European Health and Social Welfare Policies

European Health and Social Welfare Policies Laurinda Abreu (Ed.)

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European Health and Social Welfare Policies Laurinda Abreu (Ed.)

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Copyright © 2004 by the Compostela Group of Universities and the PhoenixTN, European Thematic Network on Health and Social Welfare Policies All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.

ISBN 84–607–3621–X

Prepared in cooperation with the Brno University of Technology/ VUTIUM Press

Printed by Reprocentrum, Blansko, Czech Republic

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Table of Contents

PREFACE OF THE SERIES EDITOR ................................................................................... 9 INTRODUCTION ............................................................................................................ 10 ABOUT THE AUTHORS ................................................................................................. 15 SECTION 1 HEALTH BETWEEN SELF-HELP, INFORMAL AND FORMAL INSTITUTIONS ........ 21 A History of Poverty and Poor Relief: Contributions from Research on the Early Modern Period and the Late Middle Ages and Examples from More Recent History ........................................................................................... 23 Martin Dinges Poverty as a Resource of Territorial Power: The Case of Late Medieval Geldern ..... 51 Kay Peter Jankrift Organizing Poor Relief and Health Care: The Specificity of the Portuguese Case (16th–18th Centuries) ................................................................................................... 60 Laurinda Abreu Medicine, Philanthropy and the State: The 1817–19 Fever Epidemic in Ireland ....... 81 Laurence M. Geary The Introduction of a School Health Service in Stuttgart, 1904 ............................... 100 Sylvelyn Hähner-Rombach

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The Development of School Health Services in Austria .......................................... 119 Martina Gamper

SECTION 2 SOCIAL WELFARE POLICY AND CHANGES IN THE HEALTH OF THE P OPULATION ........................................................................................ 131 Health and Social Transitions: The Need for Comparative and Multidisciplinary Knowledge ................................................................................................................ 136 Jan Sundin and Sam Willner Lisbon in the Last Two Centuries: An Example of the Difficult Relations between Urban Growth, Migration and Death ........................................................................ 169 Teresa Rodrigues Veiga and Maria João Guardado Moreira Health and Living Standards in Portugal in the Early Twentieth Century ............... 183 Joaquim da Costa Leite The Health of the Population and Health Policy in 19th-century Bohemia: The Case of Asiatic Cholera (1830s−1900s) ............................................................ 200 Petr Svobodný A Persistent Regional Mortality Pattern in Sweden during the Industrial Age ........ 216 Sam Willner Increasing Mortality Inequalities in Hungary ........................................................... 252 Janos Sandor and Mária Szucs The State of Health in the Basque Autonomous Community: Future Strategies ...... 262 Emma Sobremonte

SECTION 3 INNOVATION IN HEALTH POLICIES AND THE INSTITUTIONAL LEVEL ............. 271 Charity Practices in the Portuguese Brotherhoods of Misericórdias (16th–18th Centuries) ................................................................................................. 277 Maria Marta Lobo de Araújo

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Public Health and Poor-relief in the British-Mediterranean Colonial Context, 1800–1860s .............................................................................................................. 297 John Chircop Mixed Motives: Improving the Health of Seamen in Liverpool 1875–1939 ............ 321 Sally Sheard The Minor in Medical Care ...................................................................................... 337 Pilar León Sanz French Cities and the Origins of Medical and Social Policy: Late 19th–20th Century France ....................................................................................................................... 360 Patrice Bourdelais and Yankel Fijalkow Public Hygiene as a General Concern in an Industrial 19th-century Town: Seraing... 374 Suzy Pasleau Science, Institutions and Legislation: Aspects of the History of Public Health and the State in Norway ............................................................................................ 414 Kari Tove Elvbakken Sanitary Normalization in Portugal: Pharmacies, Pharmacopoeias, Medicines and Pharmaceutical Practices (19th–20th Centuries) ........................................................ 434 João Rui Pita

SECTION 4 CHOICES OF WELFARE POLICIES AND THEIR CONSEQUENCES: LOCAL AND REGIONAL ENVIRONMENTAL HEALTH EFFECTS ......................... 455 A Hard Row to Plough: A Historical Overview of Health Policy Dynamics in Hungary.................................................................................................................. 458 Bence Döbrössy and Péter Molnár The NHS Plan: A Healthy Rhetoric, But So Far an Unhealthy Reality .................... 485 Tony Warne, David Skidmore, Susan McAndrew Community Medicine and Primary Health Care in Norway: Competitors or Parts of an Entity? ............................................................................ 494 Øivind Larsen

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Fathers in the Swedish Family from the 1940s to the 21st Century .......................... 513 Ann-Sofie Ohlander

EPILOGUE The Politics and Policy of Population Health: A Comparative Perspective ............. 525 Daniel M. Fox

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Preface of the Series Editor

The present publication, the fourth volume in the Compostela Group of Universities’ series on European Issues, brings together a selection of papers from a conference organized in 2002 by the PhoenixTN around the theme of health care and social welfare systems. It is the second such example of cooperation between the CGU and the PhoenixTN, the first being Lucie Paquy’s European Social Protection Systems in Perspective, which appeared earlier this year in the same series. Both publications are concerned with a broad historical view of the different contexts in which, over a long period of time, mechanisms were developed in the various countries of Europe for ensuring the welfare of their populations. This was a lengthy process, marked by a complex interplay of private and public initiatives, of action from below and legislation from above. The many “case studies” presented in this publication touch on a wide range of issues affecting many countries over a period of several centuries, from the Middle Ages to the present day. Taken together, they provide a fascinating picture of the gradual development of European healthcare and welfare provision. They are also a telling reminder of just how difficult it is to create public welfare systems, but also of their effectiveness once this is achieved. At a time when such systems are under increasing pressure throughout Europe, the insights these articles offer are particularly valuable. Don Sparling Series Editor Masaryk University in Brno, Czech Republic

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Introduction

The present volume includes a series of texts presented at a seminar on “European Health and Social Welfare Policies” held at the University of Évora, Portugal, from 20–21 September 2002. The seminar was carried out by the PhoenixTN, an Erasmus Thematic Network approved by the European Commission in the summer of 2001, and can be considered one of the most important outputs attained by the project during its first year. The topic of the seminar – mechanisms of poor relief, health care and social welfare – has been a priority among researchers working in the social science fields. Free from the paradigms that have conditioned research on the Middle Ages and the Early Modern Period for years – the crisis thesis, the social disciplining and confessionalization paradigms1 – recent studies have opened up new perspectives of analysis that revalue variables such as the social and economic bases of poverty, self-help strategies and the support offered by informal institutions, trying to study the problem as a social phenomenon that reflects the intervention of different political, economic and cultural factors. Similarly, social policies, regarded in the sense of the institutionalized policies set up in Europe by the end of the nineteenth century – in constant evolution but not always adapting to social changes – have also been a stimulating area of study for social analysts. The influence of the (rapid) worldwide changes in social systems and, in some

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Martin Dinges, “A History of Poverty and Poor Relief: Contributions from Research on the Early Modern Period and the late Middle Ages – and Examples from More Recent History”, included in the present volume, pp. 23–50.

