The Red Cross Institute for Crippled and Disabled Men and the “Gospel of Rehabilitation”

Today we have a guest post written by Ms. Julie M. Powell, 2018 recipient of the Audrey and William H. Helfand Fellowship in the History of Medicine and Public Health. Ms. Powell is a PhD candidate at The Ohio State University, her dissertation topic explores the growth of wartime rehabilitation initiatives for disabled soldiers and the rhetoric that accompanied and facilitated this expansion. 

In May 1917, one month after the United States joined the First World War, the American Red Cross created the Institute for Crippled and Disabled Men to “build up re-educational facilities which might be of value to the crippled soldiers and sailors of the American forces.”[1] To this end, Director Douglas McMurtrie (1888–1944) collected approximately 3,500 separate books, pamphlets, reports, and articles from the European continent, North America, and the United Kingdom and its Dominions. He and his research staff pored over the documents, authoring reports, news articles, and lectures that were subsequently fed back into circulation both in the United States and abroad. A look at the collection and the work of the Institute provides a window into the development of rehabilitative care in the early twentieth century, demonstrating that transnational medical networks operated and expanded throughout the war and that the transmission of information and ideology often went hand in hand.

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The Red Cross Institute for Crippled and Disabled Men, 1918.

The proliferation of literature on rehabilitation (including surgical amputation, orthopaedics, prosthetic design, physical therapy, and vocational re-education) can be attributed both to a sense of urgency—20 million men were wounded in the war—and to the relative newness of the field. The first orthopaedic institute was created in Munich in 1832 and the next in Copenhagen in 1872 but these, and others that followed, focused exclusively on care for disabled children. The first significant moves toward the retraining of adults were taken up in the two decades before the war. In 1897, in Saint Petersburg, disabled men began to be trained in the manufacture of orthopaedic devices and in 1908, with the founding of a school in Charleroi, Belgium, the industrially maimed were taught bookbinding, shoe repair, basket making, and more. The first retraining school for invalided soldiers was created in December 1914 in Lyon, France, four months after the outbreak of hostilities. The school provided the inspiration for over 100 similar schools throughout France. The period 1915–1917 saw a proliferation of orthopaedic and re-education institutions throughout Europe and the western world. It was on these models that the Red Cross Institute was founded.

The first institution of its kind in the United States, the Red Cross Institute for Crippled and Disabled Men resided at 311 Fourth Avenue (now Park Avenue South) in New York. Disabled men, either funded by the U.S. Army or attending through no-interest loans, trained in four trades: welding, mechanical drafting, printing, and the manufacture of artificial limbs. McMurtrie and his staff hosted meetings of disabled men—punctuated by cake and ice cream—wherein testimonials from the recently rehabilitated served as recruitment tools for the Institute.

But the broadest impact of the Institute came from its crusade to spread what McMurtrie referred to as the “gospel of rehabilitation”—an insistence on returning the disabled man to independence and self-sufficiency that he might eschew charity and compete fairly in the labor marketplace. Such notions were deeply rooted in classical liberalism, a foil to large-scale social welfare programs that would only emerge in the wake of the Second World War. In The Disabled Soldier, McMurtrie wrote plainly:

When the crippled soldier returns from the front, the government will provide for him, in addition to medical care, special training for self-support. But whether this will really put him back on his feet depends on what the public does to help or hinder, on whether the community morally backs up the national program to put the disabled soldier beyond the need of charity… In light of results already obtained abroad in the training of disabled soldiers, the complete elimination of the dependent cripple has become a constructive and inspiring possibility. Idleness is the great calamity. Your service to the crippled man, therefore, is to find for him a good busy job, and encourage him to tackle it. Demand of the cripple that he get back in the work of the world, and you will find him only too ready to do so.[2]

no longer handicapped_watermarked

A reproduction (right) of part of McMurtrie’s poster exhibit for the Institute featuring the liberal “gospel of rehabilitation”: self-sufficiency, competition, and independence from charity.

