In April 2020, close to the start of the first U.K. COVID-19 lockdown, the U.K. government announced the development of a COVID-19 contact tracing app, which was later trialled on the U.K. island, the Isle of Wight, in May/June 2020. United Kingdom surveys found general support for the development of such an app, which seemed strongly influenced by public trust. Institutions developing the app were called upon to fulfil the commitment to public trust by acting with trustworthiness. Such calls presuppose that public trust associated with the app can emerge if the conditions for trustworthiness are met and that public trust is simplistic, i.e., linearly the sum of each member of the publics’ individual – U.K. government trust relationship. Drawing on a synthesis of the trust literature and fifteen interviews with members of the public trialling the app on the Isle of Wight, this paper aims to explore what trust mechanisms and relationships are at play when thinking about public trust in the context of the U.K. COVID-19 app. We argue that public trust is a complex social phenomenon and not linearly correlated with institutional trustworthiness. As such, attention needs to widen from calls for trustworthy infrastructures as a way to build public trust, to a deeper understanding of those doing the trusting; in particular, what or whom do people place their trust in (or not) when considering whether using the app and why. An understanding of this will help when trying to secure public trust during the implementation of necessary public health measures.The online version contains supplementary material available at 10.1007/s11673-021-10127-x. To combat the COVID-19 public health emergency, in 2020 policymakers around the globe increasingly invested in digital health technologies to support the “isolate, test and trace” approach of containing virus spread. These technologies included mobile “contact tracing” applications (apps), which could trace individuals likely to have come into contact with those who had reported symptoms or tested positive for the virus and request that they self-isolate  contact tracing app. This app was trialled on the Isle of Wight during May and June 2020. Following the trial on the Isle of Wight, this app was withdrawn, and the NHS developed a new app, which was launched for general population use in September 2020.At the time of the original app’s development, U.K. surveys found general support for the development of such an app, though reportedly a significant number felt anxious about the government’s ability to protect personal data, as well as the perceived potential for government surveillance post-pandemic . However, a growing literature has explored the nature of public trust in relation to the health sector, health systems, and practices  “calculus-based” trust grounded in a rational gamble that the other will act in your interest because they have an interest in fulfilling the trust; (2)”knowledge-based” trust is rooted in previous experiences; and/or (3) “identification-based” trust related to emotional ties, shared values, and altruism  and institutional trust  , experiences of using the app, perceptions about the benefits and harms, and views more generally about the app, and contact tracing more broadly.Wightbay), and snowballing. Interviews lasted between sixteen and sixty-seven minutes, with n = 10 between thirty and fifty minutes. Table Fifteen phone/online interviews were conducted by GS/HD in May 2020. Inclusion criteria included individuals who were over 18 years old and at the time residing on the Isle of Wight. Recruitment was online via a local Isle of Wight Facebook page advert (with moderator permission), a newsletter, an advertising site . Additional codes were added during coding, and these additional codes were shared between GS and HD in an iterative process of constant communication and reflection on the data. Codes were discussed with all authors and themes developed. The project codebook  perceived the government had provided appropriate and clear information about the app. Most, however, disagreed. Interviewees described little access to information about the organizations responsible for the app’s development, as well as to information about how exactly the app worked; “when I downloaded the app, I couldn’t find any information … telling me what it was going to do, it was just going to alert me if I was in proximity, but it didn’t say when, how long” (interviewee 7). Interviewee 3 had questions around inputting data into the app, as well as about the security risks of leaving the Bluetooth mechanism on their phone permanently. They explained; “there isn’t anywhere to ask those questions…I did email them…but the answer I got back was worse than useless.” Some interviewees explained how app-associated information was unhelpfully presented. Others mentioned how poor information provided by government was doing little to allay people’s worries about the data, how it would be handled, who would have access to it, and for what purposes; “it was just never explained very well about the app, and I think it should have been done far, far better, everybody was frightened of privacy, nobody seemed to understand how it worked” (interviewee 15).Despite most interviewees raising these concerns, as we show later, most interviewees were still accepting of the technology, and all but two interviewees (interviewees 4 and 11) downloaded the app. Reasons for not downloading the app included technological limitations (interviewee 11 had an older model phone) and critical beliefs about the app and the U.K. government more broadly ((interviewee 4); see below).This suggested a more complex relationship between the U.K. government (failing to) provide open and transparent information about the app  and views on the technology. In fact, interviewees highlighted different trust relationships that were entangled with the information provided about the app. For instance, some interviewees who expressed frustration with information gaps about the app were concerned this could increase the trust people placed in misinformation from other sources. They explained that without relevant information about how the app would function and how data would be handled, used and stored, a “space” is created “for people to fill it with their imagination …” (interviewee 6) and to breed misinformation and further distrust; “it takes one person to say something like that [negative remark about the app] and then everybody who doesn’t really know latches on to it” (interviewee 6). In this way, interviewees perceived that it was a rational gamble to trust the U.K. government when so little information was given  and that the U.K. government did not share their values (identification-based distrust). As such, interviewees suggested that an impersonal calculative distrust towards the information supplied by the U.K. government, coupled with identification-based distrust led some to trust other sources of information. These other sources of information might have been more clearly presented to them ; might have been from sources who share values/beliefs with the truster (identification-based); and/or might have come from sources whom the trustor might have a history of “good experiences” of trusting (knowledge-based). In short, some interviewees perceived the lack of U.K. government information created a lacuna to be potentially filled with other information that is trusted based on all three trust-mechanisms.political trust in) the U.K. government.Other trust relationships beyond the information provided by the U.K. government also seemed to influence interviewees’ views on the app. Below we explore these, beginning with interviewees’ pre-existing views  in the U.K. government, as well as in the government’s handling of the COVID-19 pandemic. On the one hand, for most interviewees who tended to speak more supportively of the app, also tended to speak in more supportive terms about the government, or at least their comments during the interviews seemed to be more understanding of the government’s decisions during the pandemic and more generally. In contrast, for a minority of interviewees who were exceptionally critical of the government’s decisions during the pandemic, they were concomitantly worried about the government’s handling of the app development. This revolved around two key issues—whether the government had the required competency to deliver the technology and their perceptions about the government’s underlying motivations and future intentions for the app’s implementation in society. Such views were most clearly highlighted by interviewees 1 (who downloaded the app) and 4 (who did not download the app). Interviewee 1 was particularly worried about the government’s ability to develop an app that was both workable and useful. Explaining their initial thoughts on the app, they drew on knowledge-based trust to remark; “it’s probably not going to be a great app in the world because it’s sorted out by the UK Government and with everything else that's gone wrong …” These concerns seemed to play out for this interviewee after they downloaded the app; they spoke about a range of issues they were having with relation to installing the app on their phone and interpreted these issues in line with their views of the U.K. government who “have not got it right again.” This interviewee’s concerns chimes with a knowledge-based distrust: the interviewee has repeated past experiences/perceptions of the U.K. Government reneging on promises made to the public with little or no negative consequences. As such, the interviewee is sceptical about trusting in the realization of new Government promises, such as a functioning track and trace app.Interviewees shaped at least some of their perceptions about the app by the impersonal mistrust: they do not share the values or societal norms espoused by the current government, such as the value of state health