John D. Stoeckle and the Upstream Vision of Social Determinants in Public Health

John D. Stoeckle has influenced several generations of clinicians, scholars, students, and activists concerned about the social dimensions of medicine and public health. Among his many contributions, Stoeckle fostered collaboration between practitioners and social workers, largely to address social conditions that affect the processes and outcomes of clinical care. His seminal article, “Social Work in a Medical Clinic,” was published in the American Journal of Public Health in 1966 and is excerpted here.

Stoeckle’s formulation of the “upstream” vision in public health focused on sources of illness and early death in the social and physical environment, that is, at a broader level of analysis “upstream” from the individual. Despite its limitations,^1,2 the metaphor of upstream causation continues to inspire research, teaching, and activism. John B. McKinlay elaborated the metaphor extensively in presentations and publications.^3,4 Although he cited Irving Kenneth Zola’s role in developing the upstream metaphor, McKinlay also acknowledged Stoeckle’s influence. The upstream vision pervaded Stoeckle’s teaching, scholarship, and clinical practice. He used the metaphor frequently, along with other ways to think about and to intervene in what we came to call the “social origins of illness,”⁵ much later leading to the currently favored term “social determinants.”

Stoeckle’s career emerged in the context of anticommunism and persecution of left-wing thinkers and activists in academia and academic medicine. Partly for that reason, he was careful not to identify himself within a specific political orientation. Yet through his teaching, writing, and personal practice, the influences that led to his interest in the social context and origins of illness are not hard to see.

Stoeckle’s youth in Michigan and college years at Oberlin and then Antioch in Ohio during the early 1940s seemed to give him an unusual sensitivity to social class. When he arrived at Harvard Medical School in 1945, the wealth and luxuries of that milieu struck him immediately.⁶ As a resident at Massachusetts General Hospital (MGH) from 1948 to 1952, he became troubled by the privileges enjoyed by the wealthy, who stayed in the private wings of the hospital and saw faculty practitioners in private offices, while the poor occupied the much less comfortable wards and saw primarily students and residents in the outpatient department.

Motivated by his concern about working people, Stoeckle focused on occupational health. With his mentor, Harriet Hardy, he studied occupational lung disorders, including beryllium disease, which affected workers especially in the fluorescent lighting industry.^7–9 Stoeckle and Hardy also collaborated in an early study of coal miners’ pneumoconiosis¹⁰ and later research on women with asbestosis.¹¹ Hardy had worked with her own mentor, Alice Hamilton, in essentially creating the field of industrial toxicology.¹² Hardy and Hamilton worked tirelessly to protect workers’ health and to challenge “man-made disease.”¹³

Stoeckle also emphasized the importance of social work, nursing, and community health centers located in underserved communities. The roots of these emphases grew from the urban settlement house movement during the so-called “Progressive Era” of reform in the early 20th century. Early in her career, Hamilton worked and lived at Hull House in Chicago with Jane Addams, the creator of inner-city social work based in settlement houses. Like others at Hull House, Hamilton was influenced by the socialism of Eugene V. Debs and the anarchism of Peter Kropotkin.^{14(pp237–239),15(pp62,86)} At MGH, Ida Cannon organized the social work services under the direction of Richard Cabot, a senior physician concerned about the social conditions that affected health and illness.¹⁶ In her own work, Cannon acknowledged the inspiration that Jane Addams and Hull House had provided.^17,18 Deeply influenced by Hamilton, Hardy, Cabot, and Cannon, as well as her successors, Stoeckle referred many times in his writings and in conversations to the importance of social work in clinical care and the intellectual and political roots of social work in Hull House and other settlement houses.^19,20

In addition to social work, Stoeckle emphasized nursing,^21,22 and anarchist strands entered there as well. Lillian Wald, Lavinia Dock, and other nurses who developed the “Nurses’ Settlement” on Henry Street in New York City provided examples of disciplined health services that addressed the root causes of illness and early death in poverty, inadequate nutrition, lack of sanitation and decent housing, and other oppressive social conditions. Dock, who espoused Kropotkin’s views on mutual aid^23(pp4–7) and attracted praise from other anarchists such as Emma Goldman during Goldman’s own nursing career,^24(pp9–11) later promoted community-based nursing as a professor and administrator of the Johns Hopkins School of Nursing, founded the National League of Nursing (later evolving into the American Nursing Association), and (like Hamilton and Hardy) became an activist for women’s rights and peace. Stoeckle often noted the key role that such nurses played in the settlement houses and early community health centers, and emphasized collaborative relationships with nurses in his teaching and writing.^20–22

Stoeckle’s innovative teaching and research using audiotaped and videotaped doctor–patient communication²⁵ facilitated early empirical studies conducted in different primary care settings. In this work, Stoeckle and I considered how upstream dimensions such as social class, gender, and race/ethnicity created barriers in communication.^26–28 In particular, we focused on sociolinguistic patterns linked to social class that affected information seeking and giving within the medical encounter. We also clarified how withholding information heightened the power of health professionals, and how a participatory model of medical encounters would include a lessening of this power dimension. In addition, Stoeckle collaborated with and facilitated the work of Zola and McKinlay, especially on the importance of ethnicity, social control, and disability in doctor–patient communication.^29–31 These efforts stimulated later work on the politics of medical encounters.³²

Many consider Stoeckle the father of modern primary care. This recognition emerged because of his efforts in building with colleagues one of the first residency training programs in primary care internal medicine and helping to define what constitutes the primary care curriculum.^33–36 The major textbook in the field is dedicated to him.³⁷ Less recognized are Stoeckle’s attempts to desegregate MGH in terms of social class, through a teaching group practice that was open to everyone and had a single high standard of care.

Stoeckle’s sensibility about high-quality health services for the poor and racial/ethnic minorities derived from several sources. He understood the earlier generation of settlement houses and community health centers. Another source of Stoeckle’s sensibility involved his knowledge of the primary care programs of the Farm Security Administration. He developed his notions about “plain doctoring with plain people”³⁸ partly by curating the most extensive collection of photographs showing doctors caring for poor patients during the Great Depression.³⁹ In the context of poverty, unemployment, and other economic stressors affecting families and communities, Stoeckle also highlighted somatization and depression as expressions of psychosocial difficulties rooted in the broader society.^40–43 From this perspective, he advocated collaboration with mental health professionals as well as training for primary care practitioners in psychiatric diagnosis and treatment.^44,45 Stoeckle walked the talk of plain doctoring in building and maintaining a remarkably large and intimate following of devoted patients, who regularly expressed their gratitude and affection for him.

Changes in the capacity to do plain doctoring under corporatized medicine troubled Stoeckle deeply. In a system increasingly driven by for-profit insurance and pharmaceutical corporations, health professionals were losing their ability to control the conditions of practice. With McKinlay, Stoeckle analyzed the de-skilling and loss of autonomy experienced by physicians.⁴⁶ McKinlay and others argued that physicians were experiencing proletarianization.⁴⁷ Aware that doctors were becoming more and more like other workers, Stoeckle analyzed the subtleties of these changes in an article entitled “Working on the Factory Floor.”⁴⁸

Partly because of his upstream focus, Stoeckle remained fairly marginalized in academic medicine and in his own institution until late in his career. Ultimately, one or more of his admirers made a large donation to MGH, leading to the creation of the Stoeckle Center for Primary Care Innovation.⁴⁹ Hopefully, the Stoeckle Center and this biosketch will highlight Stoeckle’s contributions to the upstream vision in public health.