Book Review

Miners and Medicine: West Virginia Memoirs

N Engl J Med 1994; 330:871-872March 24, 1994

Article

Miners and Medicine: West Virginia Memoirs
By Claude A. Frazier, with F.K. Brown. 131 pp., illustrated. Norman, Okla., University of Oklahoma Press, 1992. $19.95. ISBN: 0-8061-2454-7

The history of coal mining is rife with greed, inhumanity, and incredible danger. Sweatshops, exploitation of child labor, absentee ownership of highly profitable industries, and destruction of native culture were all phenomena of the Industrial Revolution. The mining of coal in Appalachia was a terrible example of this process. It has greatly distorted the local culture and resulted in high rates of death and disease from self-destructive lifestyles in mining areas, even now.

The story began when railroads traversed Appalachia en route to the Midwest just before and after the Civil War. Coal was needed to fuel the engines of industrial expansion, and the rail networks required more and more timber. Both were available in huge amounts in the mountains of West Virginia, Kentucky, and Pennsylvania. In the half-century after the Civil War, the mountain forests were clear-cut, providing lumber for the cities of the Eastern seaboard but also devastating thousands of square miles of the shallow soil of the hill country. Only now is the area beginning to recover.

The mountain people, originally a hearty and self-sufficient group of pioneers, were not skilled in the law or in finance. They were inveigled into selling “mineral rights” for as little as 32 cents per acre. This contract gave the coal land speculators perpetual rights to natural resources beneath the surface. It included the right to build roads and railroads over the land and to locate slag piles anywhere the owners wished. Even homes could be undermined to the point of collapse.

The inequities and the profits of the system encouraged the absentee owners of the coal fields to corrupt the entire legal system in order to protect their hegemony. Local officials, state legislatures, and other officials were bought off with no regard for the people who lived on the land. This heritage has persisted in Appalachia. Consequently, the mountain families, having lost their farmland, the hunting and trapping, and the self-sufficiency that sustained them for generations, were forced into virtual slavery in order to live. The men and most of the young boys became coal miners. Hard work in terrible conditions and a constant threat of explosions and collapsed roofs warped their lives. In 1907 in Monongah, West Virginia, 361 miners died in one disaster. There was almost no assistance in cases of death or disability from the mines or the government until the late 1930s. In the first 80 years of this century, 19,826 men and boys died in mine accidents.

This story has not been told sufficiently strongly to awaken the conscience of our nation. Miners and Medicine is a little disorganized, but it is a very readable account of health care in the coal camps. The first half vividly presents the circumstances that led to the coal-camp doctor system.

The early coal camps packed hundreds of people into isolated narrow valleys near the mines. Sanitation was abysmal; as late as 1946, 75 percent of the coal camps in West Virginia relied on outdoor privies. Water was frequently obtained from contaminated creeks and wells. Meanwhile, billions of dollars were sent out of the area in coal and lumber profits distributed to absentee owners. Shopping for supplies and food was restricted to the company store, at which scrip could be redeemed, frequently at a discounted value. Some could sign for credit and then owe more than their wages provided. Hence the well-known lament “I owe my soul to the company store.”

In this environment medical care was often lacking -- even the primitive sort that was predominant elsewhere at the turn of the century. A health care system was established in the 1920s. To my knowledge, it was the first large, organized prepaid health care system in this nation. Miners paid $1 to $3 per month for health care, part to the company doctor and part to the local hospital. This system worked well for the most part in the 1920s and early 1930s. Dr. Frazier's account describes many poignant situations in which the physician and the patients interacted well and each appreciated the other.

By the mid-1930s, coal-company policy increasingly began to use the company-physician system to block the employment of miners sympathetic to the union. Management could discharge such miners or prevent them from working by the simple expedient of encouraging the company-hired physician to report minor abnormalities as sufficient to make the miner unemployable. In the early 1930s, the regional branches of the United Mine Workers of America began to restructure medical care so that miners could have some choice among physicians and hospitals. In 1944 John L. Lewis, president of the union, faced an aggressive rival promoting health care reform in the national election. The campaign forced the autocratic Lewis to begin the same reform efforts. The United Mine Workers of America's Welfare and Retirement Fund was established in 1946. From this sprang systems of union-owned and -operated hospitals and clinics. At first these were highly successful, but only as long as coal prospered. They were finally brought down by economic factors and the lack of proper actuarial planning. The new system brought the demise of the company doctor, however, and of a prepaid checkoff, or “list,” with total control of the miners by the operators. The story of the miners' struggles to reform their health care system may have lessons for all of us in considering changes in our current health care system.

Frazier was raised in a coal camp, the son of a company doctor and a nurse; he knows the story well. In addition, he solicited accounts from many persons who had been cared for by company doctors. The doctor-patient relationship was usually a good one, but there are several stories in the book about cases that were comical or tragic. There are interesting sections about the nurses who labored with the doctors and in the hospitals, about the early hospitals, and about many other stories of those years of deprivation, danger, and pride. Frazier has created a valuable resource; he has portrayed anew the miserable lives of the people who mined coal -- a story that is unknown to most of our citizens. He has also accumulated dozens of vignettes that show how miners, their families, and the company doctors for the most part worked to improve the dreadful lot of their people. The bibliography will be useful to those who want to pursue this chapter in the history of industrial and human relations.

It would have been helpful had Frazier described in more detail the “list practice” of physicians and hospitals, which ended in the 1930s. This system was better than nothing, and it presaged the prepaid medical care systems of today.

Warren Point, M.D.
West Virginia University Medical School, Charleston, WV 25304-1299