security via surveillance.Interviewee 4, who was generally concerned about how much control the government had over society and had repeatedly pointed to the notion of “Big Brother,” was anxious that the app was being developed by government to “control” society; “the government…are looking at different ways to implement control, and it’s like using apps and technology like this to implement the next stage in control.” Other interviewees who did not express this concern directly, also spoke of “others” on the Island who were worried that the app was being used as a way for the government to “track” them (interviewee 6). These interviewees described a broader suspicious U.K. culture that is generally untrusting and “anti-government”; “we are very suspicious in this country, we don’t trust anything…we are always fighting against the government” (interviewee 5). Interviewee 4’s concerns may well bely an identification-based political trust in the government therefore played an important role in shaping beliefs about the app. A remark by interviewee 13 nicely illustrates this point; “there were some attempts … to … describe how the data [for the app] would be used. But … for me personally it comes down to … how much trust I have in them [the U.K. government] to actually tell the truth.” However, as we saw earlier, there was not a simple relationship between political (dis)trust and interviewees being unsupportive of the app, indeed interviewee 1, who was very critical of the government downloaded the app. Furthermore, while other interviewees acknowledged that whether they deemed the government to be competent to deliver the app, to have good intentions when implementing the app (not “big brother” intentions) and/or being truthful was paramount, they also described several other influencing factors. These included the information provided (described above), interpersonal trust in individuals “selling” the app in stories they heard from their peers, in the media, and in social media, all of which played a role in formulating their opinions about the app. Below we focus on two of these to exemplify this: the influence of individuals  and social networks and social media.Pre-existing interpersonal trust relationships to politicians are tied to pre-existing impersonal political trust. The influence of these pre-existing beliefs on perceptions was made most apparent when several interviewees spoke about an incident in which Bob Seely—a local Member of the U.K. Parliament and app advocate—was caught attending a barbecue during lockdown. Interviewee 13, who generally spoke critically about the U.K. government’s handling of the pandemic, reflected on their frustration that government officials did not adhere to lockdown rules. As such, this interviewee spoke about the difficulties they had in knowledge-based trusting “what the government are saying” about the app;Dominic Cummings’ lockdown break, and the same with our local MP, he was seen to be not following the lockdown rules … people in charge need to be leading by example and if they are not leading by example then it feels like we are being told to do one thing while other people in positions of power are not following that same advice. So, it makes it very difficult to trust the things they are saying in other respects. (interviewee 13)Interviewees’ narratives highlighted the importance of who was communicating about the app when considering trust. Several interviewees described how perhaps politicians were not the best placed individuals to “sell” the app to the public; interviewee 6 suggested; “I think it needed a technical person not a politician  because they don’t have a lot of credibility”; interviewee 14 noted “I think it’s all about how it’s sold.” Expertise was therefore seen as an important aspect in ensuring that trust is placed in those communicating to the public about the app. It also illustrates how identification-based trust;I have the T-shirt “where the Isle of Wight leads the rest follow.” I think that Bob Seelly probably had quite a bit to do with that, I like Bob, obviously I’m biased … The barbecue rubbish and all that, if everybody is whiter than white … and what have you. But I believe him when he said … he thought he was just going for a chat … (interviewee 15)In contrast, interviewee 15, a Conservative Party member who openly expressed their shared values with the Party,political trust. Rather, an interplay of pre-existing beliefs and different factors in “trusting” was apparent, including the behaviour of the wider U.K. government, as well as who was communicating about the app . As such, trust is not reducible to information provided (or not provided) but reflects the interplay between the identification of shared values, perceptions of “being let down before” and issues of perceived fairness regarding rule-following, as the Bob Seelly incident illustrates.These findings move us away from a simple relationship between accepting the app, the U.K. government acting with trustworthiness, and interpersonal trust; offline, friends, acquaintances) and social media  seemed to be entwined with their pre-existing political trust in the U.K. government (as described above) and/or their pre-existing trust in the app. Indeed, as we show below, pre-existing trust in the app was itself related to interviewees’ more general trust in science and technology. In other words, these pre-existing beliefs appeared to influence which information they aligned with.Interviewees’ conversations and “gossip” with others (interviewee 9) via “the Isle of Wight grapevine” (interviewee 3) played an important role in interviewees’ sourcing information about the app; “we all talked about it at work … me and my husband spoke about it and friends … everyone was talking” (interviewee 5). A number of go-to local Facebook sites were also used by residents to discuss the app, and all interviewees spoke about using these sites.identification-based trust with social media users who were perceived to share their values regarding the app, this interviewee explained that by discussing these issues online, they had decided to uninstall the app; “with the information that I got … online, and people that I spoke to, I decided to uninstall the app.” Interviewee 4, from above, was similarly influenced by online comments reinforcing their expressed distrust in the government—this time with relation to concerns that the app was acting as a tool for societal control.In particular, those interviewees less accepting of the app and/or the U.K. government, aligned themselves with negative online comments about the technology that reinforced their view. Interviewee 1 from above, who was sceptical about the government’s competence to develop the app to start with, particularly reflected on these issues when reading online about the app’s technological limitations. Highlighting a form of trusting social media as a source of information, suggesting that the influence of social media in affecting these interviewees’ beliefs about the app was linked to whether the stories and comments they read aligned with their pre-existing beliefs about the app and/or the U.K. government. These findings, together with those above, create a complex picture of the interplay between different trust relationships and pre-existing beliefs as they related to acceptance of the app. Indeed, accepting the app became a filtering and balancing process of pre-existing ideas about the U.K. Government, with existing knowledge, as well as information from social networks and social media sites, and individuals “selling” the information.In contrast, those interviewees who were seemingly more supportive of the U.K. government and/or more accepting of the app, were more sceptical of online comments; “I read some of the negativity and the positivity on … Facebook … and basically ignored all the naysayers” (interviewee 3); “it’s more rumour, it's more crap that’s out in the ‘twatesphere”’ (interviewee 15). Interestingly, when not talking specifically about the app, these same interviewees provided examples of Overall, the sense of looming threat and a desperation to control the virus, coupled with a commonly held understanding that research and technology is intrinsically good, and a sense that the app had a health benefit, all seemed to play an important role in shaping interviewees’ perceptions of whether to use the technology. All but two interviewees had downloaded and used the app, regardless of their expressed views on the U.K. government and reported trust in the app to function. So, although participants spoke directly about their (dis)trust in the government, in practice they all placed their trust in the app to offer potential health benefits.because I wanted to keep safe” (interviewee 15); “I have taken my [app] off, now I feel less safe … [..] … more vulnerable … [..]