McMurtrie’s gospel sounded the same notes as the works of U.S. Allies across the pond, whose material he’d spent years collecting. In 1918, famed novelist, advocate of the war wounded, and editor for the rehabilitation journal Reveille, John Galsworthy warned against the perils of charity, of “drown[ing] the disabled in tea and lip gratitude” and thereby “unsteel[ing] his soul.” Rather, he wrote:

We shall so re-create and fortify…[the disabled soldier] that he shall leave hospital ready for a new career. Then we shall teach him how to tread the road of it, so that he fits again into the national life, becomes once more a workman with pride in his work, a stake in the country, and the consciousness that, handicapped though he be, he runs the race level with his fellows, and is by that so much the better man than they.[3]

Such rhetoric was of a piece with appeals from British Minister of Pensions, John Hodge, for the restoration of men to “industrial independence,” that they might “hold their own in the industrial race.”[4]

When McMurtrie invited the world’s newly-minted experts in rehabilitation to New York in 1919, they shared—as they had through pamphlets, pictures, and films—not just information but ideology. Discussions on war surgery and the organization of rehabilitation schemes unfolded side-by-side with talks on public education and encouragement of the disabled to train.

Such propaganda efforts were critical. According to McMurtrie: “The self-respect of self-support or the ignominy of dependence—which shall the future hold for our disabled soldiers?” The credit or blame, he held, would rest with a public that either demanded self-sufficiency or patronized its men with charity.

References:
[1] Douglas C. McMurtrie, The Organization, Work and Method of the Red Cross Institute for Crippled and Disabled Men (New York: The Red Cross Institute for Crippled and Disabled Men, 1918).
[2] Douglas McMurtrie, The Disabled Soldier (New York: The Macmillan Company, 1919), 37.
[3] John Galsworthy, “Foreword,” The Inter-allied Conference on the After-Care of Disabled Men: Reports Presented to the Conference (London: His Majesty’s Stationary Office, 1918): 13–17. Reprinted in his book of essays Another Sheaf (New York: Charles Scribner’s Sons, 1919).
[4] John Hodge, “The Training of Disabled Men: How We Are Restoring Them to Industrial Independence,” Windsor Magazine no. 281 (1918): 569–571.
[5] McMurtrie, The Disabled Soldier, 75.

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Side Effects May Include

By Emily Miranker, Events & Projects Manager

You’re curled up on your couch watching the latest episode of a favorite show when a commercial break comes along. An actor with amazingly white teeth goes from an unhappy to a happy face suddenly able to go about their regular life without discomfort, all thanks to Some Medication. As the ad spot wraps up, a soothing and fast-talking voice rattles off a litany of side effects: dizziness, loss of appetite, dry mouth, nausea, indigestion, insomnia, and so on.

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Finding and Learning About Side Effects, FDA.gov.

I grew up used to the recitation of possible side effects and long lists of them stapled to prescriptions from the pharmacy. “Yeah, yeah; might get a headache…” But there is huge importance in a regular headache and a headache that presages something medically serious. Mrs. Anne St. C. of Buffalo, NY was not used to these warnings in the 1960s. Because they didn’t exist.

The inclusion of side effects, also called adverse events by the Food and Drug Administration, was an incredibly important milestone for patients and informed consumer choice. We owe these warning labels to another milestone event in public health; the oral contraceptive, the first of which was Enovid, approved for prevention of pregnancy in the United States in 1960.[1] This was a game changer for American women, and within two years 1.2 million women were taking the pill.[2]

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Advertisement for Enovid. American Journal of Obstetrics and Gynecology, Vol. 83 No. 3, February 1, 1962.

One of those women was Anne St. C.

Wife of a professor at a local [Buffalo, NY] university, mother of three and a user of the pill, [she] called her gynecologist and asked, “Is the pill safe? Should I be taking it?” Dr. K. snapped, “Of course, it’s all right for you to take the pill. If it weren’t, I’d never have prescribed it.” Anne did not tell the doctor the real reason why was she calling. In the preceding two weeks she had experienced several attacks of dizziness and double vision. She had also suffered from stiffness in the neck. If she had not been cowed by her doctor’s brusqueness, she might have detailed her symptoms. In that case, the doctor’s reaction might have been quite different. As it was, Anne had a stroke exactly eight days later.[3]

In that Anne survived her stroke, she was lucky. For other women, the side effects were fatal.

Two points about the world in which the oral contraceptives came to market. First, in assessing the safety of the pill, regulators focused on its “ability to prevent pregnancy because pregnancy and delivery were inherently medically risky”[4] and since the pill was effective in that objective, it met the law’s safety requirement. Second, the pill was approved before the dangers of thalidomide‑ discovered to cause birth defects in children whose mothers took it for morning sickness‑ were known and the consequent Kefauver Harris Amendment (“Drug Efficacy Amendment”) of 1962 passed.[5]

When Anne St. C. was taking the pill, doctor-patient relationships existed in the context of the 1938 Federal Food, Drug, and Cosmetic Act. That act required pharmaceutical companies to make information about drug safety available to physicians. When patients got information it was “through the filters of the prescribing physicians and the dispensing pharmacist.”[6] The balance of power rested with the medical practitioner. Come the late 1960s, the burgeoning feminist and consumer rights movements challenged the status quo of the doctor-patient relationship. The balance of power was  questioned and began to shift.