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Introduction

cases, political systems as well, during the twentieth century have given way to a series of new circumstances that have forced a rethinking of health and public welfare policies. Among the most salient aspects of the complex set of challenges faced by anyone studying and planning social policies are the consequences of the collapse of frontiers, the social problems arising from the political destructuralization of Eastern Europe and economic globalization; the demographic pressure in some countries; the lack of a sufficient labour force in others; the existence of uncontrollable illegal migration; the urban chaos in almost all the big cities; the increasing number of social outcasts and social exclusion; the increasing criminality rate (especially among young people); unemployment and poor working conditions; the increasing number of drug addicts; the catastrophic spread of AIDS, tuberculosis and hepatitis; and new social ills such as social stress. In general terms, it can be said that these are the questions under study by most academics who are part of the PhoenixTN. Nevertheless, though part of an Erasmus thematic network, the present project is not aimed at supporting research as such.2 But it should, however, create space where its members can present the results of their own research, wherever possible “fostering the development of joint programmes and specialized courses, particularly in subjects underrepresented in university cooperation in Europe”3 and, simultaneously, be applied in the working areas developed by the different projects.4 It was from this perspective that the PhoenixTN Scientific Commission – formed by professors Jan Sundin, Patrice Bourdelais, Martin Dinges, Bernardino Fantini and

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Among the main objectives of a Thematic Network Project are to “provide a more favourable environment for a deeper understanding of the discipline concerned [by] comparing the systems in different participant countries. Furthermore, in the context of such a comparative understanding Thematic Network Project should: work towards assessing the quality of cooperation and curriculum innovation; promote, within an active forum, discussions on improvements in teaching methods in specific discipline areas; foster the development of joint European programmes and specialized courses, and improve the dialogue between academic and socio-economic partners” (http://europa.eu.int.comm/education/socrates/tnp/description.html).

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This objective has been partially attained through the approval of an Intensive Programme on “Health and Social Change” elaborated by one of the members of the PhoenixTN Scientific Commission, Prof. Jan Sundin of the University of Linköping, and formed, for the most part, by members of the PhoenixTN.

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Specifically, at the level of the work carried out by the Working Groups on Pedagogical Material and Political Recommendations.

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Laurinda Abreu

Laurinda Abreu – planned and organized the seminar on “European Health and Social Welfare Policies”. Trying to profit from the fact that the members come from different scientific backgrounds, the seminar was divided into five thematic sessions in order to include as many specialization areas as possible: • health between self-help, informal and formal institutions; • social welfare policy and changes in the population’s health; • innovation in health policies and the institutional level; • social exclusion and integration policies; • reasons for different choices of welfare policies and their consequences: local and regional environmental health effects. The choice of texts published in the present volume was guided by two main criteria: the match of the studies with the specific scholarly concerns of the individual sessions and compliance with the schedule for revising the materials. Even though this selection was entirely the responsibility of the Scientific Committee, both the perspectives of analysis and the methodological positions of each author reflect their own choices. As a whole, these studies cover a great chronological range, from the late Middle Ages up to the present; from a geographical point of view, they deal with a broad spectrum of European countries. During the first session of the seminar held in Évora, the relationship between private charity – self-help included – and public relief was discussed, from two main points of view: “what benefits do charitable activities bring to the wealthy and ruling classes, and what is the relationship between self-help, outside aid and public or state support in the development of new forms of welfare?”5 These are issues that are increasingly relevant in terms of historical analysis, as was proved by some of the papers presented, which highlighted the diversity of forms of assistance and assistance organizations that were developed in Europe throughout the last millennium, and explained the social and political motivations underlying them. The second session focussed on the effects of social and economic changes on the health of the population, and underlined the importance of the nineteenth century as a period that simultaneously witnessed the worsening of the health problems and living

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See comments on this session by Martin Dinges, “Health between Self-Help, Informal and Formal Institutions”, pp. 21–22.

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Introduction

conditions of the less favoured sectors of society, but also the launching of certain measures for the improvement of the environmental and sanitary conditions that did in fact bring about a change in that situation. As stated in the papers presented, the advent of political democracy and the development of social welfare systems in the twentieth century, and particularly after the Second World War, gave rise to adequate conditions for the promotion of health and the prevention of diseases, which led to an immediate decrease in disease and mortality rates. This state of affairs, however, is not applicable to all industrial countries, the great exception being Russia, whose current health and welfare problems reflect the country’s complex social and political development in the last few decades.6 The session on “Innovation in Health Policies and the Institutional Level” took a long-term perspective on the various alternatives found by people to face poverty and illness and analyzed how the different powers – social and political included – dealt with the question of public health and how they provided the communities with health services. The main conclusion of the papers is summed up by Patrice Bourdelais: “From a long-term perspective it is possible to maintain that the multiplication of health and social institutions in Europe has been regarded by the European population as evidence of progress, that is of a more secure life, less uncertainty and a better future.”7 The main focus during the last session was the impact of political decisions on the health and welfare conditions of the population; one special feature was the linking up of the Europe and American experiences. In showing that each country organizes its health and welfare system according to its historical past and different political circumstances, all the participants agreed on two main points: that political choices play a decisive role in the shaping of health and welfare systems in any society, and that past experiences cannot continue to be neglected or the same mistakes will be repeated. Underlying these conclusions was the presupposition that there is a need to carry out

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See comments on this session by Jan Sundin, “Social Welfare Policy and Changes in the Health of the Population”, pp. 131–135.

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See comments on this session by Patrice Bourdelais, “Innovation in Health Policies and the Institutional Level”, pp. 271–276.

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Laurinda Abreu

comparative studies that promote a global perspective on the different systems and their historical past.8 In view of the particular focus of the seminar and the circumstances under which the texts were produced (there was no intention of creating a synthesis), the present publication does not constitute an attempt to offer a view of the “state of art” of the issue under study, but rather offers reflections that may encourage debate and promote studies on comparative history. In other words, we expect it to be of interest to those working in these areas, both at the academic and at the political, decision-making levels. The seminar received institutional support from the European Commission, which financed the project, from the Fundação da Ciencia e da Tecnologia, from the University of Évora and from one of its research centres, CIDEHUS (Centro Interdisciplinar de História, Culturas e Sociedades da Universidade de Évora), which I hereby wish to publicly thank. I would also like to express special thanks to the Compostela Group of Universities, which is publishing this as part of its series on European Issues. Given that the PhoenixTN developed from within the Compostela Group, and has had its support from the very beginning, there is no doubt that this publication embodies, at least partially, one of the objectives set by the European Commission for the areas of education and culture: to promote university cooperation in the sense of developing a European dimension, in this concrete case in the fields of health and social welfare policies. Laurinda Abreu University of Évora, Portugal January, 2003

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See comments on this session by Laurinda Abreu, “Choices of Welfare Politics and their Consequences: Local and Regional Environmental Health Effects”, pp. 455–457.

