rst three decades of the twentieth
century, he noted that tuberculosis had decreased consistently in the economi-
cally developed countries of Western Europe and the United States. On the other
hand, in economically less developed countries like Chile, little progress against
the disease had occurred. Within the context of underdevelopment, tuberculosis
exerted its most severe impact on the poor.
In his discussion of sexually transmitted diseases, Allende emphasized politi-
cal economic conditions that favored the spread of syphilis and gonorrhea. He
discussed deprivations of working-class life that encouraged prostitution. Citing
the prevalence of prostitution in Santiago and other cities, as well as the early
recruitment of women from poor families, he argued that social programs to
eliminate prostitution through expansion of employment opportunities must
precede significant improvements in sexually transmitted diseases.
Regarding other infectious diseases, Allende turned fi rst to typhus, the same
disease that shaped Virchow’s views about the relationships between illness and
the political economic system. Allende began his analysis with a straightforward
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 19

statement: “Some [infectious diseases], like typhus, are an index of the state of
pauperization of the masses.”22 Like Virchow in Upper Silesia, Allende found
a disproportionate incidence of typhus in the Chilean working class. He then
showed that bacillary and amebic dysentery and typhoid fever occurred because
of inadequate drinking water and sanitation facilities in residential areas densely
populated by working-class families. Similar problems fostered other infections,
such as diphtheria, whooping cough, scarlet fever, measles, and trachoma.
Drug addiction troubled Allende deeply. In La Realidad, Allende analyzed
the social and psychological problems that motivated people to use addictive
drugs. Allende’s political economic analysis of the causes of alcohol intoxication
showed similarities to that of Engels:

We see that one’s wages, appreciably less than subsistence, are not enough to supply
needed clothing, that one must inhabit inadequate housing . . . [and that] one’s
food is not sufficient to produce the minimum of necessary caloric energy. . . . The
worker reaches the conclusion that going to the tavern and intoxicating oneself is
the apparent solution to all these problems. In the tavern one fi nds a lighted and
heated place, and friends for distraction, making one forget the misery at home. In
short, for the Chilean worker . . . alcohol is not a stimulant but an anesthetic.23

Rooted in the social misery generated by conditions of capitalist production,

alcoholism exerted a profound effect on health, an impact that Allende docu-
mented for a variety of illnesses, including gastrointestinal diseases, cirrhosis,
delirium tremens, sexual dysfunction, birth defects, and tuberculosis. He also
traced some of the more subtle societal outcomes of alcoholism, offering an early
analysis of alcohol’s impact on accidental deaths.
Allende analyzed monopoly capital and international expansion by the
pharmaceutical industry, criticizing issues such as brand-name medications and
pharmaceutical advertising. In perhaps the earliest discussion of its type, Allende
compared the prices of brand-name drugs with their generic equivalents:

Thus, for example, we fi nd for a drug with important action on infectious diseases,
sulfanilamide, these different names and prices: Prontosil $26.95, Gombardol
$20.80, Septazina $21.60, Aseptil $18.00, Intersil $13.00, Acetilina $6.65. All
these products, which in the eyes of the public appear with different names, cor-
respond, in reality, to the same medication which is sold in a similar container and
which contains 20 tablets of 0.50 grams of sulfanilamide.24

Beyond the issue of drug names, Allende also anticipated a later theme by
criticizing pharmaceutical advertising: “Another problem in relation to the
20 C HAPTER 2

pharmaceutical specialties is . . . the excessive and charlatan propaganda attributing

qualities and curative powers which are far from their real ones.”25 In connect-
ing empire and health, Allende focused on such exploitation by multinational
drug companies.
Allende concluded by proposing the policy position and plan for political
action of the Ministry of Health within the popular-front government. In con-
sidering reform and its dilemmas, he reviewed the political economic origins of
illness and the social structural remedies that were necessary. Allende refused to
discuss specific health problems apart from macrolevel political economic issues.
He introduced his policy proposals with a chapter titled “Considerations Regard-
ing Human Capital.” Analyzing the detrimental political economic impact of ill
health among workers, he argued that a healthy population was a worthy goal
both in its own right and also for the sake of national development. The country’s
productivity suffered because of workers’ illness and early death, yet improving
the health of workers was impossible without fundamental political economic
changes in the society. These changes would include “an equitable distribution
of the product of labor,” state regulation of “production, distribution, and price
of articles of food and clothing,” a national housing program, and special at-
tention to occupational health problems. The links between medicine and the
broader political economy were inescapable: “All this means that the solution of
the medico-social problems of the country would require precisely the solution
of the economic problems that affect the proletarian classes.”26
He then proposed specific reforms that he viewed as preconditions for an
effective health system. These reforms called for profound changes in existing
structures of power, fi nance, and economic production. First, he suggested
modifications of wages, which if enacted would have led to a major redistribu-
tion of wealth. Regarding nutrition, he developed a plan to improve milk sup-
plies, fishing, and refrigeration and suggested land reform provisions to enhance
agricultural productivity. Recognizing the need for better housing, Allende
proposed a concerted national effort in publicly supported construction as well
as rent control in the private sector.
Allende did not emphasize programs of research or treatment for specific
diseases; instead, he assumed that the greatest advances toward lowering mor-
bidity and mortality would follow fundamental societal change. This orientation
also pervaded his proposed “medico-social program.” In this program, he sug-
gested innovations including reorganization of the Ministry of Health, planning
activities, control of pharmaceutical production and prices, occupational safety
and health policies, measures supporting preventive medicine, and sanitation
programs. Since the major social origins of illness included low wages, malnu-
trition, and poor housing, the fi rst responsibility of the public health system,
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 21

according to Allende, was to improve these conditions, some of which derived

from the actions of multinational corporations. His vision implied that medical
intervention without basic political economic change would remain ineffectual
and, in a deep sense, misguided.

Capitalism, Empire, Illness, and Early Death

Engels, Virchow, and Allende developed divergent though complementary views

about the social etiology of illness, which later generations have tended to forget
and then to rediscover. Their work conceptualized unnecessary illness and pre-
mature death as inherent outcomes of capitalist production and the expansion of
empire. The divergences reflected certain differences in theoretical orientation.
For Engels, economic production was primary. Even in his early work, Engels
emphasized the organization and process of production. Disease and early death,
in his view, developed directly from exposure to dusts, chemicals, time pressures,
bodily posture, visual demands, and related difficulties that workers faced in their
jobs. Environmental pollution, bad housing, alcoholism, and malnutrition also
contributed to the poor health of the working class, but these factors mainly
reflected or exacerbated the structural contradictions of production itself.
While he shared Engels’s view that the working class suffered disproportion-
ately, Virchow focused on inequalities in the distribution and consumption of
social resources. In Virchow’s analysis, important sources of illness and early
death included poverty, unemployment, malnutrition, cultural and educational
deficits, political disenfranchisement, linguistic difficulties, inadequate medical
facilities and personnel, and similar deficiencies that affected the working class.
He believed that public officials could prevent epidemics by distributing food
more efficiently. Disease and mortality, he argued, would improve if a “public
health service” made medical care more available. Virchow did criticize profi-
teering by businessmen and the high fees of the private medical profession. But
he did not emphasize the illness-generating conditions of production itself.
Instead, he viewed unequal access to society’s products as the principal problem
of social medicine.
Allende also concerned himself with the impact of class structure but focused
on the context of empire and underdevelopment. The deprivations that the
working class experienced in countries like Chile reflected the exploitation of
less developed countries by advanced capitalist nations. Allende attributed low
wages, malnutrition, poor housing, and related problems directly to the extrac-
tion of wealth by international imperialism. He recognized that production itself
could produce illness but, unlike Engels, devoted less attention to occupational
22 C HAPTER 2

illness per se. He did document distributional inequalities of goods and services
that, as in Virchow’s analysis, ravaged the working class. On the other hand, the
most crucial political economic determinant of illness and death, in Allende’s
view, was the contradiction of development and underdevelopment. Economic
advancement of the society as a whole, although impeded by empire, was the
major precondition for meaningful improvements in medical care and individual
health.
The contributions of Engels, Virchow, and Allende shared the framework of
social causation. These writings conveyed a vision of multiple social structures
and processes impinging on the individual. Disease was not the straightforward
outcome of an infectious agent or pathophysiological disturbance. Instead, a
variety of problems—including malnutrition, economic insecurity, occupational
risks, bad housing, and lack of political power—created an underlying predisposi-
tion to disease and death. Although these writers differed in the specific factors
they emphasized, they each saw illness as deeply embedded in the complexities of
social reality. To the extent that social contradictions affected individual disease,
therapeutic intervention that limited itself to the individual level proved both
naive and futile. Social etiology implied social change as therapy, and the latter
linked medical practice to political practice.
Another crucial divergence concerned policy, reform, and political strategy.
Engels, Virchow, and Allende differed in their views of the strategies needed
for change. They also held varying visions of the society in which these policies
would take effect. Although their explanations of the social origins of illness
complemented one another, the question of how to change illness-generating
conditions evoked different strategic analyses.
Already present in his early work, Engels’s strategy involved revolution, not
reform. His documentation of the occupational and environmental conditions
that caused illness and early death did not aim toward limited reform of those
problems. Instead, he intended his data to serve, at least in part, as propaganda.
The purpose was to provide a focus of political organizing among the working
class. Notably, Engels did not advocate specific changes in the conditions he
described. While he detailed the defects of housing, sanitation, occupational
safety, maldistribution of medical personnel, and promotion of drugs, he did not
explicitly seek reforms in any of these areas. The alternatives that he occasionally
suggested, such as the cursory outlines of a public health service, were always
speculations about how a more effective system might appear in a postrevolution-
ary society. The many deprivations of working-class life required fundamental
change in the entire social order, rather than limited improvements in parts of
society. The companion piece of The Condition of the Working Class in England
was clearly The Communist Manifesto, with its aim to address problems such as
 ILLNESS-GENERATING CONDITIONS OF CAPITALISM AND EMPIRE 23