… I haven't got any of that safeguard at the minute” (interviewee 14). In this way, the threat of COVID-19 seemed to mitigate how interviewees enacted trust—the risk COVID-19 posed, and therefore the benefit or protection the app ostensibly promised, trumped any concerns they had about the app and/or the U.K. government.Nearly all interviewees were hopeful that the app would bring an end to the pandemic by helping control the spread of the virus. Interviewees described the concept of an app as “a good idea” (interviewee 12), “a very useful tool” (interviewee 13), and as a “technological solution” (interviewee 11) to helping contain the pandemic given the limited resources available for manual contact tracing. For these and some other interviewees, this hope was sometimes mixed with misconceptions about the potential for the app to deliver individual benefit, in addition to population health benefit. Indeed, the potential for health benefit seemed closely connected with the threat COVID-19 posed; that is, the health benefit was synonymous with risk management: “I downloaded it … potential health value; “I think if it does actually help, if people are traced and it does work, that way then yes by all means use it” (interviewee 10). Interviewee 9, for example, reflected they would “give it a go.” These interviewees perceived little harm could come from trialling the app and could articulate few concerns relating to its use; “I thought, well there is no harm in it at all, so go for it” (interviewee 8); “I don't really see many downsides to having it …” (interviewee 11). Even those interviewees whose support for the app was shaped by their negative view of government, or by the technology’s reliability issues and limitations, and/or concerns about potential infringements on privacy (via “Big Brother” narratives), perceived a value in trialling and/or using the app in the hope of controlling the spread of the virus. Only two interviewees—the two that had particular concerns with the government—were apprehensive about the role of the app in containing the pandemic, viewing the promotion of the app as more about playing on people’s fears of the virus to ensure they downloaded the app, either as a way of “fear-mongering” to elicit control on the population (interviewee 4), or to give them a sense that they were doing something, rather than nothing; “it seems [the app] is more of a psychology thing to deal with people’s mental frame of mind rather than a function that it does this, it does that” (interviewee 1).The extent of perceptions about the app as providing benefit also seemed connected to interviewees’ understanding of the app, as well as their pre-existing beliefs about science as an intrinsically good endeavour. Some interviewees, who tended to place a lot of trust in the intrinsic value of research and science, equally placed a lot of hope that the app would bring about a population health benefit. In other words, these interviewees trusted the promise associated with the app to deliver these benefits. Other interviewees, who tended to have a more pragmatic outlook on what science could deliver to society in general, were less inclined to assume that the app could help control the pandemic but were pragmatically in strong support of trialling the technology because of the Despite these criticisms, interviewee 1, who explicitly described their fear of the virus, still downloaded the app. Interviewee 4—who had little concern or fear about the virus , did not download the app.empirically explored the concept of public trust as it relates to such apps. Analysing our data by drawing on the conceptualization of “ecologies of trust” allowed us to identify a range of trust mechanisms and types that were associated with interviewees’ views of the original U.K. COVID-19 NHS app trialled on the Isle of Wight. These included political trust, calculus-based, knowledge-based, and identification-based trust; interpersonal and impersonal trust; and political trust. Our findings also highlighted a range of inter-connected, pre-existing beliefs and trust relationships related to the app, including with the U.K. government, individuals, private corporations, social networks, social media, the media, science more generally, the capabilities of the app, the threat of the virus (fear), and the promise of the technology to help control the pandemic. Our findings therefore show that public trust in relation to this particular app did not simply imply that individual people trust the app to work or they trust the government. Rather, trust in the app needed to be understood in the context of the ecology of trust relationships . This aspect is under-discussed in the trust  literature. Hope is a trust relationship, understood in terms of trusting that the app will help contain the virus when there is little other way to do so. In fact, our capacity to hope supports our capacity to trust McGeer . Though how public trust is formed. Trust is not a quality conferred to a person or object but a relational and iterative process of comparing, filtering, and balancing pre-existing ideas, hopes, and fears, and that trust is placed in individuals (on the Isle of Wight this was Bob Seeley), institutions (the U.K. Government), and things (the app).Overall, our data shows that trust is not binary but a spectrum where degrees of trust are given to different actors and institutions ) of the app to contain the virus Below is the link to the electronic supplementary material.


To date, 11 scientists have received the Nobel Prize for discoveries directly related to cancer research. This article provides an overview of cancer researchers nominated for the Nobel Prize from 1901 to 1960 with a focus on Ernst von Leyden (1832–1910), the founder of this journal, and Karl Heinrich Bauer (1890–1978).We collected nominations and evaluations in the archive of the Nobel committee of physiology or medicine in Sweden to identify research trends and to analyse oncology in a Nobel Prize context.We found a total of 54 nominations citing work on cancer as motivation for 11 candidates based in Germany from 1901 to 1953. In the 1930s, the US became the leading nation of cancer research in a Nobel context with nominees like Harvey Cushing (1869–1939) and George N. Papanicolaou (1883–1962).The will of Alfred Nobel stipulates that Nobel laureates should have “conferred the greatest benefit to mankind”. Why were then so few cancer researchers recognized with the Nobel medal from 1901 to 1960? Our analysis of the Nobel dossiers points at multiple reasons: (1) Many of the proposed cancer researchers were surgeons, and surgery has a weak track record in a Nobel context; (2) several scholars were put forward for clinical work and not for basic research ; (3) the scientists were usually not nominated for a single discovery, but rather for a wide range of different achievements. Although cancer research has been a prevalent topic in the discussions among the Nobel Prize committee members since the first Nobel Prize in physiology or medicine was awarded in 1901, only eleven scientists have received the Nobel medal for work directly related to oncology. The list of Nobel laureates with cancer as a keyword in the official prize motivation includes scientists ranging from Johannes Fibiger in 1926 “for his discovery of the Spiroptera carcinoma”  and Karl Heinrich Bauer (1890–1978).Ernst von Leyden grew up in Danzig  His . After hJournal of Cancer Research and Clinical Oncology, then called Zeitschrift für Krebsforschung, published in German until 1977  he portrayed Ernst von Leyden as the only internist worthy of being awarded the Nobel Prize among German clinicians. Even though he was aware that von Leyden probably had not made a single, outstanding discovery, Fränkel argued that his lifetime achievements still made him prizeworthy because of his work on tuberculosis, asthma, and nutritional therapy. This “lifetime” argument mirrors the rhetoric in the Nobel nominations for Leyden’s colleague Vinzenz Czerny for efforts in interdisciplinary oncology  honours outstanding merits in cancer research was named after him.The name of K H Bauer is still well-known among German surgeons and cancer researchers Lindner . After sDas Krebsproblem to the nomination. He added that experimental research by Strong on the genetic links in the origin of cancer had provided “solid support” for Bauer’s theory and that it was of “fundamental importance”. As noted in Henschen’s autobiography  determines some of the characteristics of cancer in the offspring (mice).In December 1953, Folke Henschen (1881–1977), professor of anatomical pathology at the Karolinska Institute 1920–1946, submitted a Nobel Prize nomination to the Nobel committee for physiology or medicine for the 1954 prize . Since the early 1930s, it had become common that the Nobel Prize in physiology or medicine was awarded jointly to two or three scientists and not only one, as earlier had been the rule, a fact that Henschen as a former member of the Nobel Committee was well aware of. Henschen put forward two candidates: Bauer and Leonell C. Strong . Henschen nominated the two for their research on the relation between cancer and heredity, more specifically for mutation processes in somatic cells. Underlining that Bauer had conducted research on cancer for 25 years, Henschen attached a chapter of Bauer’s book Henschen , he had Henschen . While hDas Krebsproblem is an impressive textbook, but it sums up past findings and debates rather than pointing in new directions, and is distinctly German in style, at a time when this may have been viewed as increasingly old-fashioned. Bauer’s achievements in cancer research in the post-war period were predominantly administrative, leading to the establishment of the government-funded DKFZ in Heidelberg in 1964 . In his introduction of the 29 type-written pages, Caspersson noted that tumor research had experienced a boom during the last two decades [1930s and 40s]. Thus, according to Caspersson, the various methods and assumptions from a genetic perspective made such a Nobel evaluation of this vibrant field a meticulous task. He gave an overview on studies on tumor growth in mammals, fish and Drosophila, divided into (1) transplanted tumors, (2) spontaneous tumors and (3) induced tumors, citing work going forty years back. Focusing on Bauer, Caspersson noted that he had published a number of relatively general articles and books on cancer, along with more detailed articles on treatment methods and prophylaxis. “These works seem valuable for the treatments in medicine and surgery, but none of them contains such a significant discovery that it might be worthy of a Nobel Prize.” “In conclusion”, Caspersson added: “Bauer’s scholarly production covers a very wide spectrum in the tumor field. The focus of his original efforts is on treatment, first and foremost surgical treatment, but also chemotherapy. His efforts in the discussion about cancer prophylaxis is of great practical value […] but none of these aspects are