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About the Authors

Laurinda Abreu completed her PhD in Early Modern History at Coimbra University and teaches at the History Department of the Évora University. Her research deals with the Portuguese poor relief, healthcare and welfare system, focused on the fifteenth to eighteenth centuries. She is the coordinator and a member of the Scientific Committee of a Portuguese research project and of two European projects: PhoenixTN – European Thematic Network on Health and Social Welfare Policy and GRAPH – Graduate Programme in the Social Dynamics of Health. Patrice Bourdelais is Professor in the Ecole des hautes études en sciences sociales (EHESS) and head of the interdisciplinary programme “Medicine, Health and Social Sciences”. A specialist in population history (epidemics, health and welfare policies, concepts), he has published or edited ten books, the most recent being Les hygiénistes – Enjeux, modèles et pratiques (2001) and Les épidémies terrassées. Une histoire de pays riches (2003). He is a member of the PhoenixTN Scientific Committee. John Chircop received his doctorate from the University of Essex in 1997. At present he is a lecturer in social and economic history within the Department of History of the University of Malta. His main research interest lies in the comparative social and economic history of the central Mediterranean during the nineteenth and early twentieth centuries, giving special attention to the various dimensions of social assistance, provisioning and health care to the poor. Joaquim da Costa Leite studied in Portugal and at the University of Lund and Columbia University. Currently he is Associate Professor at the Department of

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About the Authors

Economics, Management and Industrial Engineering of the University of Aveiro, Portugal. Martin Dinges is Deputy Director of the Institute for the History of Medicine of the Robert Bosch Foundation, Stuttgart, and Adjunct Professor of Modern History at the University of Mannheim. His main fields of research are early modern social and cultural history and the history of health. He is the author of Stadtarmut in Bordeaux (1525–1675) – Alltag, Politik, Mentalitäten (1988) and editor of Patients in the History of Homoeopathy (2002). He is a member of the PhoenixTN Scientific Committee. Bence Döbrössy has worked for the National Institute for Health Promotion, Budapest, and currently teaches medical sociology and bioethics at the Institute of Behavioral Sciences, Medical and Health Sciences Centre, University of Debrecen. His research interests focus on health policy development with special reference to issues of health promotion and public health. Kari Tove Elvbakken is Director of the Rokkan Centre for Social Studies at the University of Bergen. Her fields of research include historical, institutional and comparative perspectives on public health, food control and prevention policies and their scientific framework, and promotion, information strategies and legislation as means in prevention policy. Yankel Fijalkow teaches urban geography at the University of Paris 7. His research relates to the relations between hygiene, medical and demographic statistics and town planning in France in the nineteenth and twentieth centuries. Among his publications are La construction des îlots insalubres Paris 1850–1945 (1998) and Sociologie de la ville (2001). Daniel M. Fox is President of the Milbank Memorial Fund, an endowed foundation based in New York City that works with decision-makers in the public and private sectors to improve policy for health care and population health. Prior to joining the Fund in 1990 he served in federal and state government and as a faculty member and administrator at two universities. He has published books and articles about the politics of health and social policy in the United States and the United Kingdom. Martina Gamper studied History and Politics at the Universities of Vienna and Edinburgh (1994–2001). Since then she has worked for the Diocesan Archives in St. Pölten and been engaged in several projects and publications on the social history of medicine in Vienna and women doctors in Austria as well as on school health services.

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About the Authors

Laurence M. Geary lectures in history at University College Cork. His main research interest is in famine in Ireland and elsewhere, and in the political and social history of nineteenth-century Ireland. He is the author of Medicine and Charity in Ireland, 1718–1851 (Dublin: UCD Press, 2004). Maria João Guardado Moreira took a PhD in sociology, with a specialization in demography. At present she is Associate Professor at the School of Education of the Polytechnic Institute of Castelo Branco. Her publications deal with her main fields of interest: demography, historical demography, health, mortality and regional demography. Sylvelyn Hähner-Rombach is a medical historian at the Institute for the History of Medicine of the Robert Bosch Foundation in Stuttgart. Kay Peter Jankrift teaches medieval history at the Westphalian Wilhelm University of Münster. His “Habilitationsschrift”, presented at the University of Münster in 2002, deals with epidemics in cities of Westphalia and the Rhineland during the Middle Ages. Øivind Larsen qualified as a medical doctor in Oslo in 1962 and took his medical doctorate on a medical historical subject in1968. Since 1985 he has been Full Professor in Medical History at the University of Oslo, where he works at the Department of General Practice and Community Medicine. Pilar Leon Sanz is Professor of the History of Science and Director of the Department of Biomedical Humanities at the School of Medicine at the University of Navarre, and Vice-President of the university’s European Studies. Currently her research focuses on the origin and assumptions of bioethics and the ethics of health care professionals. She is also co-editor of the journal Revista de Medicina de la Universidad de Navarra. Maria Marta Lobo de Araújo is Assistant Professor at the University of Minho. Her research, which has focused on social history, in particular the role of charity institutions and the help given to the poor, has resulted in several books and numerous articles in scholarly journals. Susan McAndrew has worked in mental health nursing for the past thirty years. She is currently a nurse lecturer at the University of Leeds and spends one day per week working as a primary mental health nurse at a GP practice. In addition she is a trained

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About the Authors

marital and sex therapist. Her areas of interest are primary mental health care; young people, self harm and suicide; psychoanalysis and psychoanalytical discourse and the political agenda of mental health nursing. Péter Molnár is Chair of the Department of Behavioural Sciences at the University of Debrecen, where he is engaged in curriculum development in the behavioural sciences, with special reference to the integration of disciplines (medical psychology, sociology, anthropology, psychosomatics and bioethics). His interdisciplinary research on empathy development ranges from inborn sociality through fine-grained analysis of early mother/child interaction to empathetic doctor-patient interaction with special reference to its psychophysiological aspects. Ann-Sofie Ohlander is Professor in History at Örebro University. Her publications have included such areas as gender history and historical demography and she is currently doing research on culture and health in history. She has been a member of the Swedish Government Research Advisory Board and is currently Chair of the board of the Swedish Secretariat for Gender Research. Suzy Pasleau is Senior Lecturer in Economic and Social History at the University of Liège and coordinates the thematic network on “The Socio-economic Role of the Domestic as a Factor of European Identity (Servant Project)”. Her fields of specialization are economic and social history, labour history, gender history, historical demography, historical statistics and computer sciences (historical sources, documentation, databases, information systems). João Rui Pita is Professor of the History of Pharmacy and Ethics and Law in the Faculty of Pharmacy, University of Coimbra, where he is also Co-coordinator, together with Prof. Ana Leonor Pereira, of the Group of History of Science, CEIS20. His research interests, which focus on the history of pharmacy and of hygiene and public health in Portugal from the eighteenth to the twentieth centuries, have led to many articles and seven books of which he was author or editor. Teresa Rodrigues Veiga took her PhD degree in modern history, with specializations in historical demography and human ecology and demography. At present she is Assistant Professor in the Faculty of Social Sciences and Humanities at the New University of Lisbon, where she heads the Master’s programme in Human Ecology. Her publications cover the areas of historical demography and health, in particular mortality and contemporary demography.