unnecessary illness and early death through broad social revolution. The strate-
gic implications of Engels’s analysis of health problems were congruent with his
role as a primary organizer of the First Internationale. From this perspective,
reformism in health care made as little sense as any other piecemeal tinkering
with capitalist society.
Taking a different approach to social change, Virchow favored policies of re-
form. Although he participated in the agitation of the late 1840s and doubted that
the ruling circles would permit needed changes in response to peaceful challenges
alone, he ultimately opted for reform rather than revolution. While the conditions
he witnessed in the Upper Silesian typhus epidemic were horrifying, he believed
that a series of reforms could correct the problem. The reforms he advocated
transcended medicine to include rationalized food distribution, modifications in
the educational system, political enfranchisement, and other changes at the level
of social structure. He also adopted a broad view of the systematic reforms that
were necessary in health care. An adequate health system, for example, demanded
a public health service. In this service, health-care professionals would work as
employees of the state and would act to correct maldistribution across class,
geographical, and ethnic lines. As an overall political goal, Virchow favored a
constitutional democracy that would reduce the power of the monarchy and nobil-
ity. He supported principles of socialism, particularly those that involved public
ownership and rational organization of health and welfare facilities. However,
Virchow argued against communism, mainly, he said, because of its naive view
that a just society was feasible without a strong state apparatus. Virchow fi rmly
believed that limited reforms within capitalist society were both appropriate and
desirable, and he was optimistic that they would be effective.
Allende’s conceptualization of political strategy was more complex than those
of Engels or Virchow. In La Realidad Medico-Social Chilena, he unambiguously
stated that the health problems of the working class were inherent in the contra-
dictions of class structure, underdevelopment, and the oppressive international
relations of empire. Without basic modification of these structural problems, he
argued, limited medical reform would prove futile.
In Allende’s view, revolutionary social change was necessary to achieve needed
improvements in health services and outcomes. Throughout his life, Allende
believed that progressive forces could achieve a socialist transformation of society
through a sequence of peaceful actions within the framework of constitutional
democracy. He and his coworkers based this position on a reading of prior social-
ist strategists, examples of other revolutions, and a detailed analysis of Chile’s
concrete historical and material reality. From this viewpoint, the most important
health-related reforms transcended medicine. Allende called for improvements
in housing, nutrition, employment, and other concrete manifestations of class
24 C HAPTER 2

oppression. Such reforms were preconditions for reduced morbidity and mortality;
without them, changes in health-care services could not succeed. On the other
hand, structural reforms in the social organization of medicine, including a public
health service and a nationalized pharmaceutical and equipment industry, were
desirable goals en route to a socialist society. Allende did not accurately anticipate
the violence of national and international groups about to be dispossessed on the
peaceful road to socialism. This grim result left the balance between reform and
revolutionary alternatives incompletely resolved in strategies for change.
The social pathologies that distressed Engels, Virchow, and Allende continue
to create suffering and early death. Public health generally has adopted the medi-
cal model of etiology. In this model, social conditions may increase susceptibility
or exacerbate disease, but they are not primary causes like microbial agents or
disturbances of normal physiology. Partly because research rarely has clarified the
causes of illness within political economic systems, political strategy—both within
and outside medicine—seldom has addressed the social roots of disease.
Inequalities of class, exploitation of workers, and conditions of capitalist
production in the context of empire cause disease now as previously. The links
between political economic conditions and disease become ever more urgent, as
economic instability, unreliable food supplies, depletion of petroleum, nuclear
and toxic chemical wastes, global warming, and related problems threaten the
survival of humanity and other life forms. In Chapter 13, I present more recent
perspectives on the social determinants of health, based largely on work in Latin
American social medicine. As Engels, Virchow, and Allende argued and as more
recent studies in social medicine have confi rmed, efforts to improve the health
of populations without addressing the social origins of illness ultimately will fail.
Strategies that do address these social origins reveal the scope of reconstruction
that is necessary for meaningful solutions, which I consider in the last part of
the book.

* * *
The impacts of capitalism and empire, however, do not only operate as causes of
illness and early death. Instead, illness and early death also provide a rationale
for the development and marketing of new products. The promotion and sales of
these products, usually involving technological advances, have further strength-
ened the capitalist system and have enhanced its ability to expand through empire.
In the next chapter I present an important example of how new technologies,
designed to improve health conditions but often without clear evidence of success
in doing so, provided growing profitability for capitalist enterprises, as markets
for these products expanded throughout the world.
 8
C HAPTER 3

THE INTERNATIONAL MARKET

FOR HEALTH PRODUCTS AND SERVICES

In both advanced capitalist countries and less developed nations, the fi nancial
burden of health care became a major concern during what I refer to as empire
past. Legislative and administrative maneuvers purportedly aimed for cost con-
tainment. Techniques in health services research entered into the evaluation of
technology and clinical practices. The purposes of this chapter are to show the
limitations of these approaches in light of medical technology’s social history
and to offer an alternative interpretation, which traces problems of costs to un-
derlying social contradictions within the capitalist economy and the expansion
of empire.

Methods to Address the Falling Rate of Profit

Health costs cannot be divorced from the structure of private profit, even
though—surprisingly enough—the problem of profit often did not enter into
analyses of the rapidly increasing costs of care during empire past. Many analyses
of costs either ignored the contradictions of capitalism and empire, or accepted
them as given. But the crisis of health costs intimately reflected the more general
fiscal crisis that advanced capitalism faced worldwide. In analyses of costs, the
connections between the health sector and the structure of the capitalist system
received little attention. Limiting the level of analysis to a specific innovation or
practice, while not perceiving the broader political economic context in which
costly and ineffective procedures were introduced and promulgated, obscured
potential solutions. Apparent irrationalities of health policy made sense when seen
from the standpoint of capitalist profit structure; the overselling of numerous

25
26 C HAPTER 3

technological advances—including the computerized axial tomography, new

laboratory techniques, fetal monitoring, many surgical procedures, and coro-
nary care units for patients with heart attacks—reflected very similar structural
problems.
One key theme that emerged from the history of technological advances in
medicine involved corporate strategies to deal with the falling rate of profit. As
Marx, in addition to Smith and Ricardo before him, pointed out, companies
enjoyed a high rate of profit when they introduced a new product for the fi rst
time into a marketplace. However, as the new product saturated its market, the
rate of profit almost always began to fall. To address this inherent problem,
corporations developed strategies to maintain or to increase the rate of profit.
Such strategies included raising the productivity of labor, diversifying into new
product lines, and searching for new markets through international exports.1
The social history of coronary care showed how the diffusion of technological
advances with unproven effectiveness, which appeared quite irrational on the
surface, played themselves out as inherent features of the capitalist economy and
the expansion of empire.

The Political Economy of Coronary Care

Early History of Coronary Care Units

Intensive care for patients suffering heart attacks emerged rapidly during the
1960s, during empire past, with the development of coronary care units (CCUs).
The rationale for the CCUs stemmed from fi ndings in pathology and physiology
about the nature of heart attacks. When a person has a heart attack, or myo-
cardial infarction, a part of the heart muscle dies. For several days, this dying
muscle acts as a source of electric instability that may cause serious irregularities
in the heart’s rhythm. If such an irregularity, or arrhythmia, occurs, the patient
may die because the heart does not pump blood to vital organs. During the
late 1950s and early 1960s, researchers in cardiology discovered techniques to
control arrhythmias if caught in time. These techniques included intravenous
drugs (such as lidocaine) and the application of electric shock to the chest wall
(defibrillation).
The CCU’s purpose was to provide continuous electronic monitoring of
the heart’s rhythm, through electrodes attached to the patient’s chest and con-
nected to electrocardiogram equipment. Through continuous monitoring, it was
possible to begin treatment, by drugs or electric shock, immediately when an
arrhythmia began. After a heart attack, a patient generally remained in a CCU
during a critical period until the heart rhythm stabilized. Since the origin of
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 27

CCUs, medical practitioners have used them for other problems, including con-
gestive heart failure or blood pressure abnormalities, which sometimes followed
a heart attack. The CCU’s major rationale, however, remained the monitoring
and control of heart rhythm disturbances.
This rationale led to a reasonable hypothesis: that CCUs would reduce
morbidity and mortality from heart attacks. As reasonable as this hypothesis ap-
peared, however, it remained to be proved. A random controlled trial evaluating
CCUs, in which patients would be randomly assigned to CCUs versus standard
care and their comparative outcomes assessed, could have resolved such doubts.
Nonetheless, CCUs proliferated throughout the United States and around the
world during empire past without any defi nite documentation of their effective-
ness. Clinicians and investigators did not try to perform random controlled trials
regarding the outcomes of CCU care. Instead, they advocated the adoption of
the intensive care approach, with the unproven assumption that CCUs would
improve survival by controlling early heart rhythm disturbances. With an aura
of scientific rigor, the promotion and acceptance of technology in coronary care
bypassed the scientific demonstration of effectiveness. Early arguments for CCUs
showed an optimism unrestrained by the requirements of hypothesis testing.
A controlled trial evaluating CCUs would have been important for several
reasons. In the fi rst place, one could imagine some possible ways in which inten-
sive care could interfere with recovery after a heart attack. Iatrogenic disease may
arise, for example, because of disturbances in body chemistry stemming from
intravenous solutions. Life-threatening infections also are more likely to occur
in the hospital. In addition, the intensive care setting can be a fear-provoking
experience. Emotional upset can be life-threatening after a heart attack; for
example, patients in CCUs have died suddenly after witnessing other patients’
deaths. Such technical and psychological problems warranted assessment before
concluding that CCUs were effective. Second, although CCUs might improve
short-term mortality in the hospital, they may have little effect on longer-term
outcomes during the weeks and months after patients leave the hospital. Properly
evaluating intensive care would consider later survival and quality of life, beyond
the acute period of hospitalization. Third, CCUs were enormously expensive.
Capital expenditures for CCU equipment amounted to millions of dollars for a
single hospital. The daily costs of care in CCUs were two to three times more
expensive than for hospitalization without intensive care.
Despite the lack of controlled studies showing effectiveness, there were many
calls for the expansion of CCUs to other hospitals and increased support from
the U.S. government and private foundations. In 1968, the U.S. Department of
Health, Education, and Welfare issued a set of Guidelines for CCUs.2 Largely
because of these recommendations, CCUs grew rapidly in the following years.
Table 3-1 shows the expansion of CCUs in the United States between 1967 and
28 C HAPTER 3