prizeworthy.” Regarding Strong, however, the verdict was more positive: “If his works [as described by Henschen above] are verified in new experimental research, I find them to be of Nobel class, but for now he should not be considered for the prize” .Henschen’s nomination of Bauer and Strong led to a comprehensive special investigation by the Nobel committee, carried out by Karolinska Institute geneticist and cytologist Torbjörn Caspersson (1910–1997), head of the Institute of Medical Cell Research and Genetics, signed on 18 August 1954 . At that time, Caspersson had recently published his landmark book Das Krebsproblem, “a one of a kind achievement […] one can say without exaggeration, that this book is a milestone for cancer research” . During these years, cancer research was repeatedly on the agenda in the Nobel committee discussions. In 1959, for example, vice-chairman Axel Westman (1894–1960), gynecologist and obstetrician, voted for one half of the prize to Huggins and one half to George Papanicolaou (1883–1962), but the other committee members were in favor of Severo Ochoa and Arthur Kornberg who received it that year “for their discovery of the mechanisms in the biological synthesis of ribonucleic acid and deoxyribonucleic acid.” Nominations kept coming in for Huggins, who was awarded the prize seven years later, in 1966 , Georg von Békésy , Charles H. Best (cholin functions), Frank MacFarlane Burnet/George Hirst , John Franklin Enders/Frederick O. Robbins/Thomas H. Weller , Karl Folkers/Lester E. Smith (B 12), and Vincent du Vigneaud . Finally, the 1954 physiology or medicine prize was awarded jointly to John Franklin Enders, Thomas Huckle Weller, and Frederick Chapman Robbins “for their discovery of the ability of poliomyelitis viruses to grow in cultures of various types of tissue.” In subsequent years, Bauer kept being nominated, e.g. in 1956 by the Erlangen otorhinolaryngologist Josef Beck (1891–1966), underlining research on “blood brain barrier”, but that did not lead to a new special investigation by the Nobel Committee. In 1961, Bauer was—along with urologist Charles Huggins—proposed anew, this time by the Frankfurt surgeon Rudolf Geissendörfer (1902–1976), who underlined publications around the “Mutationstheorie” Bauer . GeissenThe will of Alfred Nobel (written in 1895) stipulates that scientists should have “conferred the greatest benefit to mankind” to be eligible for the award. Cancer has been viewed as an insurmountable problem by many since the early Nobel Prize history, leading frequently into research cul-de-sacs. Leonell Strong, in a memoir published in 1976, quotes the German bacteriologist Paul Ehrlich, often celebrated as the father of chemotherapy: “Many a man has distinguished himself in science, then made a fool of himself by entering cancer research” Strong . CorneliAs this article shows, a number of scientists were nominated as candidates for the Nobel Prize from 1901 to 1960 for innovations in the prevention or treatment of cancer. Why, then, was only Fibiger recognized with the Nobel medal during this period of time, a prize that in hindsight has been described as a Nobel error? Our analysis of the Nobel dossiers points at three main reasons.First, many of the proposed cancer researchers were surgeons, and surgery has a weak track record in a Nobel context. During the first six decades of the twentieth century, only three prizes were awarded for the development of surgical procedures: Theodor Kocher (1841–1917) in 1909 ‘for his work on the physiology, pathology and surgery of the thyroid gland’, Alexis Carrel (1873–1944) in 1912 ‘in recognition of his work on vascular suture and the transplantation of blood vessels and organs’, António Egas Moniz (1874–1955) in 1949 ‘for his discovery of the therapeutic value of leucotomy in certain psychoses’. In the pool of nominees in surgery, the Nobel committee was more interested in brain, heart, and transplant surgery than surgeons specializing on cancer operations  (brain tumors) and George N. Papanicolaou (Pap smear). On a more general level, we argue that Nobel Prize nominations provide valuable information to reconstruct research trends and networks in cancer research.


Over the last fifty years, American psychiatrists have embraced psychotropic drugs as their primary treatment intervention. This has especially been the case in their treatment of patients suffering from psychotic disorders such as schizophrenia. This focus has led to an increasing disregard for patients’ subjective lived-experiences, life histories, and social contexts. This transformation of American psychiatry occurred abruptly beginning in the late 1960s and 1970s. My essay looks the ways these major transformations played themselves out in everyday clinical practices of state hospital psychiatrists from 1950 to 1980. Using clinical case records from California state hospitals, I chronicle the ways institutional and ideological forces shaped the clinical care of patients with psychotic disorders. I show there was an abrupt rupture in the late 1960s, where psychiatrists’ concerns about the subjective and social were replaced by a clinical vision focused on a narrow set of drug-responsive signs and symptoms. Major political, economic, and ideological shifts occurred in American life and social policy that provided the context for this increasingly pharmacocentric clinical psychiatry, a clinical perspective that has largely blinded psychiatrists to their patients’ social and psychological suffering. Since the late 1960s and 1970s, American psychiatry has undergone dramatic changes. Though psychoanalytic and psychodynamic thought and practice dominated American psychiatry throughout the 1950s, it was a short-lived hegemony, replaced by growing faith in biological explanations of disease and an increasing reliance on psychotropic drugs. The National Institute of Mental Health (NIMH) research investment portfolio underwent a similarly drastic transformation in which research funding the social, psychological, and cultural dimensions of mental illness was dramatically curtailed from the late 1970s and early 1980s onward, replaced by increased funding into the biological aspects of mental illness. Accompanying this shift and, aided by it, the field of neuroscience grew at an extraordinarily rapid pace, producing spectacular discoveries in the fundamental understanding of the molecular biology, circuitry, and genomic regulation of the brain. But perhaps the most dramatic change since the 1960s has been complete dismantling of the U.S. system of care for those with serious mental illness. Peaking in 1955 with a resident patient population of over 550,000, state psychiatric hospitals had provided the vast majority of psychiatric care for over a century and, though already declining in size, disgorged most of their charges between 1970 and 1980.At first blush, these dramatic changes look like progress fueled by science and effective interventions. “For the first time in its long and notorious history,” according to a former President of the American Psychiatric Association and current chair of a major academic psychiatry department, “psychiatry can offer scientific, humane, and effective treatments to those suffering from mental illness .” With a history of lobotomy and a host of other “heroic” and terrifyingly dangerous and infamous treatments in the profession’s rearview mirror, it is understandable that many view the present as progress against a vilified past. “The past two hundred years,” the former APA President continued, “the history of psychiatry has been characterized by long stretches of stagnation punctuated by abrupt and transformative changes—many of which, regrettably, were not for the better. But we have entered a period of scientific advances that will produce a stream of innovations more dazzling than any that have come before (p. 306).” This optimism is understandable as the millennium ushered in a new era of blockbuster psychiatric drugs that proved fabulously profitable for the pharmaceutical industry and that, in the case of Prozac, made sufferers of psychiatric ills “better than well” Kramer .Yet, if one pokes just slightly beneath this rosy surface, one finds a much more complicated and darker picture. Most tragically for those with serious mental illness and most glaringly obvious has been the failure of our public mental health care system in the wake of deinstitutionalization. Irrespective of how effectively psychotropic drugs alleviate symptoms, they clearly do not provide food, clothing, shelter, significantly improved functioning, and a meaningful life. Far more individuals with serious mental illness now cycle through homelessness and incarceration in U.S. jails and prisons than occupied state hospitals at their mid 1950s peak. And, since the 1960s, the life expectancy gap between those with serious mental illness and rest of the population progressively widened. Today, an individual diagnosed with schizophrenia is likely to die 15–20 years prematurely.At the same time, while the last fifty years have witnessed an unprecedented explosion in facts about the brain, this has not translated into enduring biological explanations of psychiatric disease. If anything, the biological sciences have undermined simple causal explanations of psychiatric disease. Complicating matters even more, new powerful genetic technologies have shaken the biological  distinctiveness of the major psychiatric diagnostic categories. By the second decade of the twenty-first century, the sheen of the new antipsychotic and antidepressant drugs had worn off, revealing drugs that worked no better (but cost vastly more) than those discovered in the 1950s and 1960s.Psychiatry is failing our sickest and most vulnerable patients. As a psychiatrist who treats primarily patients with psychotic disorders, I experience nearly daily my impotence to treat the core symptoms of my patients’ illnesses. Just as auditory