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About the Authors

Janos Sandor graduated from the Medical University of Pécs, specializing in epidemiology. At present, he is head of the Public Health Department in the Faculty of Health Sciences at the University of Pécs. His main research interest is research in the (social, environmental and health-sector-related) determinants of geographical inequalities of health status and the surveillance of congenital malformations and noninfectious diseases. Sally Sheard is Senior Lecturer in the History of Medicine in the Department of Public Health and School of History at the University of Liverpool. She has written on British public health and health services, most recently with Liam Donaldson, The Nation’s Doctor: The Role of the Chief Medical Officer, 1855–1998 (forthcoming). Her current research projects include the development of international maritime health strategies and the use of historical context to inform contemporary health policy. David Skidmore’s original qualifications were in social anthropology, but worked in med-lab sciences in the NHS prior to becoming a nurse. He left the NHS in 1978 to pursue an academic career. Currently Head of the Department of Health Care Studies at Manchester Metropolitan University, he has focused his research on the fields of health and social care. Educationally he has specialized in learning through work and pioneered several schemes at the undergraduate and postgraduate levels. Emma Sobremonte is Assistant Professor in Public Health and Social Work at the University of Deusto. From 1978 to 2000 she was Director of the Department of Social Services, Hospital de Basurto, Bilbao. President of the Spanish Association of Social Work and Health, fellow of the Basque Association of Sociology and of the Bioetics Committee of the Hospital de Basurtol, she in involved in international research projects on mental health promotion and prevention strategies for coping with anxiety and depression and has published many papers on social work and public health. Jan Sundin is Professor at the Department of Health and Society, Linköping University. His major field is the history of public health. He is a member of the PhoenixTN Scientific Committee and editor of an international anthology on Health and Social Change published electronically in autumn 2004 in Hygiea Internationalis. An Interdisciplinary Journal for the History of Public Health. He has coordinated and collaborated in many international projects. Petr Svobodný is senior research scientist and Associate Professor at the Institute for the History of Charles University/Archive of Charles University in Prague and at the

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About the Authors

Research Centre for the History of Sciences and Humanities, Prague. He teaches Czech history and the history of medicine and publishes on the history of universities and the history of medicine and health. Editor of the yearly Acta Universitatis Carolinae – Historia Universitatis Carolinae Pragensis. Mária Szücs is a graduate of the Medical University of Pécs. Currently head of the Epidemiology Unit at the Tolna County Department of Public Health, she is also doing a Master’s course at the Hungarian School of Public Health. Her main areas of interest include the organization of multidisciplinary teams for disease burden reduction, quality assurance programs on routine health-related data collection and processing, and research projects for the prevention of non-infectious diseases of high public health importance. Tony Warne’s early background was in retail management. In 1978 he qualified as a nurse, working in learning disabilities and mental health. Joined Manchester Metropolitan University in 1995, teaching health service management, health economics and the sociology of health care. His research interests include the social anthropology of organizations; much of this work focuses on mental health nursing practice, policy, organization and education using an emergent psycho-dynamic and managerialist analytical discourse. Sam Willner is Assistant Professor in Demography at the Department of Health and Society at the University of Linköping. He has done research on Swedish demographic history from 1750 to the present time, is a member of several international associations and networks and an editor of an international anthology on Health and Social Change published electronically in autumn 2004 in Hygiea Internationalis. An Interdisciplinary Journal for the History of Public Health.

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Section 1 Health between Self-Help, Informal and Formal Institutions Presented by Martin Dinges

At the conference in Évora, we followed up two central questions in this section. First, what benefits do charitable activities bring to the wealthy and the ruling classes? Second, what is the relationship between self-help, outside aid and public or state support in the development of new forms of welfare? For a Rhenish town in the late Middle Ages, Kay Peter Jankrift demonstrates that opening a hospital did more to upgrade the infrastructure of the town than to help the impoverished sick. The foundation of the institution was chiefly an expedient for the emerging public authority. Laurinda Abreu reports on the creation and development of the Portuguese Misericórdias from the later Middle Ages until the end of Early Modern times. She thus presents a very distinctive and too little known Portuguese form of institutionalized poor relief. Larry Geary shows how public authorities, doctors, other interested parties and ordinary citizens took part in setting up medical relief during the severe epidemics in Ireland in the fifty years around 1800. For Linz in Austria, Martina Gamper investigates how, around 1900, an innovative industrialist developed measures for improving the health of schoolchildren that then became the model for the whole country. Sylvelyn

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Martin Dinges

Hähner-Rombach, looking at Stuttgart in Germany, shows how private organizations with upper-class members “discovered” holiday camps on the outskirts of town as a way of improving the health of children from the poorer classes; these camps later passed into municipal hands. These case studies with their common structural pattern reveal the following course of events: new areas of relief are “devised”, mostly from philanthropic or paternalistic motives, while in some cases fear of particular political tendencies among the lower classes or of contagious diseases played a role. After an initial phase in which the necessity of such measures is demonstrated, the demand generally exceeds the limited means of the original supplier. Moreover, from the beginning of the nineteenth century the medical profession discovered areas where it could expand its markets and the community or state saw opportunities for extending its influence, so that both the market for medicine and state health care were able to grow.

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A History of Poverty and Poor Relief: Contributions from Research on the Early Modern Period and the Late Middle Ages and Examples from More Recent History Martin Dinges (Robert Bosch Foundation, Stuttgart / University of Mannheim, Germany)

Previous attempts at comprehending the long-term developments of the related phenomena of poverty and poor relief in the late Middle Ages and the early modern period have resulted in the crisis thesis, the social disciplining and the confessionalization paradigms. What they have in common is that attitudes and reactions to poverty are the objects of analysis. These are attributed or made subordinate to more general developments. The emergence of poor relief and the increasing repression of paupers are thus conceptualized as a consequence of the crisis of the late Middle Ages; poor-relief measures are interpreted as one aspect of the early modern rise of public authorities and the later emergence of the state or as an expression of growing religious competition. The institutionalization and rather repressive character of poor relief are the focus of attention in all three schools of thought as well as their normative implications; moreover, these approaches contain statements on longer-term, historical developments and perspectives. In the following research study, I should like to show how, in the past fifteen years, research on poverty has begun to free itself from the restricting influence of these three paradigms.1 The studies and areas of research mentioned have thus been chosen according to the extent to which they address questions that advance the field,

1

Cf., most recently, Knefelkamp, 2001.

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Martin Dinges

particularly with innovative methods.2 The focus will, however, be on German-language literature and on literature on German-speaking countries.

Definition of poverty, images of poverty The well-known difficulties concerning the definition of poverty have not lessened. Indeed, the few recent semantic investigations of German and French have served to underline the manifold connotations of poverty (Jütte, 1998). That is why I should like to recall the proposal of distinguishing between poverty and destitution. According to this distinction, poverty is a state in which it is possible to live at subsistence level without outside aid. In normal times, the poor can secure their own subsistence; loss of work, extreme youth or old age, illness or disability as well as times of crisis mean that destitution soon threatens. The poor attempt to avoid destitution by means of self-help. This is thus the most important strategy in the fight against poverty. A person becomes destitute when he or she is – at least partially – dependent on outside aid. Destitution is often a temporary phenomenon. This contradicts the static picture of poverty associated with certain criteria mostly defined in economic terms. Since the end of the 1980s, the inclusion of gender history in the study of poverty has represented one of the most important contributions to the revival of the field (Schnegg, 1989). The gender debate yielded a clearer comprehension of the concept of poverty. There was already consensus that, for historians, poverty is always only what is defined as such in the sources – for example, fiscal poverty or the poverty “combatted” by an institution; the gender debate has exposed gender-specific distortions of the image of poverty. As a consequence, we are considerably less certain nowadays whether the widows and orphans supported in so many cases really were that much worse off than other groups of women or whether they were significantly worse off than men and widowers in the same situation. Not only American women historians suspect that this was the attempt of a paternalistic welfare to stabilise the image of the weaker woman (Farmer, 1998, 2002). I should like to add that this favourable treatment in poor relief may have been to the disadvantage of male contemporaries. The discussion continues –

2

Introductions to this – now established – area of research can be found in Jütte, 2000 (translation of the English edition of 1994) for Europe as a whole, and von Hippel, 1995 (the Roman Empire). In the following, reference is made chiefly to more recent literature which could not be included in these introductions.