1974.3 Although some regional variability was present, a large increase in the pro-
portion and an even larger increase in the absolute number of hospitals with CCUs
occurred during this period, still without demonstration of effectiveness.
Serious research on the effectiveness of CCUs did not begin until the 1970s.
“Before-after” studies done during the 1960s could not lead to valid conclusions
about effectiveness, since none of these studies used adequate control groups
or randomization.4 Later studies compared treatment of heart attack patients
in hospital wards versus CCU settings.5 Patients were “randomly” admitted to
the CCU or the regular ward, simply based on the availability of CCU beds.
Ward patients were the “control” group; CCU patients were the “experimen-
tal” group. From this research, it remained unclear whether CCUs improved
in-hospital mortality.
Other research contrasted home versus hospital care.6 In a prospective random
controlled trial by Mather and colleagues in the United Kingdom, the one-year
mortality was not different in the home and hospital groups, and there was no evi-
dence that heart attack patients did better in the hospital. A second random con-
trolled trial of home versus hospital treatment, conducted by Hill and colleagues
also in the United Kingdom, tried to correct certain methodological difficulties
of the Mather study by achieving a higher rate of randomization and strict criteria
for the entry and exclusion of patients from the trial. This later study confi rmed
the earlier results; the researchers concluded that for the majority of patients with
suspected heart attack, admission to a hospital “confers no clear advantage.” A
third study of the same problem in the United Kingdom used an epidemiological

Table 3-1 Growth of Coronary Care Units

in the United States, by Region, 1967–1974
Coronary Care Units (% of Hospitals)
1967 1974
United States 24.3 33.8
New England 29.0 36.8
Mid-Atlantic 33.8 44.2
East North Central 31.0 38.2
West North Central 17.0 25.3
South Atlantic 23.3 38.2
East South Central 13.4 30.1
West South Central 15.3 24.3
Mountain 21.4 29.3
Pacific 32.7 37.8
Source: see note 3.
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 29

approach. This investigation was not a random controlled trial but rather a twelve-
month descriptive study of the incidence of heart attacks, how they were treated
in practice, and the outcomes in terms of mortality. Both the crude and age-stan-
dardized mortality rates were better for patients treated at home.
These issues remained far from settled. The thrust of available research in-
dicated that home care constituted a viable treatment alternative to hospital or
CCU care for many patients with heart attacks. Early CCU investigations used
unsound methods; more adequate studies did not confi rm CCU effectiveness.
One other question became clear: if intensive care was not demonstrably more
effective than simple rest at home, how could we explain the tremendous pro-
liferation of this very expensive form of treatment?

Explaining the Diffusion of Coronary Care Units

These events did not represent simply another uncritical acceptance of high tech-
nology in industrial society. Instead, one must search for the social conditions
that fostered their growth and impeded their serious evaluation. Several elements
played key roles in the political economy of coronary care during empire past:
corporations, academic medical centers, private philanthropists, the state, and
changes in the health-care labor force.
To survive, capitalist industries must produce and sell new products; expansion
is a necessity for capitalist enterprises. The economic surplus must grow continu-
ally larger. Medical production also falls into this same category, although it is
seldom viewed in this way. The economist Mandel emphasized the contradictions
of the economic surplus: “For capitalist crises are incredible phenomena like noth-
ing ever seen before. They are not crises of scarcity, like all pre-capitalist crises;
they are crises of over-production.”7 This scenario also included the health-care
system, where an overproduction of intensive care technology contrasted with
the fact that many people lacked access to the simplest and most rudimentary
medical services.

The Corporate Connection

Large profit-making corporations in the United States participated in essentially

every phase of CCU research, development, promotion, and proliferation. Many
companies involved themselves in the intensive care market. Here I consider the
activities of two such fi rms: the Warner-Lambert Pharmaceutical Company and
the Hewlett-Packard Company. I selected these corporations because information
about their participation in coronary care was accessible, because they occupied
30 C HAPTER 3

prominent market positions, and because their worldwide expansion constituted

an important phase of the international market in health-care products during
empire past. However, many other fi rms, including at last eighty-five major
companies, also participated in coronary care.
During the late 1970s, Warner-Lambert Pharmaceutical Company was a
large multinational corporation, with $2.1 billion in assets and over $2.5 billion
in sales annually. The corporation included a number of interrelated subsidiary
companies. Warner-Chilcott Laboratories produced such drugs as Coly-Mycin,
Gelusil, Anusol, Mandelamine, Peritrate, and Tedral. The Parke-Davis Com-
pany manufactured Caladryl lotion, medicated throat discs, influenza vaccines,
Norlestrin contraceptives, Dilantin, Benadryl, Chloromycetin, and many other
pharmaceuticals. Another division, Warner-Lambert Consumer Products,
produced Listerine, Smith Brothers (cough drops), Bromo-Seltzer, Chiclets,
DuBarry, Richard Hudnuts, Rolaids, Dentyne, Certs, Cool-ray Polaroid (sun-
glasses), and Oh! Henry (candy). Warner-Lambert International operated in
more than forty countries.
Although several divisions of the Warner-Lambert conglomerate participated
actively in the development and promotion of coronary care, the most prominent
was the American Optical Company, which Warner-Lambert acquired during
1967. American Optical’s research, development, and promotion of coronary
care produced rapidly increasing profits after the mid-1960s.
After purchasing American Optical in 1967, Warner-Lambert maintained
American Optical’s emphasis on CCU technology and sought wider acceptance
by health professionals and medical centers. Promotional materials contained
the assumption, never proven, that the new technology was effective in reducing
morbidity and mortality from heart disease. Early products and systems included
the American Optical Cardiometer, a heart monitoring and resuscitation device;
the Lown Cardioverter, the fi rst direct-current defibrillator; and an Intensive
Cardiac Care System that permitted simultaneous monitoring of sixteen patients
by oscilloscopes, recording instruments, heart rate meters, and alarm systems.8
In 1968 the company introduced a new line of monitoring instrumentation and
implantable pacemakers. Regarding the monitoring systems, Warner-Lambert
reported that “acceptance has far exceeded initial estimates” and that “to meet
the increased demand for its products” the Medical Division was doubling the
size of its plant in Bedford, Massachusetts.9 By 1969, the company introduced
another completely new line of Lown Cardioverters and Defibrillators and claimed
that “this flexible line now meets the requirements of hospitals of all sizes.”10 The
company continued to register expanding sales throughout the early 1970s.
Despite this growth, Warner-Lambert began to face a typical corporate prob-
lem: saturation of markets in the United States. Since coronary care technology
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 31

was capital intensive, the number of hospitals in the United States that could buy
coronary care systems, though large, was fi nite. Without other maneuvers, the
demand for coronary care products eventually would decline. For this reason,
Warner-Lambert began to implement new and predictable initiatives to ensure
future growth.
First, the company expanded coronary care sales into foreign markets, espe-
cially in Latin America. Subsequently Warner-Lambert reported notable gains
in sales in such countries as Argentina, Colombia, and Mexico, despite the fact
that during the 1970s “political difficulties in southern Latin America slowed
progress somewhat, particularly in Chile and Peru.”11 In short, the company
dealt with market saturation in the United States partly by entering new markets
within the U.S. sphere of influence during empire past.
In addition to the expansion of sales through empire, a second method to deal
with market saturation involved further diversification in the coronary care field
with products whose intent was to open new markets or to create obsolescence
in existing systems. For example, in 1975 American Optical introduced two new
instruments. The Pulsar 4, a lightweight portable defibrillator designed for local
paramedic and emergency squads, created “an exceptionally strong sales demand.”
The Computer Assisted Monitoring System used a computer to anticipate and to
control changes in cardiac patients’ conditions and replaced many hospitals’ CCU
systems that American Optical had installed but that lacked computer capabilities.
According to the 1975 annual report, these two instruments “helped contribute
to record sales growth in 1975, following an equally successful performance in
the previous year.”12 This strategy of diversification overlapped the fi rst strategy
of expansion through empire, because the corporation could promote these new
products in less developed countries.
A third technique to ensure growth involved the modification of coronary
care technology for new areas gaining public and professional attention. With
an emphasis on preventive medicine, American Optical introduced a new line
of electrocardiogram telemetry instruments, designed to provide early warn-
ing of heart attack or rhythm disturbance in ambulatory patients. In addition,
American Optical began to apply similar monitoring technology to the field of
occupational health and safety. In 1970 Warner-Lambert noted:

Sales of safety products were lower in 1970 than in 1969 as a result of cutbacks
in defense spending, the general business slowdown, and the lengthy automobile
industry strike. The outlook for the future, however, is encouraging because
of the increased industry and government concern with safety on the job, as
evidenced by the passage of the Federal Occupational Safety and Health Act
late in 1970.13
32 C HAPTER 3