hallucinations, delusions, and moments of motoric fury are symptoms of psychiatric disease, so too are the more visible social markers such as abject poverty, social isolation, homelessness, and a whole host of signs and symptoms that lead to arrest and incarceration. Nevertheless, I am largely trapped in a system of care that provides little leeway in providing the kind of solace, care, and treatment that, I believe, most psychiatrists would agree is genuinely adequate. Out of necessity, since nearly all I have to offer my patients is a prescription for a psychotropic drug (most commonly an antipsychotic), my relationship with my patients orbits nearly exclusively around the suffering that my drugs might help alleviate and the suffering that my drugs almost always inflict. In the case of the new generation of antipsychotic drugs, I am constantly worried that I may be contributing to my patients shortened life span as they balloon in weight and lipids clog their arteries.As with most psychiatrists, I intuitively grasp that psychiatric disease is simultaneously biological, psychological and social. Yet, it is nearly impossible for me not to shove to the periphery of my clinical vision concerns about my patients’ social and experiential realities. If we take seriously that contemporary clinical psychiatry is the product of an increasingly better understanding of psychiatric disease and increasingly more effective interventions, we take comfort in the belief that we are on the right road, and just around the corner we will find ourselves in a “period of scientific advances that will produce a stream of innovations more dazzling than any that have come before.”Others, including myself, are less optimistic. Andrew Scull, looking back over the last fifty years of American psychiatry, sees a profession undergoing a deepening crisis, largely of its own making Scull . He writTo better understand why psychiatry is in such an odd predicament, where we now often ignore the most obvious forms of our patients’ suffering and convince ourselves that our clinical practices and responsibilities can legitimately remain circumscribed by a narrow set of symptoms and imperfect medications, I want to take us back to the scene of the crime, a moment when clinical psychiatric care took an abrupt turn. Our story will begin with state hospital physicians and their patients in the 1950s. We will then follow our protagonists as their world begins to unravel and they find themselves in a decidedly harsher reality in the late 1960s and 1970s. Though I believe more expansive ways of caring for and treating individuals with serious mental illness are more humane and ethical than an approach that reduces psychological suffering to a biological dysfunction that requires a biological solution, I am not intending this history as necessarily a defense of state hospital care, even if it appears more humane than we might have imagined when we look more closely at actual clinical practices during this period of time. Instead, my aim is to understand how everyday contexts, resources, and constraints shaped the ways in which psychiatrists understood their patients’ ills, listened to them, and treated them. In other words, by looking at what actually went on between psychiatrists and patients we might better understand the forces that have created our contemporary way of caring for those with serious mental illness.I base this examination on patient case files from California state hospitals of patients treated between the 1950s and 1980s.Over the last century, a variety of social critics, journalists, former patients, and physicians have written accounts of state hospitals in order to reveal patient abuse, systematic dehumanization and neglect, massive overcrowding, and unspeakably horrific living conditions . He went on to claim that “instances of brutality and mistreatment in our state hospitals are not uncommon occurrences.” Nevertheless, Brown defended the principle of state hospital care even as he vigorously prosecuted individuals responsible for abusive conditions. “It isn’t the system that’s wrong,” according to Brown, “it’s the administration of the system” . It would take at least another decade before politicians would seriously begin to question the wisdom of state hospitals.Of course, none of this is to say state hospital care was entirely benign. Throughout the 1950s , periodic scandals of patient abuse leapt across the state hospital grounds and onto the front pages of California newspapers. In one of the most widely publicized reports of patient abuse, five different state investigative teams were dispatched to Modesto State Hospital to investigate charges of “brutality and inhumane treatment” Goffman’s psychiatric hospitals have little to recommend as a shelter for an individual whose psychosis has made life impossible outside of the institution. “However harsh the conditions of life in total institutions, harshness alone cannot account for this sense of life wasted.” It is the illusion of treatment that adds to the depredations inflicted upon the individual by the hospital:As we will see below, the everyday world of state hospitals could and often did look very different from these depictions of state hospitals as factories of psychological and physical torture.Asylums, we see that there are far worse alternatives to state hospitals. And, with hindsight, we can see that critiques of state institutions, regardless of their truth, ironically and tragically did not aid in the liberation of those with serious mental illness but, instead, by undermining the legitimacy of state hospitals, helped provide the rhetorical justification for a far more brutal system. If there could be a dark side to the “total institution,” there is another side as well, one that requires a more nuanced vision of psychiatric care and underlines the importance that everyday institutional realities play in the “mortification” of patients as well in providing solace and asylum.Looking back since the publication of Goffman’s Just as we should take seriously  the potential and actual dangers of state hospitals, even in that hopeful moment of the 1950s, we should take seriously  what hospital administrators had to say about their institutions. Entering the 1950s, hospital administrators turned the totalizing nature of care into an exuberant and expansive therapeutic mission. The Director of the California Department of Mental Hygiene wrote in 1952, “Everything done to, for, or around a mental patient in a California hospital can be considered as therapy since therapy is the ultimate purpose of everything done”  LEAVE THE ROOM YOU DEVIL I SEE YOU ON THE CEILING! (Dr. Gorman asked ‘what is this place?’) This is the workshop of the devil, this is the death house.”Claude: Do you think I’m Crazy?Doctor: No, I do not think you are crazy.(The patient got a warm smile on his face)Claude: Shake the hand, feel the warmth.(The patient then went into a drowsy comma).Claude’s agitation finally reached a crescendo requiring chemical intervention. The stenographer notes the appearance of an attendant with a hypodermic filled with sodium amytal. With the assent of Dr. Gorman, he then injected the barbiturate into Claude’s arm. Claude’s only response was, “You can put it in, it will not stop the tongue.” The barbiturate apparently worked as the stenographer notes that the patient had calmed down and appeared drowsy. The remainder of the interview went as follows:With Claude no longer responsive and the interview effectively ended, the attendant wheeled Claude back to his ward.Over the next few weeks, Claude underwent a course of electroshock treatment, hydrotherapy, and psychotherapy. To assess his progress and ascertain a precise diagnosis, his attending psychiatrist convened a “Clinical Conference,” a ritual in which all newly admitted patients were interviewed by several staff psychiatrists (in Claude’s case there were 5 present) with a stenographer transcribing the patient interview and subsequent discussion between the assembled physicians. Claude had calmed down significantly since his first few days in the hospital and no longer ranted about God, the devil, and his possessed mother. At the same time, he had little insight into the events that brought him into the hospital. When asked by Dr. Gorman whether there was “anything wrong with your mind?” he replied that “I may have had a little fever at the time. My mind is as good as it ever was.” Unsatisfied, Dr. Weiss persisted: “All this business about God and snakes, does it represent any illness?” Again, Claude answered, unwilling to see himself as psychotic: “I was reading the Bible.”Dr. Weiss: The mother says he is a quiet boy, never fights or quarrels.Dr. Brunnell: Schizophrenia, catatonic type.Dr. Batko: Schizophrenia, mixed type.Dr. McCullough: Mixed. He will turn out to be paranoid.Dr. Doody: Catatonic.Dr. Galioni: Catatonic.Dr. Weiss: Dementia Praecox, catatonic type. He should have EST.After dismissing Claude, the physicians had the task of arriving at a diagnosis.At first glance, there is very little to distinguish Claude’s psychiatrist from how a psychiatrist today might have approached Claude’s disease. Then, as now, little has changed about the kinds of behaviors considered to be psychotic and central to a diagnosis of schizophrenia or dementia praecox (used interchangeably with schizophrenia in the early 1950s). While psychiatrists today might prescribe electroshock therapy after trying numerous antipsychotic drugs, Claude’s psychiatrists would have to wait another five years for the first effective antipsychotic drug  to be available. But, on the surface, one could imagine that the logic of today is quite similar as it was in the 1950s where a set of psychotic symptoms  signify an underlying biological disorder requiring a biological solution.If we probe deeper, however, we see that Claude’s psychiatrists had a significantly more complex notion