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A History of Poverty and Poor Relief: Contributions from Research on the Early Modern Period and the Late Middle Ages and Examples from More Recent History

and it will be difficult to decide whether women did indeed make up two-thirds of the destitute.3 However, it is certain that the gender debate has sharpened our sense of the social construction of states of poverty. The power of social conceptions of poverty becomes perceptible. Their adoption by practical, discursive and ritual processes has been described by Rexroth, using the example of thirteenth century London urban society (1999, 334). A complete pattern of discrimination against the poor had already emerged there after the second wave of the Black Death. In the “milieu of the night”, specific attributes such as aggressiveness, sexual permissiveness and a tendency to shirking are combined to form a stereotype which, in this integral form, is a product of the need of a public authority which is not yet politically stable to exclude certain parts of society. The modesty of the “good” poor was the correlative of the “shamelessness” of excluded marginal groups. In this connection, we note the continuing lack of studies on pictorial representations and perceptions. A recent Frankfurt doctoral thesis fails to go far beyond a description of late medieval panel paintings (Glübner, 2000).4 Publications on the history of poverty may indeed contain reproductions as illustrations, but a systematic investigation on the basis of a source corpus that traces the changes in the way poverty is visually presented remains to be written. We are still a long way from a media history of the depiction of poverty. All in all, research is still imbalanced, concentrating as it does on written texts and – apart from general impressions – ignoring contemporary pictorial material.

Causes of poverty In contrast, historians have always felt on much safer ground with the causes of poverty, which count as solid “realities”. The fact that poverty is a result of an unfavourable combination of gender, employability, workplace and work opportunity remains undisputed (Dinges, 1988, 55). Single events such as a robbery or fire are less important than life-cycle causes which, to a great extent, affect men and women alike, although sometimes, because of the varying marrying ages, they may be delayed by some years.5 The risk of impoverishment is particularly high for children, in the early

3

Figures in Jütte, 2000, 53; cf. critique of statistics in Hüchtker, 1999, 70 ff.

4

On images in prints, cf. Wandel, 1990, 77 ff.

5

Recent empirical sociological research also emphasizes these driving forces behind poverty, cf. Neumann, 1999, and Andreß, 1999, 187 ff.

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Martin Dinges

years of marriage and for the aging. Unwanted pregnancies represented a considerable additional risk of poverty for women.6 Besides this, economic cycles, as structural causes of poverty, are fundamental as a reason for under-employment. In recent years, more detailed research has been undertaken into the great significance of illness as a cause of poverty (Kinzelbach, 1995); this has revealed, for example, the connection between sicknesses and the life cycle.7 In the meantime, research has been carried out on sick children in hospitals (Lammel, 2000; Meumann, 1995; Helm, 2000, 193 ff; Vanja, 2000; Barth, 2002) and on experiences of sickness as presented in ego-documents – however, because of their socially rather exclusive provenance in early modern times, these only seldom refer directly to personal experiences of poverty (Piller, 1999; Geyerz et al., 2001, Introduction). There are no comprehensive surveys of work disability in early modern times or of poverty as a consequence of war injuries.8 The few studies on invalid hospitals cannot fill these gaps. Many sources – from medieval miracle literature to the poor lists of the first half of the nineteenth century – show that sickness was often the crucial step on the path to destitution. Otherwise, as far as the causes of poverty are concerned, the times of statistical certainty regarding mass poverty, more or less compressible portions of household expenditure etc., are now over. Groebner has put the criticism of this one-time optimism in a nutshell (1993, 158): A large-scale statistical approach on the basis of annual incomes and prices averaged over several years cannot do justice to such a highly seasonal economy: calculating a mean over several years smoothes out the violent jerks in prices and incomes, causing them to disappear. In this way, however, a […] characteristic element of medieval economic reality is lost from view: the precariousness and instability of living and earning conditions. It is these changing circumstances within an urban economy which impose their particular economic logic on those with a low income.

6

On comparisons with child poverty, see Meumann, 2000.

7

Pelling, 1998, 76. (The article was written in 1988). For an attempt to assess sickness as a cause of poverty, see Jütte, 2000, 53. Sickness is the main reason for almsgiving in Langenzenn: cf. Präger, 1997, 153; at 38%, expenditure on medical aid was the largest single item, 156; see also Jütte, 1997, 114.

8

Single instances in Schubert, 1990, 143 ff.; Kappl, 1984, 343 ff.; Präger, 1997, 111 f.

26


This is why it is necessary to live in uncertainty, as the development of poverty in the late Middle Ages and early modern period can scarcely be grasped in terms of modern historical statistics. As a way out, Groebner recommends tracing the patterns of behaviour shown by the poor in their struggle to overcome poverty.

Life in poverty, self-help and survival strategies Groebner himself has made a decisive contribution to extending our knowledge of the “experiences of urban working poverty” with his example of Nuremberg towards the close of the fifteenth century. The poor had no access to the silver and gold coins which were of lasting value (Schnyder-Burghartz, 1992, 150). As they only had bad money for immediate use, material goods were crucial for accumulating savings; these were turned into ready cash in any emergency. The main characteristic of work relations was their instability: more than one skill, several jobs and winter work were common. The same was true in the countryside, as, for example, Schnyder-Burghartz has shown for the areas surrounding Basle at the turn of the sixteenth century. He interprets this from the point of view of conscious risk reduction (1992, 151):9 For members of the lower class, it made sense, and was at the same time a result of the permanent (danger of) underemployment, that they spread their economic activities over as varied a range as possible so that a failure in one area caused a relatively small loss and the risk of greater loss could be avoided or reduced.

Wages in Nuremberg fluctuated strongly and were made up of a complicated combination of, among other things, pay in kind or clothes; these are to be seen as a substantial part of the wages. Pawning work equipment and clothing – sometimes even material handed over to be processed in some way – was a necessary tactic to survive a period of price increases (Groebner, 1993, 123 ff., 207, 212, 242; Dinges, 1987). Respectable clothing was not only a pre-requisite for many jobs, it proved the wearer to be economically successful as it showed that he had not – yet – been forced to pawn it.

9

Day-labourers and seasonal workers etc. were often forced to offer their services abroad, e.g. so-called “Hollandgänger” and mercenaries. Beck, 1993, in his “natural economy”, has shown how farmers even up to yeomen tried to survive on a variety of jobs and by skilful participation in emerging markets. Devising new, chiefly seasonal forms of earning supplementary income served especially to pay increasing levies and taxes.