During each subsequent year, the sales of safety and health equipment, manu-
factured by the American Optical subsidiary and adopted partly from coronary
care technology, continued to increase.
A second major corporation, the Hewlett-Packard Company, with more than
$1.1 billion in assets and over $1.3 billion in sales at the time, followed a similar
pattern in the coronary care marketplace. Hewlett-Packard was a less complex
corporation than Warner-Lambert because it controlled fewer subsidiaries. On
the other hand, Hewlett-Packard’s growth led to enormous wealth for a relatively
small number of stockholders. David Packard, chairman of the Hewlett-Packard
board of directors and former assistant secretary of defense, as of 1978 owned
Hewlett-Packard stock valued at approximately $562 million; the second-highest
holdings by a corporate executive in his own company at the time were David
Rockefeller’s $13 million in shares of Chase Manhattan Bank.14
Since its founding in 1939, Hewlett-Packard grew from a small fi rm, manu-
facturing analytical and measuring instruments mainly for industry, to a leader
in electronics. Until the early 1960s, its only major product designed for medical
markets was a simple electrocardiogram machine. But during the 1960s, Hewlett-
Packard introduced a series of innovations in coronary care that soon reached
world markets.
Initially, Hewlett-Packard focused on the development of CCU technology,
promoting equipment aggressively to hospitals with the consistent claim that
cardiac monitors and related products were clearly effective in reducing mortality
from heart attacks and rhythm disturbances. Hewlett-Packard’s promotional lit-
erature made no reference to the problem of proving CCU effectiveness. Instead,
such claims as the following remained unambiguous: “In the cardiac care unit
pictured here at a Nevada hospital, for example, the system has alerted the staff
to several emergencies that might otherwise have proved fatal, and the cardiac
mortality rate has been cut in half.”15 Alternatively, “hundreds of lives are saved
each year with the help of Hewlett-Packard patient monitoring systems installed
in more than 1,000 hospitals throughout the world. . . . Pictured here is an HP
system in the intensive care ward of a hospital in Montevideo, Uruguay.”16
Fairly early in its involvement with coronary care, Hewlett-Packard emphasized
the export of CCU technology to hospitals and practitioners abroad, anticipat-
ing the international sales that companies like Warner-Lambert already enjoyed
during empire past. In 1966, the Hewlett-Packard annual report predicted that
the effects of a slumping economy would be offset by “the great sales potential
for our products, particularly medical instruments, in South American, Cana-
dian, and Asian markets. These areas should support substantial gains in sales
for a number of years.”17 Hewlett-Packard developed an elaborate promotional
apparatus, including “mobile laboratories” that could be transported by airplane
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 33

or bus, especially in less developed countries. By 1969, these exhibits had

been “viewed by thousands of customers in Asia, Australia, Africa, and Latin
America.”18 In materials prepared for potential investors, Hewlett-Packard made
explicit statements about the advantages of international operations. For example,
because Hewlett-Packard subsidiaries received “pioneer status” in Malaysia and
Singapore, income generated in these countries remained essentially tax-free:
“Had their income been taxed at the U.S. statutory rate of 48 percent in 1974,
our net earnings would have been reduced by 37 cents a share.”19 By the mid-
1970s, Hewlett-Packard’s international medical equipment business, as measured
by total orders, surpassed its domestic business. More than one hundred sales
and service offices were operating in sixty-four countries.
Like Warner-Lambert, Hewlett-Packard also diversified its products to deal
with the potential saturation of the coronary care market. During the late 1960s,
the company introduced a series of complex computerized systems that were de-
signed as an interface with electrocardiogram machines, monitoring devices, and
other CCU products. Through the construction of computer-linked systems, as
the company argued in its promotional activities, hospitals could achieve efficient
data analysis for clinical decision making and CCU organization. A computer-
ized system to analyze and interpret electrocardiograms led to the capability of
processing up to five hundred electrocardiograms per eight-hour day.20 Similar
considerations of profitability motivated the development of telemetry systems for
ambulatory patients with heart disease and battery-powered electrocardiogram
machines designated for regions of less developed countries where electricity was
not yet available for traditional machines.
From the corporate perspective, spiraling health-care expenditures, far from
a problem to be solved, were the necessary fuel for desired profits. Corporations,
however, were not the only organizations responsible for diffusing coronary care
technology. Corporate profitability in coronary care and related fields would not
have proved possible without the active support of clinicians and professionals who
helped create new technology of unproven effectiveness and put it into use.

The Academic Medical Center Connection

Academic medical centers played a key role in the development and promotion
of costly innovations like those in coronary care. These institutions composed
a focus of monopoly capital in the health sector, yet they seldom attracted at-
tention in critiques of technology. New approaches generally received their fi rst
clinical use in medical centers, before their adoption by practitioners in local
communities and less developed countries. Both corporations considered here,
Warner-Lambert and Hewlett-Packard, obtained important bases at medical
34 C HAPTER 3

centers located in geographic proximity to corporate headquarters. Academic

cardiologists participated in the proliferation of CCU equipment; their work
doubtless derived in part from a sincere belief that the new technologies would
save lives and help patients, rather than greed or a desire for personal profit.
Yet, their uncritical support for these innovations fostered CCUs’ widespread
acceptance without documented effectiveness.
Before its purchase by Warner-Lambert, American Optical—with head-
quarters in Southbridge, Massachusetts—established ties with the Peter Bent
Brigham Hospital in Boston. The company worked with Bernard Lown, an
eminent cardiologist, who served as an American Optical consultant, on the
development of defibrillators and cardioverters. Lown pioneered the theoretical
basis and clinical applications of these techniques, and American Optical engi-
neers collaborated with Lown in the construction of working models. American
Optical marketed and promoted several lines of defibrillators and cardioverters
that bore Lown’s name.
American Optical provided extensive support for technological innovation
at the Peter Bent Brigham Hospital. The CCU developed in the mid-1960s
received major grants from American Optical that Lown and his group acknowl-
edged.21 American Optical also used data and pictures from the Brigham’s CCU
in promotional literature distributed to the medical profession and potential
investors. Lown and his group continued to influence the medical profession
through a large number of publications, appearing in both the general medical
and cardiology literature, that discussed CCU-linked diagnostic and therapeu-
tic techniques. In these papers Lown emphasized the importance of automatic
monitoring. He also advocated the widespread use of telemetry for ambulatory
patients and computerized data-analysis systems, both areas into which American
Optical diversified during the late 1960s and early 1970s. American Optical’s
relationship with Lown and his colleagues apparently proved beneficial for all
concerned. The dynamics of heightened profits for American Optical and prestige
for Lown did not provide optimal conditions for a detached, systematic appraisal
of CCU effectiveness.
Hewlett-Packard’s academic base was Stanford University Medical Center,
located about one-half mile from corporate headquarters in Palo Alto, California.
For many years William Hewlett, Hewlett-Packard’s chief executive officer, served
as a trustee of Stanford University. In addition, a private philanthropy established
by Hewlett figured prominently among the university’s fi nancial benefactors.
More pertinent were Hewlett-Packard’s links to the Division of Cardiology
at Stanford. Donald Harrison, professor of medicine and chief of the Division of
Cardiology, acted as Hewlett-Packard’s primary consultant in the development of
coronary care technology. Harrison and his colleagues at Stanford collaborated
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 35

with Hewlett-Packard engineers in the design of CCU systems intended for

marketing to both academic medical centers and community hospitals in the
United States and abroad, including less developed countries. Hewlett-Packard
helped construct working models of CCU components at Stanford University
Hospital, under the direction of Harrison and other faculty members. Stanford
physicians introduced these Hewlett-Packard systems into clinical use.
Innovations in the treatment of patients with heart disease exerted a pro-
found impact on the costs of care at Stanford, setting a pattern for rising costs
at hospitals throughout the world. As documented in a general study of the
costs of treatment for several illnesses at Stanford, the effects of coronary care
technology proved dramatic:

Of the conditions covered by the 1964–1971 study, the changes in treatment in

myocardial infarction had their most drastic effect on costs. This was due principally
to the increased costs of intensive care units. In 1964, the Stanford Hospital had a
relatively small Intensive Care Unit (ICU). It was used by only three of the 1964
coronary cases. . . . By 1971, the hospital had not only an ICU but also a Coronary
Care Unit (CCU) and an intermediate CCU. Of the 1971 cases, only one did not
receive at least some care in either the CCU or the intermediate CCU.22

Beyond the costs of coronary care beds, this study observed rapid increases
in expensive inputs of care that derived from the intensive approach, such as
laboratory tests, electrocardiograms, intravenous solutions, X-rays, inhalation
therapy, and pharmaceuticals. As the investigators noted, these changes occurred
even while doubt remained about the overall effectiveness of CCUs in reducing
morbidity and mortality.
During the late 1960s and early 1970s, many articles from the Harrison group
described new technological developments or discussed clinical issues tied to
CCU care. Several papers acknowledged the use of Hewlett-Packard equipment
and assistance. These academic clinicians also participated in continuing medical
education programs on coronary care, both in the United States and abroad.
The Stanford specialists played an important role in promoting technology in
general and Hewlett-Packard products in particular.

Private Philanthropies

Philanthropic support also figured prominently in the growth of CCUs. The

motivations for philanthropic spending included a complex mix of humanitar-
ian goals and profit considerations (as they did in the early expansion of empire
past, described in Chapter 1). These initiatives often emerged from the actions
36 C HAPTER 3

of corporate executives whose companies produced medical equipment or

pharmaceuticals. Specific philanthropies enthusiastically supported the CCU
approach.
Primary among the philanthropic proponents of CCUs was the American
Heart Association, which sponsored research that led to the development of
CCU products, especially monitoring systems. In addition, the association helped
fi nance local hospitals establishing CCUs. The “underlying purpose” of these
activities, according to an annual report of the association, was “to encourage and
guide the formation of new [CCU] units in both large and small hospitals.”23
Later in the 1960s the American Heart Association’s annual number of esti-
mated beneficiaries kept rising, again with undocumented claims of effectiveness.
According to the 1968 annual report, doctors were helpless to deal with heart
attacks until well into the twentieth century, the era that “Dr. Paul Dudley White
characterized . . . as ‘B.C.’—Before Cardiology.” Now, however,

survival rates of hospitalized patients have been substantially increased by coronary

care units. . . . Intensive coronary care units will be greatly expanded in hospitals
treating acutely ill patients. At present, only about one third of hospitalized heart
attack patients are fortunate enough to be placed in coronary care units. If all of
them had the benefits of these monitoring and emergency service facilities, it is
estimated that 50,000 more heart patients could be saved yearly.24