of Claude’s illness. Claude’s psychotic symptoms and signs signified more than an underlying biological disease. His psychiatrists believed that his fantastical and terrifying delusions about the devil and his mother had psychological and historical meaning that not only helped to explain the cause of his psychosis, but had therapeutic value. They extensively probed his early childhood. Impoverished and often desperate, his parents hit him frequently and, when he managed to avoid their frequent beatings, he felt neglected and alone. His physicians paid particular attention to his psychosexual development. “The patient said, when he was very young, he saw his parents have intercourse many times and many times he would lie awake all night listening to his parents argue because of sex.” His physicians gave these early experiences a causal role in Claude’s psychosis. They described his early experiences as psychological pathogens, lurking in his past and slowly eating away at him until they erupted into psychosis.The psychiatrists carefully chronicled what they considered most important and pathogenic. His “early home life [of] destitution,” forced to work at the age of 14, “hired out for 50 cents a day and worked from daylight to dark driving mules around plowing fields,” and, most importantly, the “many traumatic incidences involving sex and parental relationships” gave psychological meaning to his disease. “She [his mother] never done nothing for me but brought me into the world,” Claude told his ward physician. He continued, “She let me run around with shit in my pants. Box my ears until I was deaf and I would lose my senses.” In what his physician thought was most meaningful, Claude said, “I was seeking love, she did not have any for me.” Suggesting that something recently had triggered his psychosis, his physician asked whether he frequented sex workers. “The last time I went to one was three month ago,” he confessed and then began to cry. “I loved them…I asked many of them to marry me, to love them, they said maybe.” Then, echoing his earlier comments about his mother and what he had experienced as her having “done nothing for me,” his love turned dark: “They would suck the dick with their mouth, eat the shit from the ass. They would do anything for money.” For Claude’s physicians, electroshock therapy could do nothing for what genuinely gnawed at Claude and ultimately proved the most pathogenic. While electroshock therapy may have been useful for his acute symptoms, his psychiatrists believed that psychotherapy would get at the core of his psychosis by helping him forge connections between his pathogenic past and his psychotic signs and symptoms.Claude’s hospitalization was short, lasting only three and half months. He improved rapidly, receiving psychotherapy, electroshock therapy, occupational therapy, and attending the various entertainments, such as movies, picnics, and field trips into the surrounding city of Stockton. Brought before the “Clinical Conference” a few days before his discharge, the physicians made certain that he was no longer psychotic and that his mother was willing to take him back. Curious about what accounted for his improvement, one of the physicians present asked “which helped the most, EST or group therapy?” Claude replied, “Well, I don’t know—they both helped me.” Of course, we cannot be certain whether Claude simply wanted to please his physicians and gave them an answer he knew they wanted to hear. Nevertheless, we do know that his physicians tried to give meaning to his psychosis, a meaning embedded in his past and present desires that, at least from the physicians’ perspectives, required both somatic and psychological interventions.The same year Claude was admitted to Stockton, 1950, the French pharmaceutical company Rhône-Poulenc, synthesized RP 4560 . Chlorpromazine, which was marketed as Thorazine in the United States, inaugurated an unprecedented and massive psychopharmacological revolution that continues to reverberate through present-day psychiatry. Indeed, many have assumed that our contemporary dependence on psychotropic drugs inevitably followed from their effectiveness . As a corollary, psychiatrists often see the fact that a drug’s capacity to alter a particular behavior or experience  as proof that the psychiatric disease is fundamentally biological in nature and that the social and psychological are largely epiphenomenal, playing a secondary role. A close look at the ways in which psychiatrists used antipsychotic drugs reveals that there was nothing inevitable about the specific ways in which physicians would eventually use these drugs beginning in the 1970s. As we will see, the social, institutional, political, and ideological contexts of care mattered as much, if not more so, than the actual biological effects of the drugs in shaping psychiatrists’ growing reliance on them as their most important interventions.A synthetic phenothiazine, RP 4560 was a product of the company’s efforts to create centrally acting antihistamines. Having given the drug to a number Parisian clinicians to try on their patients, some observed that the drug calmed psychotically agitated patients Swazey . By 1952Early on, Smith Kline French recognized the size of the potential psychiatric market. Over a half a million captive potential consumers housed in the United States sprawling state hospital system, no doubt, motivated Smith Kline French initially to provide Thorazine free of charge to state hospitals so physicians could judge for themselves the effectiveness of this new pharmaceutical agent. Ultimately, affirming the published literature, practitioners found chlorpromazine enormously useful in quelling many psychotic symptoms, especially agitation, combative and violent behavior, extreme anxiety, as well as overtly psychotic symptoms such as auditory hallucinations, disordered and chaotic thinking, and delusions. By 1955, Thorazine had become an early blockbuster drug with profits of $75 million It is worth stressing that the new psychotropic drugs were not initially framed as particularly revolutionary. Useful, yes. But, at least from this former administrator’s perspective, the drugs remained largely an adjunctive treatment to “other forms of psychiatric techniques.” Just as importantly, there was nothing in the nature of prescribing these new psychoactive drugs that necessarily dictated a particular way of understanding psychiatric illness. The fact that an agent acted through a biological mechanism did not in and of itself suggest that the illness was either solely biological in nature or that psychological and social interventions were less important.In a series of public hearings in late 1955 and 1956, California state hospital superintendents summarized their experiences with the new tranquilizing agents, views that largely affirmed Rapaport’s cautious optimism that Thorazine was not curative, but a new useful addition to their therapeutic armamentarium. Summarizing the sentiments of many of his fellow psychiatrists, the former Superintendent of Stockton State Hospital, Rudolph Toller, said:In what follows, we will follow a couple of patients in their sojourns through California state hospitals so we can witness firsthand the ways psychiatrists in their everyday clinical care made sense of these new interventions. To foreshadow my argument, it was the structure of state hospital care that played a dominant role in structuring how antipsychotic drugs would be deployed and rationalized. What much of the antipsychiatric literature ignores or downplays is that these institutions were, at least in principle, designed, funded, and staffed with the aim of comprehensive care for those individuals whose family and friends had forsaken and who were far too impaired to survive employed and housed. These structural forces, as much as the drugs and their effects, dictated the meaning of psychosis and its treatment.Albert Russo already had spent a relative brief stint at Stockton State Hospital, when in the fall of 1959, just after his twenty-first birthday, he again became psychotic. Still living at home, Albert was convinced he had been endowed with “magical powers” that would allow him to visit the moon. Not surprisingly, his parents expressed skepticism and a good deal of alam since his previous hospitalization had followed a similar episode. Along with his growing delusional fantasies, Albert had become “aggressive and belligerent.” Unable to keep him safely at home, they decided that they had no choice but to seek help. Cajoling him into their car, they drove him to the local county hospital. There, the examining physician transferred him to Stockton, diagnosing a psychiatric disorder that required longer and more intensive care than the county hospital could provide. Albert arrived at Stockton’s receiving hospital just as delusional and agitated as he had been at the county hospital. The psychiatrist had little trouble arriving at a diagnosis of schizophrenic reaction.In his family the father appears to be very rigidly and aggressively domineering and the mother appears to be a warm and loving, but ineffectual parent. There appears to be a great deal of conscious and unconscious hostility between these parents. Shortly after the patient’s older sister eloped, an action which the father firmly disapproved, and after the patient’s own failure to make an athletic team at school, his behavior became erratic, hyperactive, and less well organized in general. It seems possible that the patient is torn between the desire to act out his father’s hostility and the desire to be more passive or submissive like his mother.At the end of the nineteenth century, psychiatrists developed what would become a fairly standardized structure to their psychiatric histories, which has changed little, if at all, over the course of the twentieth century.  