27

Martin Dinges

In this way, symbolic dimensions of the economics of poverty can be recognised, exactly as they are found again in Berlin in the first half of the nineteenth century. The crucial step from poverty to destitution was often caused by sickness. For this reason, a study of the self-help networks of poor women in Paris in the 1280s is of particular interest. First, it shows that self-help strategies can be investigated for a considerably earlier period. Second, it re-opens a well-known source, that of miracle literature, which, in the corresponding context, leads to important findings. Farmer names four self-help networks – support from within and outside the family, lay sisterhoods, work relationships and neighbourhood or community – and, as the only form of outside help, charitable institutions. As early as the end of the thirteenth century, all forms of reciprocal aid – between siblings, between spouses, between parents and children, employers and employees, masters and apprentices, neighbours and fellow guild members – can be ascertained (Dinges, 1997; Jütte 2000, 106 ff.).10 These relations can in part replace11, or otherwise supplement and overlap one another. Accordingly, housing or working circumstances were less important than the ability to call upon a certain number of such relations, for what they performed was similar in all cases.12 This “social capital” could help a poor person survive a particular emergency. Craftsmen merely had additional “social capital” in the form of guilds etc.; this should not, however, be overrated. What is particularly important about the self-help networks observed by Farmer is that they were also effective in the case of migrants – providing, for example, care in the case of long-term sickness or lodgings for the needy in another migrant household – both at the goal of their migration, Paris, as well as by feedback with their places of origin. What has long been suspected following studies of Florentine and London tax records can be documented explicitly as self-help on the basis of miracle literature. Farmer summarizes her results, differentiated according to gender, as follows (Farmer, 1998, 368 f.):

10

The extreme case of willingness to exercise self-help is shown by the inmates of poorhouses who, without permission, begged for money to cover their burial costs so that their corpses should not be handed over for dissection, see Stukenbrock, 2001, 53 ff.

11

If a husband was unwilling to support his sick wife, her brother, for example, could take his place.

12

It is necessary to distinguish between this and the more recent concept of “social capital” which denotes a type of collective social capital; cf. Wissenschaftliche Arbeitsgruppe für weltkirchliche Aufgaben der Deutschen Bischofskonferenz, 2000.

28


Women suffering from long-term disabilities were less likely than men to receive assistance from craft-guilds – but both men and women were sometimes assisted by employers, with whom they often lived... While women without men were often the objects of charitable giving, and a number of institutions were founded to shelter women without men, formal institutions did not adequately meet the needs of single widowed women in Paris. ... Poor single or widowed female companions were apparently more likely to help each other during long-term illnesses than were single and widowed male companions. ... while it is reasonable to assume that women who married master craftsmen or merchants were better off than single women – indeed, some married women had to beg, at times, in order to enhance their family incomes. Single women, moreover, were not necessarily isolated individuals: some of them had companions to whom they could turn when they were in trouble.

What is remarkable is that people living alone were by no means without networks of reciprocal aid. For women, marriage was a safe way of being provided for only under certain very limited conditions (Stannek, 1998).13 It should also be mentioned that marriage could be a similarly important precautionary maintenance strategy for men; this is certainly true of the remarriage of widowers, some of whom explicitly declared that this was a household strategy (Schlumbohm, 1997, 488). Otherwise, living together, often over long periods, without a formal marriage is a pattern for poor couples that can be traced through the centuries (Brauer, 1996, 99, 108 ff.; Henderson and Wall, 1994, 13). In such cases, the interests of the higher wage earner regarding his or her lower-earning partner may have predominated, as may their joint wish to save the expense of the formalities and festivities. For this reason as well,

13

Stannek, 1998. Taking particular groups, craftsmen’s wives in Saxony, Simone Stannek has presented the set of options with which this group, defined according to gender, wanted to ensure their survival: 1. Marriage; 2. Gainful employment to provide for their own needs or to contribute to the maintenance of the household; 3. Fighting to obtain material or maintenance provisions due, but refused to them. 4. Calling on support provided by the emerging early modern social security system. This is a – relatively randomly chosen – example which, on the one hand, shows strategies that were probably employed by other groups and, on the other hand, indicates causes of impoverishment specific to women (point 3), namely extramarital pregnancy. First, marriage for maintenance purposes was only a partially successful strategy; second, it is necessary to discover more precisely to what extent this – apart from the question of access to the official work market – was also a strategy applied by men – not only apprentices. Who maintains whom, in which stages of life and how: this is not always clear, as is suggested by the nineteenth century concept of the single breadwinner.

29

Martin Dinges

we can agree with Signori that the bourgeois concepts of couples and families should not be defined as the centrepiece of normal behaviour while those living alone or without children are deviations, all too soon considered of inferior value (Signori, 2001, 362). Last but not least, the Parisian results are so significant because, before 1300, this town offered at most 1000 to 1200 places in all its institutions for the 100,000 paupers who, in the course of their life cycles, could repeatedly become destitute. Once again, this shows very clearly that research into poverty should deal mainly with these patterns of self-help if it is to understand how contemporaries solved the problem of poverty.14 All in all, the ways in which poor households in England responded to the pressures of a subsistence economy are better researched. There, it was not rare for the widowed or out-of-work to give up their own households and to move in with relatives for what was deemed an interim period without a partner or work. Moving from the town to the country or vice versa was apparently a great deal more widespread than has so far been assumed. This, at least, is the conclusion suggested by data gained from an analysis of rents and population turnover. The data also show a high inner-urban mobility, not the least important reason for which might have been a means of escaping rent debts that could not be paid and of relieving the strain on the household budget. Grand speculations have been made on the effects of household systems on ensuring against destitution. The development of nuclear families is supposed to have decisively diminished the chances of the unmarried or old. According to the latest research, this does not seem to be the case, since those living alone were by no means without assistance. The idea that the extended households more common in Southern Europe, e.g. those with unmarried siblings as well as three-generations units, showed a greater capacity for self-help, is also incorrect (Henderson and Wall, 1994, 16 ff.; Blaikie, 2002, 253f). Poor rural households in Essex at the end of the early modern period, for example, took in grandmothers living alone: a precise demographic examination proves that here, self-help strategies were at work, so that old grandmothers practically never had to live alone.15 In Essex, the poorest households were somewhat larger than the better-off ones and followed the multi-generation pattern more often: it is, therefore, not

14

This applies for a population assumed to be under 200,000; see Farmer, 1998, 360.

15

Sokoll, 1993, 180 f., 258 f.: only one case from a total of 700 people living in poor households.