This unsubstantiated estimate persisted in American Heart Association literature

into the early 1970s. During this same period the association cosponsored, with
the U.S. Public Health Service and the American College of Cardiology, a series
of national conferences on coronary care whose purpose was “the successful
development of the CCU program” in all regions of the United States.
Other foundations also supported CCU proliferation. For example, the John
A. Hartford Foundation gave generous support to several hospitals and medical
centers during the early 1960s to develop monitoring capabilities. Recipients of
Hartford wealth included Lown’s group in Boston. The Hartford Foundation’s
public view of CCU effectiveness was unequivocal; the coronary care program
“has demonstrated that a properly equipped and designed physical setting staffed
with personnel trained to meet cardiac emergencies will provide prophylactic ther-
apy which will materially enhance the survival of these patients and substantially
reduce the mortality rates.”25 Another foundation that supported CCU growth,
though somewhat less directly, was the W. R. Hewlett Foundation, founded by
Hewlett-Packard’s chief executive officer. The Hewlett Foundation earmarked
large annual grants to Stanford University, which, after an undoubtedly fierce
 THE INTERNATIONAL MARKET FOR HEALTH PRODUCTS AND SERVICES 37

competitive evaluation of alternatives, chose Hewlett-Packard equipment for its

CCU and other intensive care facilities.26
The commitment of private philanthropy to technological innovations
emerged as a structural problem that transcended the personalities that controlled
philanthropy at any specific time. The bequests that created philanthropies
historically came largely from funds generated by North American industrial
corporations oriented toward technological advances. Moreover, the invest-
ment portfolios of philanthropic organizations usually included stocks in a
sizable number of industrial companies. Such structural conditions encouraged
fi nancial support for technological advances like those in coronary care. These
same conditions tended to discourage philanthropic funding for new programs
or organizational changes that would have modified the overall structure of the
health-care system, which favored the position of corporations producing and
selling high-technology products.
In addition, it is useful to ask which people made philanthropic decisions to
fund CCU development. During the mid-1960s the American Heart Associa-
tion’s officers included eight physicians with primary commitments in cardiol-
ogy, executives of two pharmaceutical companies, a metals company executive,
a prominent banker, and several public officials (including Dwight Eisenhower).
At the height of CCU promotion in 1968, the chairman of the American Heart
Association’s annual Heart Fund was a drug company executive. During the
1960s and early 1970s bankers and corporate executives also dominated the
board at the Hartford Foundation. The Hewlett Foundation remained a family
affair. Mr. and Mrs. W. R. Hewlett made the decisions about grants until the
early 1970s, when R. W. Heyns—former chancellor of the University of Cali-
fornia, Berkeley, and also a director of Norton Simon Inc., Kaiser Industries,
and Levi-Strauss—assumed the foundation’s presidency. It is not surprising that
philanthropic policies supporting CCU proliferation showed a strong orientation
toward the interests of major corporations.

The Role of the State

The state, in the form of governmental agencies, also played a key role in CCU
growth. For instance, the U.S. Public Health Service provided substantial sup-
port to clinicians for CCU development during the early 1960s. An official of
the U.S. Department of Health, Education, and Welfare provided an “estimate”
of 50,000 potential lives saved annually by future CCUs27; without apparent
basis in data, this figure became a slogan for CCU promotion. Conferences and
publications by the Department of Health, Education, and Welfare during the
Discovering Diverse Content Through
Random Scribd Documents
gentle footsteps of him, whom on earth she most longed to behold,
entered the chamber. As she caught a glimpse of that benign, that
venerated countenance, she felt a glow of happiness pervading her
being, of which she thought her waning life almost incapable. She
clasped her feeble hands together, and exclaimed, "Oh! Mr. M——."
It was all she could utter, for tears, whose fountains she had thought
dried for ever, gushed into her eyes and rolled down her pallid
cheeks. Mr. M—— took one of her cold hands in his, and looked
upon her, for a time, without speaking.
"My daughter," at length he said, and he did not speak without much
emotion, "do you find the hand of God laid heavy upon your soul, or
is it gentle, even as a father's hand?"
"Gentle, most gentle," she answered. "Oh! blessed, for ever blessed
be the hour that sent you, heaven-directed, to guide the wanderer in
the paths of peace! Had it not been for you, I should now be
trembling on the verge of a dark eternity, without one ray to illumine
the unfathomable abyss. Pray for me once more, my beloved friend,
and pray too for my dear mother, that she may be enabled to seek
Him in faith, who can make a dying bed 'feel soft as downy pillows
are.'"
Ellen clasped her feeble hands together, while Mr. M——, kneeling by
her bed-side, in that low, sweet solemn tone, for which he was so
remarkable, breathed forth one of those deep and fervent prayers,
which are, as it were, wings to the soul, and bear it up to heaven.
Mrs. Loring knelt too, by the weeping Agnes, but her spirit, unused
to devotion, lingered below, and her eyes wandered from the
heavenly countenance of that man of God, to the death-like face of
that child, whose beauty had once been her pride. She remembered
how short a time since, she had seen that form float in airy grace
before the mirror clothed in fair and flowing robes, and how soon
she should see it extended in the awful immobility of death, wrapped
in the still winding-sheet, that garment whose folds are never more
waved by the breath of life. Then, conscience whispered in her
shuddering ear, that, had she acted a mother's part, and disciplined
her daughter to prudence and obedience, the blasts of death had
not thus blighted her in her early bloom. And it whispered also, that
she had no comfort to offer her dying child, in this last conflict of
dissolving nature. It was for this world she had lived herself, it was
for this world she had taught her to live, but for that untravelled
world beyond, she had no guiding hand to extend. It was to a
stranger's face the fading eyes of Ellen were directed. It was a
stranger's prayers that hallowed her passage to the tomb. The
realities of eternity for the first time pressed home, on that vain
mother's heart. She felt, too, that she must one day die, and that
earth with all its riches and pleasures could yield her no support in
that awful moment. That there was something which earth could not
impart, which had power to soothe and animate the departing spirit,
she knew by the angelic expression of Ellen's upturned eyes, and by
the look of unutterable serenity that was diffused over her whole
countenance. The voice of Mr. M—— died away on her ear, and an
unbroken silence reigned through the apartment. Her stormy grief
had been stilled into calmness, during that holy prayer. The eyes of
Ellen were now gently closed, and as they rose from their knees they
sat down by her side, fearing, even by a deep-drawn breath, to
disturb her slumbers. A faint hope began to dawn in the mother's
heart, from the placidity and duration of her slumbers.
"I have never known her sleep so calm before," said she, in a low
voice, to Mr. M——. Mr. M—— bent forward and laid his hand softly
on her marble brow.
"Calm indeed are her slumbers," said he, looking solemnly upward;
"she sleeps now, I trust, in the bosom of her Saviour and her God."
Thus died Ellen Loring—just one year from that night when Agnes
followed her retreating figure, with such a wistful gaze, as she left
her for the ball-room, exclaiming to herself, "Happy, beautiful Ellen!"
and Agnes now said within herself, even while she wept over her
clay-cold form, "Happy Ellen!" but with far different emotions; for
she now followed, with the eye of faith, her ascending spirit to the
regions of the blest, and saw her, in imagination, enter those golden
gates, which never will be closed against the humble and penitent
believer.
A few evenings after, a brilliant party was assembled in one of those
halls, where pleasure welcomes its votaries.—"Did you know that
Ellen Loring was dead?" observed some one to a beautiful girl, the
very counterpart of what Ellen once was. "Dead!" exclaimed the
startled beauty, for one moment alarmed into reflection; "I did not
think she would have died so soon. I am sorry you told me—it will
throw a damp over my spirits the whole evening—poor Ellen!" It was
but a moment, and the music breathed forth its joyous strains. She
was led in haste to the dance, and Ellen Loring was forgotten.
 THE FATAL COSMETIC.