The typical psychiatric admission history contained the following headings: present illness, past illnesses, family history, personal history, mental status, formulation, and diagnosis. While the broad structure remained remarkably stable over time, psychiatrists’ narrative styles and the kinds of stories they told about their patients’ suffering did change over the course of the century. In the first few decades of the twentieth century, physician histories read more like natural histories charting the unfolding of an autonomous disease process that gradually revealed itself over the course of the patient’s illness. By the 1940s and 1950s, one can discern a marked change in the ways in which psychiatrists wrote about their patients.  Instead of only cataloguing the appearance of signs and symptoms, psychiatrists’ increasingly tried to fashion a causal story about their patients’ ills. In particular, psychiatrists increasingly wrote stories where their patients’ childhood experiences, losses, desires, failures, and psychological traumas played a necessary, if not sufficient, causal role in their diseases.  Albert’s psychiatrist leaves no doubt that he saw Albert’s disease as flowing directly out of his childhood relationships with his “passive” mother and “hostile” father:Albert’s psychiatrist constructed a narrative of Albert’s disease that wove the parents’ internecine battles as the pathogenic nidus that eventually laid the groundwork for a “schizophrenic reaction.” The psychiatrist’s treatment recommendations reflected his analysis of Albert’s troubles; namely to make conscious his largely unconscious conflicts revolving around his relationships with his parents and the meanings these had for him. This would be possible through psychotherapy. Of course, we should be cautious as to what “psychotherapy” means in this context. The psychiatrist failed to jot down how often he met with Albert as well as what may have transpired in their meetings. Most likely, their sessions had little in common with psychodynamic, let alone, psychoanalytic psychotherapy. Instead, given the time constraints the psychiatrist faced in caring for a large number patients, he most likely met with Albert for short intervals, giving practical advice, playing a surrogate parent, and shoring up Albert’s sagging self-esteem.The psychiatrist’s psychological explanation for Albert’s ills and his psychotherapeutic solution did not preclude him from prescribing antipsychotic drugs for Albert. Immediately upon Albert’s admission, the psychiatrist ordered Stelazine (trifluperazine), another antipsychotic drug that Smith Kline French began marketing in 1958 Shorter : 55. It This use of psychotropic drugs was not unusual. A 1959 advertisement for the antipsychotic drug Sparine (promazine), Fig. Throughout the nineteenth and first half of the twentieth century, state hospitals provided a safety net of last resort for those whose mental illness made it impossible to survive on their own.  All of the stuff that makes life possible outside of the hospital was the responsibility of the physicians within its walls.  As such, the claim that “Everything done to, for, or around a mental patient in a California hospital can be considered as therapy” underlines the historical contingency of treatment practices and the boundaries of psychiatric disease.  For state hospital physicians, responsible for all aspects of their patients’ lives,  disease its treatment easily traversed across the domains of biology, psychology, and social life. It is not surprising, then, that psychoactive drugs  had little overall effect in altering the ways in which psychiatrists understood and treated their psychotic patients.The totalizing nature of state hospitals, where physicians tried to regulate (even if for therapeutic ends) all aspects of patient life, did not dissuade patients from voluntarily admitting themselves into state hospitals.  Following the war, increasingly large numbers of individuals sought voluntary hospitalization. Embarking on a massive post-War construction spree, California nearly entirely vanquished overcrowding. At the same time, California state hospital administrators hired numerous psychiatrists, psychologists, and social workers who were awash in the growing cultural influence of psychoanalysis and psychotherapeutic approaches to mental ills. California state hospitals of the 1950s provided asylum not only for those involuntarily forced into the state hospital, but also a growing and significant number of individuals voluntarily submitting themselves to the psychiatric discipline of the state hospital care and consolation  safe and gentle refuges. But, even when patients experienced the more carceral, disciplinary nature of state hospitals, we can see a therapeutic rationale in what appears in hindsight as punitive and dehumanizing. Largely dictated by institutional imperatives to care for those unable to care for themselves, we can see a countervailing tendency.Esther Erving’s comparatively long hospitalization illustrates the ways in which two seemingly incompatible forms of care—the “right hand” of disciplinary care and the “left hand” of therapeutic care, to analogize Pierre Bourdieu’s concepts of the Left and Right hands of the state Loyal —constituEsther is all I have in life…I love her to no end and there is nothing more that I would care for than to see her well physically and mentally….I know that it was beyond my power to know what to do in such a case as hers but I have always had faith in technical doctors because I feel that they evidently possess a greater ability to do more for people or else they would remain just a common doctor.His faith and Dr. Tock’s and her colleagues’ desire to “do something,” even if a last resort, led to the decision to perform a transorbital lobotomy.Over a hundred electroshock treatments, untold hours in restraints, and hundreds of hydrotherapy treatments did nothing to alter Esther’s increasingly unpredictably violent outbursts. Her husband’s desperation to have Esther returned to sanity, no doubt, added to the physicians’ sense of impotence. He wrote to her ward physician, Dr. Tock:The lobotomy proved less than successful. A note shortly afterwards read, “Patient was started on EST since lobotomy because she was so combative with patients and unpredictable. Has to be watched all the time.” A note from July 1954 read, “Receives hydro, has maintenance with fair results. Seems to benefit more from seclusion.” Nine months later, after over 100 electroshock treatments, Esther’s physicians started her on Thorazine, hoping that they would not have to perform a more extensive lobotomy. “Took medicine reluctantly at first but is now taking it readily and seems more relaxed.” Six weeks later and prescribing 700 mg a day, physicians noted that “there has been some improvement.” The addition of Thorazine effectively quelled Esther’s doctors’ consideration of a more extensive second lobotomy. In fact, physicians at all California state hospitals abruptly ceased performing lobotomy once Thorazine become available. Nevertheless, despite the unusually large doses, the antipsychotic drug proved only partially successful and Esther again spiraled back into her unpredictable violent attacks on fellow patients and unsuspecting staff who passed within reach of her fists or feet. In what would become a similar pattern over the next few years, a new antipsychotic drug would be tried, often at hefty doses, with initial success and then, a few months later, Esther would lapse back into another round of unpredictable attacks on any one she believed had crossed her. This, in turn, would necessitate a try at a new antipsychotic drug, which invariably followed the same cycle of initial success followed by failure.Throughout Esther’s hospitalization, her family remained involved in her care. They visited her often and took her home for extended leaves of absence. However, for Esther’s physicians, the successful elimination of her psychotic symptoms did not necessarily make her ready to permanently leave the hospital. Despite Esther’s husband’s and mother’s pleas, Dr. Tock steadfastly refused to discharge Esther, certain that Esther would tumble back into psychosis. Dr. Tock reminded the family that treatment involved much more than simply the taking of a drug. Esther’s care and treatment required the entire web of relationships and interventions that the hospital provided.With the total embrace of its denizens, the state hospital provided the scaffolding for an expansive definition of disease and its treatment, where the social, psychological, and biological were legitimate explanations for as well as targets of therapeutics. The actual care, consolation, and effective treatment state hospital physicians provided for patients such as Martha, Esther, Claude and Albert stands in contrast to the narratives that depict state hospitals as horrors of an unenlightened past. At the same time, the logic of state hospital care that enabled these institutions to shelter those with serious mental illness also gave psychiatrists the instruments of control and domination that made interventions, such as lobotomy, legitimate treatments. Whether in the service of care and consolation or control and discipline, the same clinical vision shaped the care and treatment of Martha as well as Esther despite the dramatically different ways in which Dr. Tock treated the two patients. Dr. Tock’s clinical world view saw both patients and their diseases as embedded in a social context that was critical to each one’s care and treatment. In both cases, the asylum’s function required taking into account a patient’s wishes and desires and weighing that against the severity of the patient’s illness. When we consider Claude, Albert, Martha, and Esther together, we see a clinical vision that saw the social context and subjective meaning of psychosis as inextricably bound to understanding, treating, and caring for their patients. Control, discipline, alienation, empathy, consolation, care