30


the household size that determines the potential for self-help; on the contrary, self-help strategies lead to altered household sizes. Even a simple demographic investigation of the procreative behaviour of poor couples after the Black Death or other epidemics – as in Basle in the seventeenth century (Hatje, 1992, 94 ff., 104 f.) – shows that poor households planned the development of their families with an eye on the future: the number of children remained in reasonable proportion to their material resources. While increased wealth as a result of inheritances following the Black Death incited more radical anti-poor feeling among the upper classes, the poor themselves evidently kept a clear head, even in bed. In order to counteract a tendency to social romanticism, there has been an intensive discussion within Anglophone research on the question of the possibility of solidarity among the poor. Quite rightly, attention has been drawn to the fact that the important socio-historical perception of internal tensions, e.g. in the village, should not be neglected. However, findings showing that relatives favoured one another in the sale of land do speak for solidarity within extended families (Levi, 1986, 80 ff.; SchnyderBurghartz, 1992; Sabean, 1990, 202, 371 ff., 394, 413). Why, then, should other forms of solidarity aiming at avoiding destitution not exist as well? The starting point of the English discussion was the so-called “helpbeers”, festivities at which those threatened by destitution brewed beer, invited all their friends and sold the beer at an exorbitant price. Everyone involved knew that this was a charity event for the host, who was to receive the profits. The host himself could not be truly poor – nevertheless, this seems to be one of the social practices for successfully counteracting destitution (Moisà and Bennett, 1997). Basically, the needy were taking into account that “poverty is a permanent condition for some and a periodic problem for many”.16 The sense of solidarity achieved within a social community can hardly be disputed – and the helpbeers can be shown to have taken place in many areas. This example is one of the conceivable answers to the question of forms of solidarity. Research should aim at discovering such signs in the sources and following them up: what at first was an inconspicuous fine for beer not brewed at the manor house proved on closer inspection to be a socio-historically highly interesting form of preventive self-help.

16

Dyer, quoted by Moisà and Bennett, 1997, 236.

31

Martin Dinges

As a result of more precise knowledge of the efforts made by a household to overcome poverty, new problems arise in two directions: on the one hand, not only the strategies of the households – as units – but also those of individuals within households are considered more closely. For example, an able-bodied youth or a man entitled to poor relief may indeed leave the household and no longer contribute to the joint budget if it is of advantage to him. This changes the former unit. The household unit, originally taken as a basis for demographic analysis, thus proves very elastic (Fontaine and Schlumbohm, 2000, 5).17 In earlier surveys of self-help, attention was continually drawn to single groups of poor people. A number of the studies carried out in recent years have explored what action was available to the historical individuals. As shown above, this applies to women, unattached women as well as widows and children (Henderson and Wall, 1994; Harrington, 1997, Pelling, 1998, Ch. 5), and reveals differing chances of overcoming poverty for boys and girls (Fontaine and Schlumbohm, 2000, 9; Jütte, 2000, 52). The older tendency towards a certain emphasis on economics in the research on poverty has been replaced to a great extent by a more precise consideration of gender-specific and life-cycle risks. Begging was often the only self-help strategy that remained. The boundaries between the various forms are fluid. The sick and convalescent might beg during or following an illness, new arrivals, seasonal beggars and victims of the job market be a result of underemployment, supplementary or interim begging point to momentary shortages which could, however, mean that temporary begging became permanent (Bräuer, 1996, 137 ff.).18 These various forms show that begging was turned to as a matter of course in order to earn additional money, with the result that a generally accepted culture of begging could be ascertained up to and into the nineteenth century. Not only in Berlin did this contravene centuries-old by-laws prohibiting begging; evidently, however, these were virtually ineffective (Hüchtker, 1999, 26 ff., 49 ff., 81 ff.). Thanks to Bräuer’s parallel evaluation of the Viennese beggars’ register and almoners’ lists, begging in the last third of the seventeenth century is now considerably better researched.19 For obvious reasons, applicants for beggar’s licences

17

Cf. the illustrative example in Jütte, 1986, 169.

18

Titz-Matuszak, 1988, is also empirically very rich.

19

f. also Präger, 1997, 32–138.

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stress their infirmities – usually a result of old age – for this was one of the main conditions for the issue of a permit. Thus, values of over 40 percent can be expected for each sex (Bräuer, 1996, 98 f.). In contrast to this, the corresponding numbers in the 1500 statements of arrested beggars are considerably lower. Sickness was simply not a matter of priority to the hospital staff questioning the beggars. They were more interested in finding out why those arrested had been begging rather than working. The beggars explained their plight, their crises and failures, lack of work and shattered hopes. What is striking is the high proportion of very old beggars; this proves the great significance of the decreasing income of most paupers after reaching the age of 40 (Pelling and Smith, 1991). For women, the descent into begging began on average somewhat earlier than for men. As for migrational behaviour, it is also confirmed that many beggars made repeated attempts to settle down. Here, too, the frequent alternation of individuals or families between “working poverty” and destitution is shown. As Schindler has already proved, feedback with their places of origin and families was not unusual (1992, 288 ff.). Finally, there was more than one household in the towns that offered the beggars shelter and – sometimes – a place to settle. This was a blatant breach of the prevailing regulations on begging and was indeed occasionally connected with petty-criminal dealings.20 As for the “inside experience of poverty”, we no longer have to fall back exclusively on drawing conclusions from the practices of the paupers or on extrapolating retrospectively the deprivative aspects of the experience of poverty.21 It may be that what the Swiss student Grunholzer was able to discover around 1840 about the selfperception of the inhabitants of the Berlin Voigtland with whom he lived by observing and talking to them cannot be found either in ego-documents or in applications for poor relief, even in the late eighteenth century.22 Yet requests for support are texts that articulate the applicants’ opinions and interests, even when they are formulated with the recipient in mind. Rather, they were quite evidently plausible. Such statements should therefore not merely be attributed to the influence of the interrogation situation, which called for particular responses.

20

Cf. the analysis for Moscow in Schmidt, 1996, 228 f., 265 f.; cf. Blauert, 2001.

21

Cf. Rodriguez Rabanal, 1990; personal statements also in, for example, Karsch et al., 1992, 65.

22

Grunholzer’s notes can be found in the appendix to Vortriede, 1969.

33

Martin Dinges

The statements the Viennese beggars made during their interrogations make it clear that hardship forced them to beg. We can therefore assume that the majority of beggars were willing to work. They felt that their situation had been forced on them. Research into individual cases provides an additional differentiation (Schlumbohm, 1997, Ulbricht, 1994). All in all, recent research has shown strikingly that it is worth turning from the study of poverty to the study of the self-help strategies and tactics of the poor.

Organized self-help As the sources make the study of organized self-help easier, this area has long been better researched. Schulz has set up a development model for the craftsmen of the Upper Rhine. According to this, in the fifteenth century, sick guild members received a kind of supplementary maintenance only in the form of a loan. This was always intended to be subsidiary to the support offered by the sick person’s own household or that of his master. Not until around 1500 did the journeymen – initially only those in particular crafts – go directly to the local hospitals to secure beds in case they became ill. Towards the end of the sixteenth century, disillusionment with the service actually to be expected of the hospitals apparently set in so that the hospital confraternities became less attractive (Schulz, 1985, 196–208; Kinzelbach, 1995, 336 f.). In seventeenth century Saxony, the increasingly elaborate burial customs became a further cause of impoverishment. Accordingly, journeymen tried to ward off this threat with death and burial funds (Stannek, 1998, 108).23 Members of the lower classes thus organized themselves to react to the demands of a consumer model that called for a more visible expenditure in order to defend their own honourable position in society. At the same time, this example is a further indication of the “modernization” of poverty in early modern times: while increasing dues levied by the emerging early modern state weighed on the rural lower classes, the urban poor also had to cushion the financial pressure of a demonstrative expenditure intended to stabilize the society of orders symbolically.24

23

A project at present being carried out in Saxony is examining poverty among early modern craftsmen. It is to be hoped that it will provide comparative results and compact information on the early modern period for this region of lively craftsmanship; cf. Keller, 2000.