Charles Brown sat with Mr. Hall in a corner of the room, apart from
the rest of the company. Mr. Hall was a stranger, Charles the familiar
acquaintance of all present. The former evidently retained his seat
out of politeness to the latter for his eyes wandered continually to
the other side of the room, where a group of young ladies was
gathered round a piano, so closely as to conceal the musician to
whom they were apparently listening. The voice that accompanied
the instrument was weak and irregular, and the high tones
excessively shrill and disagreeable, yet the performer continued her
songs with unwearied patience, thinking the young gentlemen were
turned into the very stones that Orpheus changed into breathing
things, to remain insensible to her minstrelsy. There was one fair,
blue-eyed girl, with a very sweet countenance, who stood behind
her chair and cast many a mirthful glance towards Charles, while she
urged the songstress to continue at every pause, as if she were
spell-bound by the melody. Charles laughed, and kept time with his
foot, but Mr. Hall bit his lips, and a frown passed over his handsome
and serious countenance. "What a wretched state of society!"
exclaimed he, "that admits, nay, even demands such insincerity.
Look at the ingenuous countenance of that young girl—would you
not expect from her sincerity and truth? Yet, with what practical
falsehood she encourages her companion in her odious screeching!"
"Take care," answered Charles, "you must not be too severe. That
young lady is a very particular friend of mine, and a very charming
girl. She has remarkably popular manners, and if she is guilty of a
few little innocent deceptions, such, for instance, as the present, I
see no possible harm in them to herself, and they certainly give
great pleasure to others. She makes Miss Lewis very happy, by her
apparent admiration, and I do not see that she injures any one
else."
Mr. Hall sighed.
"I fear," said he, "I am becoming a misanthropist. I find I have very
peculiar views, such as set me apart and isolate me from my fellow
beings. I cannot enjoy an artificial state of society. I consider truth
as the corner stone of the great social fabric, and where this is
wanting, I am constantly looking for ruin and desolation. The person
deficient in this virtue, however fair and fascinating, is no more to
me than the whited sepulchre and painted wall."
"You have, indeed, peculiar views," answered Charles, colouring with
a vexation he was too polite to express in any other way; "and if you
look upon the necessary dissimulations practised in society as
falsehoods, and brand them as such, I can only say, that you have
created a standard of morality more exalted and pure than human
nature can ever reach."
"I cannot claim the merit of creating a standard, which the divine
Moralist gave to man, when he marked out his duties from the
sacred mount, in characters so clear and deep, that the very blind
might see and the cold ear of deafness hear."
Mr. Hall spoke with warmth. The eyes of the company were directed
towards him. He was disconcerted and remained silent. Miss Lewis
rose from the piano, and drew towards the fire.
"I am getting terribly tired of the piano," said she. "I don't think it
suits my voice at all. I am going to take lessons on the guitar and
the harp—one has so much more scope with them; and then they
are much more graceful instruments."
"You are perfectly right," replied Miss Ellis, the young lady with the
ingenuous countenance, "I have no doubt you would excel on either,
and your singing would be much better appreciated. Don't you think
so, Margaret?" added she, turning to a young lady, who had hitherto
been silent, and apparently unobserved.
"You know I do not," answered she, who was so abruptly addressed,
in a perfectly quiet manner, and fixing her eyes serenely on her face;
"I should be sorry to induce Miss Lewis to do anything
disadvantageous to herself, and consequently painful to her friends."
"Really, Miss Howard," cried Miss Lewis, bridling, and tossing her
head with a disdainful air, "you need not be so afraid of my giving
you so much pain—I will not intrude my singing upon your delicate
and refined ears."
Mr. Hall made a movement forward, attracted by the uncommon
sincerity of Miss Howard's remark.
"There," whispered Charles, "is a girl after your own heart—Margaret
Howard will speak the truth, however unpalatable it may be, and see
what wry faces poor Miss Lewis makes in trying not to swallow it—I
am sure Mary Ellis's flattery is a thousand times kinder and more
amiable."
Mr. Hall did not answer. His eyes were perusing the face of her,
whose lips had just given such honourable testimony to a virtue so
rarely respected by the world of fashion. A decent boldness lighted
up the clear hazel eyes that did not seem to be unconscious of the
dark and penetrating glances at that moment resting upon them.
She was dressed with remarkable simplicity. No decoration in colour
relieved the spotless whiteness of her attire. Her hair of pale, yet
shining brown, was plainly parted over a brow somewhat too lofty
for mere feminine beauty, but white and smooth as Parian marble.
Her features, altogether, bore more resemblance to a Pallas than a
Venus. They were calm and pure, but somewhat cold and
passionless—and under that pale, transparent skin, there seemed no
under current, ebbing and flowing with the crimson tide of the heart.
Her figure, veiled to the throat, was of fine, though not very slender
proportions. There was evidently no artificial compression about the
waist, no binding ligatures to prevent the elastic motions of the
limbs, the pliable and graceful movements of nature.
"She has a fine face—a very handsome face," repeated Charles,
responding to what Mr. Hall looked, for as yet he had uttered
nothing; "but to me, it is an uninteresting one. She is not generally
liked—respected, it is true, but feared—and fear is a feeling which
few young ladies would wish to inspire. It is a dangerous thing to
live above the world—at least, for a woman."
Charles availed himself of the earliest opportunity of introducing his
friend to Miss Howard, glad to be liberated for a while from the close
companionship of a man who made him feel strangely
uncomfortable with regard to himself, and well pleased with the
opportunity of conversing with his favourite, Mary Ellis.
"I feel quite vexed with Margaret," said this thoughtless girl, "for
spoiling my compliment to Miss Lewis. I would give one of my little
fingers to catch her for once in a white lie."
"Ask her if she does not think herself handsome," said Charles; "no
woman ever acknowledged that truth, though none be more firmly
believed."
He little expected she would act upon his suggestion, but Mary was
too much delighted at the thought of seeing the uncompromising
Margaret guilty of a prevarication, to suffer it to pass unheeded.
"Margaret," cried she, approaching her, unawed by the proximity of
the majestic stranger—"Mr. Brown says you will deny that you think
yourself handsome. Tell me the truth—don't you believe yourself
very handsome?"
"I will tell you the truth, Mary," replied Margaret, blushing so
brightly, as to give an actual radiance to her face, "that is, if I speak
at all. But I would rather decline giving any opinion of myself."
"Ah! Margaret," persisted Miss Ellis, "I have heard you say that to
conceal the truth, when it was required of us, unless some moral
duty were involved, was equivalent to a falsehood. Bear witness,
Charles, here is one subject on which even Margaret Howard dares
not speak the truth."
"You are mistaken," replied Miss Howard; "since you force me to
speak, by attacking my principles, I am very willing to say, I do think
myself handsome; but not so conspicuously as to allow me to claim
a superiority over my sex, or to justify so singular and unnecessary a
question."
All laughed—even the grave Mr. Hall smiled at the frankness of the
avowal—all but Miss Lewis, who, turning up her eyes and raising her
hands, exclaimed, "Really, Miss Howard's modesty is equal to her
politeness. I thought she despised beauty."
"The gifts of God are never to be despised," answered Miss Howard,
mildly. "If he has graced the outer temple, we should only be more
careful to keep the indwelling spirit pure."
She drew back, as if pained by the observation she had excited; and
the deep and modest colour gradually faded from her cheek. Mr. Hall
had not been an uninterested listener. He was a sad and
disappointed man. He had been the victim of a woman's perfidy and
falsehood—and was consequently distrustful of the whole sex; and
his health had suffered from the corrosion of his feelings, and he
had been compelled to seek, in a milder clime, a balm which time
alone could yield. He had been absent several years, and was just
returned to his native country, but not to the scene of his former
residence. The wound was healed, but the hardness of the scar
remained.
One greater and purer than the Genius of the Arabian Tale, had
placed in his breast a mirror, whose lustre would be instantaneously
dimmed by the breath of falsehood or dissimulation. It was in this
mirror he saw reflected the actions of his fellow beings, and it
pained him to see its bright surface so constantly sullied. Never,
since the hour he was so fatally deceived, had he been in the
presence of woman, without a melancholy conviction that she was
incapable of standing the test of this bosom talisman. Here,
however, was one, whose lips cast no cloud upon its lustre. He
witnessed the marvellous spectacle of a young, beautiful, and
accomplished woman, surrounded by the artifices and
embellishments of fashionable life, speaking the truth, in all
simplicity and godly sincerity, as commanded by the holy men of old.
There was something in the sight that renovated and refreshed his
blighted feelings. The dew falling on the parched herbage, prepares
it for the influence of a kinder ray. Even so the voice of Margaret
Howard, gentle in itself and persuasive, advocating the cause he
most venerated, operated this night on the heart of Mr. Hall.
For many weeks the same party frequently met at the dwelling of
Mrs. Astor. This lady was a professed patroness and admirer of
genius and the fine arts. To be a fine painter, a fine singer, a fine
writer, a traveller, or a foreigner, was a direct passport to her favour.
To be distinguished in any manner in society was sufficient, provided
it was not "bad eminence" which was attained by the individual. She
admired Mr. Hall for the stately gloom of his mien, his dark and
foreign air, his peculiar and high-wrought sentiments. She sought an
intimacy with Margaret Howard, for it was a distinction to be her
friend, and, moreover, she had an exquisite taste and skill in drawing
and painting. Mary Ellis was a particular favourite of hers, because
her own favourite cousin Charles Brown thought her the most
fascinating young lady of his acquaintance. Mrs. Astor's house was
elegantly furnished, and her rooms were adorned with rare and
beautiful specimens of painting and statuary. She had one apartment
which she called her Gallery of Fine Arts, and every new guest was
duly ushered into this sanctuary, and called upon to look and admire
the glowing canvas and the breathing marble. A magnificent pier-
glass was placed on one side of the hall, so as to reflect and multiply
these classic beauties. It had been purchased in Europe, and was
remarkable for its thickness, brilliancy, and fidelity of reflection. It
was a favourite piece of furniture of Mrs. Astor's, and all her servants
were warned to be particularly careful, whenever they dusted its
surface. As this glass is of some importance in the story, it deserves
a minute description. Mrs. Astor thought the only thing necessary to
complete the furnishing of the gallery, were transparencies for the
windows. Miss Howard, upon hearing the remark, immediately
offered to supply the deficiency, an offer at once eagerly accepted,
and Mrs. Astor insisted that her painting apparatus should be placed
in the very room, that she might receive all the inspiration to be
derived from the mute yet eloquent relics of genius, that there
solicited the gaze. Nothing could be more delightful than the
progress of the work. Margaret was an enthusiast in the art, and her
kindling cheek always attested the triumph of her creating hand.
Mrs. Astor was in a constant state of excitement, till the whole was
completed, and it was no light task, as four were required, and the
windows were of an extra size. Almost every day saw the fair artist
seated at her easel, with the same group gathered round her. Mary
Ellis admired everything so indiscriminately, it was impossible to
attach much value to her praise; but Mr. Hall criticised as well as
admired, and as he had the painter's eye, and the poet's tongue,
Margaret felt the value of his suggestions, and the interest they
added to her employment. Above all things, she felt their truth. She
saw that he never flattered, that he dared to blame, and when he
did commend, she was conscious the tribute was deserved. Margaret
was not one of those beings, who cannot do but one thing at a time.
She could talk and listen, while her hands were applying the brush
or arranging the colours, and look up too from the canvas, with a
glance that showed how entirely she participated in what was
passing around her.
"I wonder you are not tired to death of that everlasting easel," said
Mary Ellis to Margaret, who grew every day more interested in her
task. "I could not endure such confinement."
"Death and everlasting are solemn words to be so lightly used, my
dear Mary," answered Margaret, whose religious ear was always
pained by levity on sacred themes.
"I would not be as serious as you are, for a thousand worlds,"
replied Mary, laughing; "I really believe you think it a sin to smile.
Give me the roses of life, let who will take the thorns. I am going
now to gather some, if I can, and leave you and Mr. Hall to enjoy all
the briers you can find."
She left the room gayly singing, sure to be immediately followed by
Charles, and Mr. Hall was left sole companion of the artist. Mary had
associated their names together, for the purpose of disturbing the
self-possession of Margaret, and she certainly succeeded in her
object. Had Mr. Hall perceived her heightened colour, his vanity
might have drawn a flattering inference; but he was standing behind
her easel, and his eyes were fixed on the beautiful personification of
Faith, Hope, and Charity—those three immortal graces—she was
delineating, as kneeling and embracing, with upturned eyes and
celestial wings. It was a lovely group—the last of the transparencies,
and Margaret lavished on it some of the finest touches of her genius.
Mary had repeated a hundred times that it was finished, that
another stroke of the pencil would ruin it, and Mrs. Astor declared it
perfect, and more than perfect, but still Margaret lingered at the
frame, believing every tint should be the last. Every lover of the arts
knows the fascination attending the successful exercise and
development of their genius—of seeing bright and warm imaginings
assume a colouring and form, and giving to others a transcript of the
mind's glorious creations; but every artist does not know what
deeper charm may be added by the conversation and companionship
of such a being as Mr. Hall. He was what might be called a
fascinating man, notwithstanding the occasional gloom and general
seriousness of his manners. For, when flashes of sensibility lighted
up that gloom, and intellect, excited and brought fully into action,
illumined that seriousness—it was like moonlight shining on some
ruined castle, beauty and grandeur meeting together and exalting
each other, from the effect of contrast. Then there was a deep vein
of piety pervading all his sentiments and expressions. The
comparison of the ruined castle is imperfect. The moonbeams falling
on some lofty cathedral, with its pillared dome and "long-drawn
aisles," is a better similitude, for devotion hallowed and elevated
every faculty of his soul. Margaret, who had lived in a world of her
own, surrounded by a purer atmosphere, lonely and somewhat
unapproachable, felt as if she were no longer solitary, for here was
one who thought and sympathized with her; one, too, who seemed
sanctified and set apart from others, by a kind of mysterious sorrow,
which the instinct of woman told her had its source in the heart.
"I believe I am too serious, as Mary says," cried Margaret, first
breaking the silence; "but it seems to me the thoughtless alone can
be gay. I am young in years, but I began to reflect early, and from
the moment I took in the mystery of life and all its awful
dependencies, I ceased to be mirthful. I am doomed to pay a
constant penalty for the singularity of my feelings: like the priestess
of the ancient temples, I am accused of uttering dark sayings of old,
and casting the shadows of the future over the joys of the present."
Margaret seldom alluded to herself, but Mary's accusation about the
thorns and briers had touched her, where perhaps alone she was
vulnerable; and in the frankness of her nature, she uttered what was
paramount in her thoughts.
"Happy they who are taught by reflection, not experience, to look
seriously, though not sadly on the world," said Mr. Hall, earnestly;
"who mourn from philanthropy over its folly and falsehood, not
because that falsehood and folly have blighted their dearest hopes,
nay, cut them off, root and branch, for ever."
Margaret was agitated, and for a moment the pencil wavered in her
hand. She knew Mr. Hall must have been unhappy—that he was still
suffering from corroding remembrances—and often had she wished
to pierce through the mystery that hung over his past life; but now,