and treatment traveled together in State hospitals of the 1950s and 1960s. Perhaps the “right and left” sides of care were inherent in this system of care that defined disease based as much on violations of social norms as psychological distress. The state hospital as both a place of last resort and a place of refuge depended upon a larger political economy and set of ideological commitments, none of which survived intact beyond the 1960s.The psychiatric world changed quickly and dramatically from the late 1960s onward. Psychoanalysis quickly lost its hold over American psychiatry, replaced by a growing reliance on psychotropic drugs and a faith in biological reductionism. Most obvious, especially for those with serious mental illness, was the dismantling of the state hospital system. Over the course of less than three decades, the state hospital system and its logic of care and treatment became a bare whisper of its former self. The same political, economic, and ideological forces that attacked the welfare state also undid state governments’ commitment to provide comprehensive care for those unable to care for themselves. Armed with an ideology  of the virtues of community care, policymakers, politicians, activists, former patients, and clinicians all helped to dismantle the state hospital system. Ever since state governments began constructing asylums in the nineteenth century, the number of patients had steadily increased. The national state hospital resident population reached its zenith at 557,969 patients in 1955 , but fell more quickly than other states. In 1955, the resident state hospital population was 37,211 and, ten years later, had fallen to 25,674 . This entitlement program provided stable income for those with serious and persistent mental illness who were ineligible for Medicare and Social Security Disability Income (SSDI). This expansion maintained the sustained fall in resident population, allowing state hospital physicians to discharge patients into the community—though, as became increasingly apparent, into lives that were often far more brutal, isolating, and impoverished than they had experienced in state hospitals  to control his agitation and make him bearable by the other patients. He would be up all night rummaging through their lockers and generally behaving in a rather bizarre manner. Thorazine rapidly reduced this. The patient, although still obvious mentally ill, was able to understand that he needed treatment and he was allowed to change to voluntary status at the end of the 72 hours. On several subsequent occasions, he came in and indicated he wanted to sign out, and he was informed that we did not feel he was ready…The acute aspects of his illness subsided steadily, however, the chronic degree of illness remained substantially high, and it is obvious that this patient will remain a bizarre, chronically schizophrenic individual with intermittent aggravations leading him to repeated hospitalizations. Attempts to contact the family indicated that he was not welcome with the family in any way.Diagnosis: schizophrenia, chronic undifferentiated type.Recommendations: (1) Condition improved. The patient remains chronically schizophrenic with maximum hospital benefit. (2) Refer to mental health clinic. (3) A 14-day supply of medicine was sent with the patient.There are several points worth emphasizing. First, the psychiatrist’s focus on his psychotic symptoms and their response to chlorpromazine illustrates a substantially narrowed perspective where signs and symptoms speak for themselves and do not have much more meaning than pointing towards his schizophrenia. Second, the large chlorpromazine dose achieved over the course of just a handful of days suggests that the psychiatrist increased the dose as rapidly as possible to hasten Jonathan’s discharge. In other words, the signs and symptoms that respond to chlorpromazine were the main focus of treatment and their successful elimination was the criterion by which Jonathan was discharged.Third, and related to the rapid escalation of the dose, we see that the doctor has articulated a radically diminished horizon for psychiatric treatment compared to patients admitted a few years earlier: “The acute aspects of his illness subsided steadily, however, the chronic degree of illness remained substantially high, and it is obvious that this patient will remain a bizarre, chronically schizophrenic individual with intermittent aggravations leading him to repeated hospitalizations.” The very definition of successful treatment has dramatically changed. Jonathan’s psychiatrist measured successful treatment based on eliminating a narrow set of drug-responsive signs and symptoms. Despite remaining psychotic (though no longer agitated) and facing certain homelessness, Jonathan was declared to have achieved “maximum hospital benefit.” This assessment rested upon a fundamentally new clinical vision where the social world has receded into the background in the clinical calculus of Jonathan’s psychiatrist.The escalation of antipsychotic drug dosages as hospital lengths of stay shortened was a widespread phenomenon. Based on the random sample of patients described in Sect. As Jonathan’s psychiatrist predicted, Jonathan continued to cycle in and out of the hospital throughout the 1970s. And, as hospital beds became increasingly scarce, his hospitalizations shortened, further narrowing what psychiatrists meant by the phrase “maximal hospital benefit.” In addition to a prescription, Jonathan would be given an appointment to the public mental health clinic as he exited the hospital. Neither proved useful to him since he rarely, if ever, took the prescribed medication and rarely, if ever, kept his outpatient mental health appointments. Not surprisingly, having been unable to find work and having completely exhausted his family, Jonathan returned to live in whatever makeshift shelter he could either find or piece together with the flotsam and jetsam he collected near where he called home in Downtown Los Angeles. Once he began collecting SSI checks, he interspersed stretches of homelessness with a week or so in a single room occupancy hotel.Over the course of the decade, Jonathan’s “institutional circuit” Hopper  expandedPsychiatrists in the 1950s and early 1960s had a radically different understanding of “maximum hospital benefit” than psychiatrists in the 1970s and 1980s. These differences fundamentally turned on which signs and symptoms psychiatrists saw as important, and then the ways in which they made sense of these signs and symptoms in relationship to the patient’s disease. I have tried to suggest that the “total institution” of the 1950s was not nearly as harsh, totalizing, and dehumanizing as we might have believed. Under the right historical circumstances—such as post-War America with its growing faith in the Keynesian state—state hospitals managed to create a therapeutic space, however imperfect. For better or worse, state hospital psychiatrists saw a world refracted through a lens in which they had comprehensive responsibility for their charges. Even a partial list of their most important interventions illustrates the complexity of their worldview: lobotomy, electroshock, psychotherapy, industrial therapy, occupational therapy, recreational therapy, bibliotherapy, music therapy, and beauty shop therapy. For state hospital psychiatrists, if subjective experiences mattered, it was because the social structure of the hospital made this possible.With the rapid emptying of state hospitals in the late 1960s and early 1970s, psychiatrists had little choice but to redefine the meaning of “maximum hospital benefit” and focus increasingly on a narrow set of symptoms that antipsychotic drugs could alleviate. This new world was not of their own making, nor was it the making of antipsychotic drugs. Deinstitutionalization and the delegitimization of comprehensive care for a disease that, by definition, is a failure to function, had little to do with scientific evidence or the effectiveness of psychotropic drugs. Rather, it had everything to do with the destruction of the welfare state, abandonment of Keynesian economic policy, and the shift towards neoliberal economics and policy. Left in the wake of these forces are a fragmented social safety net, impoverished families unable to care for their psychotic loved ones, and a rhetorical embrace of a barely existing and unrealized community care system. These are now the building blocks of the practical, everyday way of understanding and treating individuals with serious mental illness.Just as psychotropic drugs did not transform treatment in the 1950s and 1960s, we should not be too quick to blame psychiatrists’ reliance on them as the engine that has led to an increasingly biological reductionist clinical psychiatry. Admittedly, clinical psychiatry’s embrace of psychopharmacology and biological reductionism has functioned as clinical blinders, making patient’s lived experience increasingly irrelevant to clinical psychiatric practice. But contingent historical circumstances, as this history suggests, made the turn towards biological reductionism more of a marriage of convenience than a choice based on scientific evidence. Since the 1970s, psychiatrists increasingly have found themselves with little more to offer their patients than a prescription.It almost goes without saying that psychiatric disease is simultaneously social, biological, psychological, and experiential. Yet, this history illustrates that psychiatrists’ clinical beliefs and treatments were (and are) as dependent on the contingencies of social life as are their patients’ psychiatric disorders. Psychiatry may not own the current crisis of inequality that has plunged tens of thousands into despondency, but it owns a part in addressing it. First, though, the profession must reckon with its myths, assumptions, and shibboleths—learning from its history, rather than repeating it.