Using History to Help Reframe Today’s Health Care Debate

 President Obama and the United States Congress continue to struggle with an overhaul of the nation’s health care system, with American physicians and patients alike often expressing frustration with medical practices and the delivery of services in the 21st century. Perhaps the examination of an unusual health care model developed over a century ago by Dr. Charles David Spivak, a Russian Jewish immigrant physician in early twentieth century Denver, Colorado and how he met the challenge of providing services to impoverished victims of tuberculosis before the concept of health insurance became a part of the American lexicon, can provide us with new insights.

Spivak received his medical degree in 1890 from the Jefferson Medical College in Philadelphia, where he developed a successful practice in gastroenterology,  but moved to Denver in 1896 in search of a cure for his wife’s incipient case of tuberculosis. In 1904 he became the head of the formally non-sectarian Jewish Consumptives’ Relief Society (JCRS) sanatorium/hospital, which treated all patients in all stages of the disease free of charge. It also provided centralized local care and was locally managed with national support. Led by Spivak, the institution’s funding relied solely on thousands of voluntary small donations from the masses around the country, mostly the working class -- no government funds, no taxpayer contributions. A novel approach at the time, today it would certainly be a highly radical policy, but one that deserves examination, if only for the ideals it inspires.

 Tuberculosis, or consumption as it was also commonly known, held the dubious distinction of being the leading cause of death in nineteenth-century America. In the first years of the twentieth century 150,000 Americans died yearly due to tuberculosis, and more than ten times that number suffered at the hands of the disease. The disease was no respecter of class, but many of its victims were both immigrants and poor. Moreover, Progressive Era sanatoriums generally only accepted patients with incipient or early stage tuberculosis, rationalizing that those cases were the most likely to improve and therefore the most efficient use of resources This policy, which was common in the early twentieth century,  reminds us that the concept of rationing medical treatment is not a new one. Patients at the time with advanced cases of the disease were generally left to fend for themselves

There was no one accepted standard for tuberculosis treatment at the time. Various experimental therapies, medications, and folk remedies competed with the “open air” method of treatment. Once again, history reminds us that differing views on what constitutes best medical practice is not a contemporary development. Colorado, with its dry and sunny climate, drew tuberculosis victims like a magnet as it became a center of hope for those suffering from the disease. By the late nineteenth century thousands of health seekers descended on Colorado, and with no state or municipal hospitals to treat them it was left to local religious and ethnic communities to deal with the challenge. The Jewish community of Denver was the first to come forward with the opening of the National Jewish Hospital for Consumptives (NJH) in 1899. Within a few years a second Jewish based sanatorium appeared on the Denver landscape.

            Dr. Charles Spivak helped found Denver’s Jewish Consumptives’ Relief Society (JCRS) sanatorium, which opened in 1904 and served over 10,000 patients before it transformed its mission to cancer treatment in 1954. Like NJH, It was formally non-sectarian, but for at least the first several decades of its existence the vast majority of  JCRS patients were east European immigrants of modest means. Especially responsive to the ethnic and religious sensibilities of these patients, the JCRS treated patients in a distinctly Jewish environment. This was due in large part to Spivak, who from 1904 until his death in 1927, served as its executive secretary, or executive director, as we would term it today.

 Spivak, who had immigrated to America in 1882 to escape apprehension by the Russian secret police for his revolutionary activities (his group read translated copies of the American Declaration of Independence among other “subversive” literature!) became a democratic socialist in America as well as a proud Jewish American and successful middle-class physician. He was the guiding spirit behind the JCRS and supervised the fund-raising operations, which were strongly influenced by his personal philosophy, a rather unique blend of Jewish tradition, secularism, and socialism.

Spivak’s strong sense of ethnic consciousness, community responsibility and medical expertise shaped the direction of the JCRS sanatorium for nearly a quarter of a century. He was strongly animated by the traditional Jewish concept of tzedakah, commonly translated as charity but literally meaning justice. In fact, the doctor looked upon medicine as a calling rather than a profession and was motivated by his core belief that providing medical services to the poor was not benevolent altruism but fundamentally just. In other words Spivak viewed charity as an obligation rather than an act of noblesse oblige. He insisted the philanthropic work at the JCRS be charity of the “heart” and not merely the head, and took pains to insure that patients did not feel like public charges. By providing services free of charge, Spivak wanted to level the playing field and insure that all patients would be treated equally and that the rich could not “buy” better treatment. Spivak effectively channeled his early radical convictions into more empathetic and humane treatment of patients in general and especially toward unconventional and path breaking treatment for tuberculosis victims with severe cases of the disease, who had generally been marginalized by the medical mainstream.

It was Spivak’s outlook that influenced daily operations at the JCRS. Spivak insisted that the JCRS be a “peoples’ institution,” with money collected from thousands of working-class supporters with modest incomes from throughout the country, a policy that diverged from the norm but that proved successful from an economic standpoint for decades. Indeed, he instructed one of his traveling fundraisers to "abandon entirely the idea of making any strenuous effort to meet our rich brethren. If our Institution is to be a peoples’ institution, it should be supported by the people only. Let us collect our moneys in dollars and quarters.”  Certainly those dollars and quarters added up and allowed the JCRS to operate in the black for decades. On the occasion of the tenth anniversary of the JCRS Spivak proudly reported “The first lesson [the JCRS] taught was that a national [medical] organization can be brought into the world without the midwifery of the rich and the professional philanthropist…. It proved to the world that a national organization can be launched, built and maintained by small tradesmen and working-men, the so-called hoi-polloi.”

Spivak brought to the subject of health care a far different approach than today’s dollar-driven system affords. The needs of the patients, patients from every socio-economic level, were always at the heart of his treatment, and for Spivak rationing was not an option. He insisted on compassionate treatment for all using the most up-to-date methods available –- and he was able to pay for it without resorting to tax dollars by stressing the responsibility of every individual, rich or poor, to contribute according to their means. True, advances in medical technology have made treatment today proportionately far more expensive, and the constraints of time, insurance rules, and financial limitations often tie the hands of physicians, but Dr. Charles Spivak’s philosophy should give us pause to consider what was and what still should be.