when he himself alluded to it, she shrunk from an explanation. He
seemed himself to regret the warmth of his expressions, and to wish
to efface the impression they had made, for his attention became
riveted on the picture, which he declared wanted only one thing to
make it perfect—"And what was that?"—"Truth encircling the trio
with her golden band."
"It may yet be done," cried Margaret; and, with great animation and
skill, she sketched the outline suggested.
It is delightful to have one's own favourite sentiments and feelings
embodied by another, and that too with a graceful readiness and
apparent pleasure, that shows a congeniality of thought and taste.
Mr. Hall was not insensible to this charm in Margaret Howard. He
esteemed, revered, admired, he wished that he dared to love her.
But all charming and true as she seemed, she was still a woman,
and he might be again deceived. It would be a terrible thing to
embark his happiness once more on the waves which had once
overwhelmed it; and find himself again a shipwrecked mariner, cast
upon the cruel desert of existence. The feelings which Margaret
inspired were so different from the stormy passions which had
reigned over him, it is no wonder he was unconscious of their
strength and believed himself still his own master.
"Bless me," said Mary, who, entering soon after, banished, as she
said, Mr. Hall from her presence, for he retired; "if you have not
added another figure to the group. I have a great mind to blot Faith,
Hope, and Charity, as well as Truth from existence," and playfully
catching hold of the frame, she pretended to sweep her arm over
their faces.
"Oh! Mary, beware!" exclaimed Margaret; but the warning came too
late. The easel tottered and fell instantaneously against the
magnificent glass, upon which Mrs. Astor set such an immense
value, and broke it into a thousand pieces. Mary looked aghast, and
Margaret turned pale as she lifted her picture from amid the ruins.
"It is not spoiled," said she; "but the glass!"
"Oh! the glass!" cried Mary, looking the image of despair; "what shall
I do? What will Mrs. Astor say? She will never forgive me!"
"She cannot be so vindictive!" replied Margaret; "but it is indeed an
unfortunate accident, and one for which I feel particularly
responsible."
"Do not tell her how it happened," cried Mary, shrinking with moral
cowardice from the revealing of the truth. "I cannot brave her
displeasure!—Charles, too, will be angry with me, and I cannot bear
that. Oh! pray, dearest Margaret, pray do not tell her that it was I
who did it—you know it would be so natural for the easel to fall
without any rash hand to push it. Promise me, Margaret."
Margaret turned her clear, rebuking eye upon the speaker with a
mingled feeling of indignation and pity.
"I will not expose you, Mary," said she, calmly; and, withdrawing
herself from the rapturous embrace, in which Mary expressed her
gratitude, she began to pick up the fragments of the mirror, while
Mary, unwilling to look on the wreck she had made, flew out to
regain her composure. It happened that Mr. Hall passed the window
while Margaret was thus occupied; and he paused a moment to
watch her, for in spite of himself, he felt a deep and increasing
interest in every action of Margaret's. Margaret saw his shadow as it
lingered, but she continued her employment. He did not doubt that
she had caused the accident, for he had left her alone, a few
moments before, and he was not conscious that any one had
entered since his departure. Though he regretted any circumstance
which might give pain to her, he anticipated a pleasure in seeing the
openness and readiness with which she would avow herself the
aggressor, and blame herself for her carelessness.
Margaret found herself in a very unpleasant situation. She had
promised not to betray the cowardly Mary, and she knew that
whatever blame would be attached to the act, would rest upon
herself. But were Mrs. Astor to question her upon the subject, she
could not deviate from the truth, by acknowledging a fault she had
never committed. She felt an unspeakable contempt for Mary's
weakness, for, had she been in her place, she would have
acknowledged the part she had acted, unhesitatingly, secure of the
indulgence of friendship and benevolence. "Better to leave the
circumstance to speak for itself," said Margaret to herself, "and of
course the burden will rest upon me." She sighed as she thought of
the happy hours she had passed, by the side of that mirror, and how
often she had seen it reflect the speaking countenance of Mr. Hall,
that tablet of "unutterable thoughts," and then thinking how his
hopes seemed shattered like that frail glass, and his memories of
sorrow multiplied, she came to the conclusion that all earthly hopes
were vain and all earthly memories fraught with sadness. Never had
Margaret moralized so deeply as in the long solitary walk she stole
that evening, to escape the evil of being drawn into the tacit
sanction of a falsehood. Like many others, with equally pure
intentions, in trying to avoid one misfortune she incurred a greater.
Mrs. Astor was very much grieved and astonished when she
discovered her loss. With all her efforts to veil her feelings, Mary saw
she was displeased with Margaret, and would probably never value
as they deserved, the beautiful transparencies on which she had so
faithfully laboured.
"I would not have cared if any other article had been broken," said
Mrs. Astor, whose weak point Mary well knew; "but this can never be
replaced. I do not so much value the cost, great as it was, but it was
perfectly unique. I never saw another like it."
Mary's conscience smote her, for suffering another to bear the
imputation she herself deserved. A sudden plan occurred to her. She
had concealed the truth, she was now determined to save her
friend, even at the cost of a lie.
"I do not believe Margaret broke it," said she. "I saw Dinah, your
little black girl in the room, just before Margaret left it, and you
know how often you have punished her for putting her hands on
forbidden articles. You know if Margaret had done it, she would have
acknowledged it, at once."
"True," exclaimed Mrs. Astor; "how stupid I have been!" and glad to
find a channel in which her anger could flow, unchecked by the
restraints of politeness, she rung the bell and summoned the
unconscious Dinah.
In vain she protested her innocence. She was black, and it was
considered a matter of course that she would lie. Mrs. Astor took her
arm in silence, and led her from the room, in spite of her prayers
and protestations. We should be sorry to reveal the secrets of the
prison-house, but from the cries that issued through the shut door,
and from a certain whizzing sound in the air, one might judge of the
nature of the punishment inflicted on the innocent victim of
unmerited wrath. Mary closed her ears. Every sound pierced her
heart. Something told her those shrieks would rise up in judgment
against her at the last day. "Oh! how," thought she, "if I fear the
rebuke of my fellow-creature for an unintentional offence, how can I
ever appear before my Creator, with the blackness of falsehood and
the hardness of cruelty on my soul?" She wished she had had the
courage to have acted right in the first place, but now it was too
late. Charles would despise her, and that very day he had told her
that he loved her better than all the world beside. She tried, too, to
soothe her conscience, by reflecting that Dinah would have been
whipped for something else, and that as it was a common event to
her, it was, after all, a matter of no great consequence. Mrs. Astor,
having found a legitimate vent for her displeasure, chased the cloud
from her brow, and greeted Margaret with a smile, on her return,
slightly alluding to the accident, evidently trying to rise superior to
the event. Margaret was surprised and pleased. She expressed her
own regret, but as she imputed to herself no blame, Mrs. Astor was
confirmed in the justice of her verdict. Margaret knew not what had
passed in her absence, for Mrs. Astor was too refined to bring her
domestic troubles before her guests. Mary, who was the only one
necessarily initiated, was too deeply implicated to repeat it, and the
subject was dismissed. But the impression remained on one mind,
painful and ineffaceable.
Mr. Hall marked Margaret's conscious blush on her entrance, he had
heard the cries and sobs of poor Dinah, and was not ignorant of the
cause. He believed Margaret was aware of the fact—she, the true
offender. A pang, keen as cold steel can create, shot through his
heart at this conviction. He had thought her so pure, so true, so
holy, the very incarnation of his worshipped virtue—and now, to
sacrifice her principles for such a bauble—a bit of frail glass. He
could not remain in her presence, but, complaining of a headache,
suddenly retired, but not before he had cast a glance on Margaret,
so cold and freezing, it seemed to congeal her very soul.
"He believes me cowardly and false," thought she, for she divined
what was passing in his mind; and if ever she was tempted to be so,
it was in the hope of reinstating herself in his esteem. She had given
her promise to Mary, however, and it was not to be broken. Mary,
whose feelings were as evanescent as her principles were weak,
soon forgot the whole affair in the preparations of her approaching
marriage with Charles, an event which absorbed all her thoughts, as
it involved all her hopes of happiness.
Margaret finished her task, but the charm which had gilded the
occupation was fled. Mr. Hall seldom called, and when he did, he
wore all his original reserve. Margaret felt she had not deserved this
alienation, and tried to cheer herself with the conviction of her own
integrity; but her spirits were occasionally dejected, and the figure of
Truth, which had such a beaming outline, assumed the aspect of
utter despondency. Dissatisfied with her work, she at last swept her
brush over the design, and mingling Truth with the dark shades of
the back ground, gave up her office as an artist, declaring her
sketches completed. Mrs. Astor was enraptured with the whole, and
said she intended to reserve them for the night of Mary's wedding,
when they would burst upon the sight, in one grand coup d'œil, in
the full blaze of chandeliers, bridal lamps, and nuptial ornaments.
Margaret was to officiate as one of the bridemaids, but she gave a
reluctant consent. She could not esteem Mary, and she shrunk from
her flattery and caresses with an instinctive loathing. She had once
set her foot on a flowery bank, that edged a beautiful stream. The
turf trembled and gave way, for it was hollow below, and Margaret
narrowly escaped death. She often shuddered at the recollection.
With similar emotions she turned from Mary Ellis's smiles and graces.
There was beauty and bloom on the surface, but hollowness and
perhaps ruin beneath.
A short time before the important day, a slight efflorescence
appeared on the fair cheek and neck of Mary. She was in despair,
lest her loveliness should be marred, when she most of all wished to
shine. It increased instead of diminishing, and she resolved to have
recourse to any remedy, that would remove the disfiguring eruption.
She recollected having seen a violent erysipelas cured immediately
by a solution of corrosive sublimate; and without consulting any one,
she sent Dinah to the apothecary to purchase some, charging her to
tell no one whose errand she was bearing, for she was not willing to
confess her occasion for such a cosmetic. Dinah told the apothecary
her mistress sent her, and it was given without questioning or
hesitation. Her only confidant was Margaret, who shared her
chamber and toilet, and who warned her to be exceedingly cautious
in the use of an article so poisonous; and Mary promised with her
usual heedlessness, without dreaming of any evil consequences. The
eruption disappeared—Mary looked fairer than ever, and, clad in her
bridal paraphernalia of white satin, white roses, and blonde lace,
was pronounced the most beautiful bride of the season. Mr. Hall was
present, though he had refused to take any part in the ceremony. He
could not, without singularity, decline the invitation and,
notwithstanding the blow his confidence in Margaret's character had
received, he still found the spot where she was, enchanted ground,
and he lingered near, unwilling to break at once the only charm that
still bound him to society. After the short but solemn rite, that made
the young and thoughtless, one by indissoluble ties, and the rush of
congratulation took place, Margaret was forced by the pressure close
to Mr. Hall's side. He involuntarily offered his arm as a protection,
and a thrill of irrepressible happiness pervaded his heart, at this
unexpected and unsought proximity. He forgot his coldness—the
broken glass, everything but the feeling of the present moment.
Margaret was determined to avail herself of the tide of returning
confidence. Her just womanly modesty and pride prevented her
seeking an explanation and reconciliation, but she knew without
breaking her promise to Mary, she could not justify herself in Mr.
Hall's opinion, if even the opportunity offered. She was to depart in
the morning, with the new-married pair, who were going to take an
excursion of pleasure, so fashionable after the wedding ceremony.
She might never see him again. He had looked pale, his face was
now flushed high with excited feeling.
"You have wronged me, Mr. Hall," said she, blushing, but without
hesitation; "if you think I have been capable of wilful deception or
concealment. The mirror was not broken by me, though I know you
thought me guilty, and afraid or ashamed to avow the truth. I would
not say so much to justify myself, if I did not think you would believe
me, and if I did not value the esteem of one who sacrifices even
friendship at the shrine of truth."
She smiled, for she saw she was believed, and there was such a
glow of pleasure irradiating Mr. Hall's countenance, it was like the
breaking and gushing forth of sunbeams. There are few faces, on
which a smile has such a magic effect as on Margaret's. Her smile
was never forced. It was the inspiration of truth, and all the light of
her soul shone through it. Perhaps neither ever experienced an hour
of deeper happiness than that which followed this simple
explanation. Margaret felt a springtide of hope and joy swelling in
her heart, for there was a deference, a tenderness in Mr. Hall's
manner she had never seen before. He seemed entirely to have
forgotten the presence of others, when a name uttered by one near,
arrested his attention.
"That is Mrs. St. Henry," observed a lady, stretching eagerly forward.
"She arrived in town this morning, and had letters of introduction to
Mrs. Astor. She was the beauty of ——, before her marriage, and is
still the leader of fashion and taste."
Margaret felt her companion start, as if a ball had penetrated him,
and looking up, she saw his altered glance, fixed on the lady, who
had just entered, with a dashing escort, and was advancing towards
the centre of the room. She was dressed in the extremity of the
reigning mode—her arms and neck entirely uncovered, and their
dazzling whiteness, thus lavishly displayed, might have mocked the
polish and purity of alabaster. Her brilliant black eyes flashed on
either side, with the freedom of conscious beauty, and disdain of the
homage it inspired. She moved with the air of a queen, attended by
her vassals, directly forward, when suddenly her proud step faltered,
her cheek and lips became wan, and uttering a sudden ejaculation,
she stood for a moment perfectly still. She was opposite Mr. Hall,
whose eye, fixed upon hers, seemed to have the effect of
fascination. Though darkened by the burning sun of a tropical clime,
and faded from the untimely blighting of the heart, that face could
never be forgotten. It told her of perjury, remorse, sorrow—yes, of
sorrow, for in spite of the splendour that surrounded her, this
glittering beauty was wretched. She had sacrificed herself at the
shrine of Mammon, and had learned too late the horror of such ties,
unsanctified by affection. Appreciating but too well the value of the
love she had forsaken, goaded by remorse for her conduct to him,
whom she believed wasting away in a foreign land—she flew from
one scene of dissipation to another, seeking in the admiration of the
world an equivalent for her lost happiness. The unexpected
apparition of her lover was as startling and appalling as if she had
met an inhabitant of another world. She tried to rally herself and to
pass on, but the effort was in vain—sight, strength, and recollection
forsook her.
"Mrs. St. Henry has fainted! Mrs. St. Henry has fainted!"—was now
echoed from mouth to mouth. A lady's fainting, whether in church,
ball-room, or assembly, always creates a great sensation; but when
that lady happens to be the centre of attraction and admiration,
when every eye that has a loop-hole to peep through is gazing on
her brilliant features, to behold her suddenly fall, as if smitten by the
angel of death, pallid and moveless—the effect is inconceivably
heightened. When, too, as in the present instance, a sad, romantic-
looking stranger rushes forward to support her, the interest of the
scene admits of no increase. At least Margaret felt so, as she saw
the beautiful Mrs. St. Henry borne in the arms of Mr. Hall through
the crowd, that fell back as he passed, into an adjoining apartment,
speedily followed by Mrs. Astor, all wonder and excitement, and
many others all curiosity and expectation, to witness the termination
of the scene. Mr. Hall drew back, while the usual appliances were
administered for her resuscitation. He heeded not the scrutinizing
glances bent upon him. His thoughts were rolled within himself, and
 "The soul of other days came rushing in."