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Barbara Seaman, Alliance for Human Research Protection.

Journalist Barbara Seaman, exposed the dangers of the pill in her 1969 book The Doctors’ Case Against the Pill. She wrote that “a typical package insert that is supplied with one of the most popular oral contraceptives…lists more than 50 side effects of the pill, including a number that can be fatal…Relatively few women ever see these warnings because they are written for physicians; doctors or pharmacists usually remove them from the pill packages,” advocating that it was the patient’s privilege to decide. A woman was “entitled to know the risks and give her informed consent.”[7]

Seaman’s book brought the issue to the attention of Wisconsin Senator Gaylord Nelson (organizer of the first Earth Day). In January 1970 Nelson instigated Congressional hearings on the safety of the pill and the sufficiency of information about its side effects.[8] Attending the hearings, Seaman and fellow activist Alice Wolfson (both future founders of the National Women’s Health Network) were struck by “the fact that there were no women testifying and that there are no women on panel.”[9] Wolfson’s collective, D.C. Women’s Liberation, organized women to position themselves in the hearings’ audiences and outside the Capitol to voice their twofold concerns; the dangers of the pill and the exclusionary structure of the hearings. The feminist activists’ strategic interruptions at the hearings and protests outside the Capitol captured media attention.

Policeman Approaching Young Feminists

D.C. Women’s Liberation demonstrators at the Nelson Hearings, 1970

Amid the media coverage the feminists brought, FDA Commissioner Dr. Charles Edwards announced on the final day of the hearings “that his agency planned to require a … package insert in every package of birth control pills … written by the FDA in lay language and directed to the patient.”[10] While compromise about the writing and scope of the inserts continued, the activists’ efforts laid the groundwork for the warnings that come with all prescription packages today. And today’s pills contain lower doses of hormones than the first Enovid pill.[11]

We continue this important work in increasing the public health literacy and access at the Academy with our Language Access in Chain Pharmacies project, which supports multilingual medication labels. Being able to understand firsthand how to use and any risks or side effect is immensely empowering for a patient and goes a long way to fostering trust in the healthcare system.

Special thanks to Allison Piazza for research assistance with this post.
References:
[1] Suzanne White Junod. FDA’s Approval of the First Oral Contraceptive, Enovid. Update. 1998, July-August. https://www.fda.gov/downloads/AboutFDA/WhatWeDo/History/ProductRegulation/UCM593499.pdf Accessed July 9, 2018.
[2] Alexandra Nikolchev. A brief history of the birth control pill. Need to Know on PBS. http://www.pbs.org/wnet/need-to-know/health/a-brief-history-of-the-birth-control-pill/480/ Published May 7, 2010. Accessed July 10, 2018.
[3] Barbara Seaman. The Doctors’ Case Against the Pill. New York: Peter H. Wyden, Inc., 1969: 109.
[4] Junod. https://www.fda.gov/downloads/AboutFDA/WhatWeDo/History/ProductRegulation/UCM593499.pdf Accessed July 12, 2018.
[5] Sam Peltzman. An Evaluation of Consumer Protection Legislation: The 1962 Drug Amendments. The Journal of Political Economy, Vol. 81, No. 5. 1973 Sept-Oct.
[6] Elizabeth Siegel Watkins. Expanding Consumer Information: The Origin of the Patient Package Insert. Advancing Consumer Interest, Vol. 10, 1. 1998.
[7] Seaman, 9 & 15.
[8] Nikolchev. A brief history of the birth control pill. http://www.pbs.org/wnet/need-to-know/health/a-brief-history-of-the-birth-control-pill/480/ Accessed July 10, 2018.
[9] National Women’s Health Network. https://nwhn.org/pill-hearings/ Accessed July 12, 2018.
[10] Watkins. Expanding Consumer Information. 1998.
[11] Pamela Verma Liao. Half a century of the oral contraceptive pill. Can Fam Physician, Vol. 58, No. 12. 2012 December. Accessed August 24, 2018.