The lava that had hardened over the ruin it created, melted anew,
and the greenness and fragrance of new-born hopes were lost under
the burning tide. When Mrs. St. Henry opened her eyes, she looked
round her in wild alarm; then shading her brow with her hand, her
glance rested where Mr. Hall stood, pale and abstracted, with folded
arms, leaning against the wall—"I thought so," said she, in a low
voice, "I thought so;"—then covered her eyes and remained silent.
Mr. Hall, the moment he heard the sound of her voice and was
assured of her recovery, precipitately retired, leaving behind him
matter of deep speculation. Margaret was sitting in a window of the
drawing-room, through which he passed. She was alone, for even
the bride was forgotten in the excitement of the past scene. He
paused—he felt an explanation was due to her, but that it was
impossible to make it. He was softened by the sad and sympathizing
expression of her countenance, and seated himself a moment by her
side.
"I have been painfully awakened from a dream of bliss," said he,
"which I was foolish enough to imagine might yet be realized. But
the heart rudely shattered as mine has been, must never hope to be
healed. I cannot command myself sufficiently to say more, only let
me make one assurance, that whatever misery has been and may
yet be my doom, guilt has no share in my wretchedness—I cannot
refuse myself the consolation of your esteem."
Margaret made no reply—she could not. Had her existence
depended on the utterance of one word, she could not have
commanded it. She extended her hand, however, in token of that
friendship she believed was hereafter to be the only bond that was
to unite them. Long after Mr. Hall was gone, she sat in the same
attitude, pale and immovable as a statue; but who can tell the
changes and conflicts of her spirit, in that brief period?
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