24

On reactions to the pressure of levies and taxes, see footnote 19; on changing dress behaviour in the countryside, cf. Medick, 1996, Ch. 5.

34


Confraternities with charitable aims were particularly important in the fight to alleviate poverty in the Romance-language countries of the Mediterranean.25 Their efficiency in poor relief and their adaptability to new types of poverty, e.g. following epidemics, can be shown for many towns from the thirteenth century onwards (Henderson, 1994a, Ch. 8; Henderson, 1994b, 177). During early modern times, the development of the hospital system relativized the significance of the confraternities. What is striking is the coincidence of the Counter-Reformation revival of Catholic confraternities and the foundation of craftsmen’s death and burial funds in Protestant towns in the seventeenth century (Keller, 2000). Both forms of collective self-help carry on a medieval legacy, though in the case of the journeymen’s funds with a considerably narrower scope.

Charitable bequests and private charity Charitable bequests and private charity are not only a means of counteracting poverty; analysing them also provides a key to collective mentalities. The multi-layered religious context has recently been investigated for the late medieval Hanseatic town of Stralsund (Lusiardi, 2000). The variety of aims, provisions and target groups has been shown by studies on Osnabrück and Cologne during the late Middle Ages and on Münster during the early modern period as well.26 A comparison of over 4000 testaments drawn up in six central Italian towns has revealed that the attitude towards poverty did not change until after the second wave of the Black Death, i.e. from 1363 onwards, but then in a similar way in all six towns (Cohn, 1992, 17 ff. 282). First of all, the pious gifts, which had previously been distributed widely, were concentrated on dowry funds. Secondly, larger single gifts

25

The confraternities were self-administering; nevertheless, as some of their leading members were also members of the ruling elites, the boundary is not clearly defined. Cf. various contributions on these countries in Grell et al., 1999. On Portugal, see also Abreu, 1999, 262 ff.; Flynn, 1989. On the attempt of a confraternity of the poor founded by the public authorities with the aim of getting to grips with urban poverty in Münster, see Küster, 1995, 44 ff.

26

Unfortunately, Queckenstadt (1997, e.g. 121 ff.) is hardly analytical. The list of those who received more than one donation of clothing and who, over the years, had turned to various council members might at least have inspired the question as to the reasons for this behaviour: chance, increased opportunity of success by addressing various different people, using the donation of clothes as a means of securing influence and stabilizing one’s clientele. The irregular time intervals might point to only temporary destitution.

35

Martin Dinges

were now intended to secure the remembrance of the donor to a greater extent than before. This development was decisively influenced by a stronger orientation to male succession and a corresponding sense of family. For Germany, there are only studies on individual towns. On the basis of skilfully chosen examples, Klosterberg has compared the testamentary behaviour of men and women, laymen and clergy in late medieval Cologne for the period between 1250 and 1500 (1995, 99, 160 ff., 164). Her findings show that, in the fourteenth century, approximately two-thirds of all wills contained charitable bequests; clergymen could be somewhat more generous. In the fifteenth century, the willingness to make pious gifts declines steadily for both groups; around 1500, it drops dramatically. Laymen increasingly favour public poor relief and the “shamefaced” poor, whereas clergymen remain faithful to hospitals – often under church supervision – for longer. In contrast to Italy, bequests are not intended for specific beneficiaries until the fifteenth century. These long-term trends reveal the connection between the social status of the donor and the favoured groups in relation to the parish, the type of administration or the institution. Around 1550 in Münster in Westphalia, the poor as a group overtake all other pious causes; individuals are now also preferred to institutions (Klötzer, 1997; Jakobi and Lambacher, 1996)27. Around 1570, bequests concentrate to a greater extent on the poor of the testator’s own parish. This pattern is very similar to contemporary trends in Bordeaux (Dinges, 1988, 510 ff.). Regrettably, no studies on the same level exist for early modern Germany.28 For France or Italy, the considerably better research shows that such trends could alter many times in the three centuries up to 1800 (Dinges, 1999).29 These studies also allow conclusions to be drawn on the attitude of the citizens towards policies regarding the poor, a field which remains insufficiently researched. Recent investigations link bequests for the poor in a more differentiated way with the changing interests of the donors. On an international level, the question of the provisions made for the poor is at present less in the foreground than the problem: What good does the legacy do the testator? The decisive historical watershed in the memorial function of the bequests is apparently not so much the Reformation, which merely

27

Cf. partially different results in Po-chia, 1983, 335 ff.

28

Lassota, 1984, is, unfortunately, completely uninformative as no samples were made; see, however, Pammer, 1999.

29

For comparisons with Münster, see Küster, 1995, 23 ff. Cf. Foucault, 1995.

36


altered the reasons, as the intervention of Enlightenment town administrations or of territories at the time of secularisation, which arbitrarily shift the aims (Queckenstedt, 1997).

Demand for poor relief In the meantime, preliminary research has been undertaken into the demand for poor relief in seventeenth and eighteenth century France. Allegedly, from the last third of the seventeenth century onwards, an increasing “Great Confinement” (“grand enfermement”) of the poor was undertaken by the general hospitals. Under pressure of demand, which could hardly be dismissed, from the life-cycle poor, i.e. widows and orphans as well as invalids, what had been conceived as a work and re-education programme for marginal groups became an extension of poor relief for this traditional clientele. With appropriate support from the parish priest, the resources of the general hospitals were for the most part re-directed so that eventually only a few prostitutes and tramps were locked up there (Dinges, 1999). This sort of change in the function of institutions as a result of demand from below is not unique. In Turin, the actual inmates of the general hospital were certainly not those it was intended for. In seventeenth century London, the poor succeeded in “working on” poor-relief administrators who were well-disposed to them so that payments made to them under the Poor Law were above the designated level (Henderson and Wall, 1994). The case was similar in Cologne around 1800 (Finzsch, 1990).30 In the seventeenth century, by persistently petitioning Parliament, English Civil War widows even succeeded in getting hold of disability pensions intended for men (Hudson, 1994, 157 ff.). We must therefore assume that, first of all, early modern poor relief was made use of by the poor in the way they needed it and, second, in this way, public funds were re-directed to households that should not actually have received any money. With this in mind, similar instances from the Middle Ages and from leper houses are less astounding (Jankrift, 1998).31 Finally, recent investigations reveal that the needy alternated between availing themselves of institutional poor relief and self-help. Half-orphans in Italian towns, for

30

This requires solidarity among the poor, and the passing on of information as to who they would have the best chance with. This coincides with the behaviour shown in applications for justice; see Dinges, 2000.

31

For applications of non-lepers for admittance to leper houses, see Kinzelbach, 1995, 360, 399.

37

Martin Dinges

example, were commonly referred to an appropriate hospital, particularly when their families were large (with more than three children) and following the death of a parent (Sonino, 1994; Terpsta, 2000; Meumann, 1995, 342 f.). After some time, however, they returned to their families. In other cases as well, taking temporary advantage of the provisions of poor relief was a prevalent phenomenon, for it corresponded to life-cycle disorders and thus to the requirements. However, there is no systematic evaluation of applications for admittance to hospitals.32 In any case, the alternation between institutions and self-help shows the negotiating potential families had when dealing with institutions; the latter’s, in part supposed, chances of meting out discipline were thus reduced.

Poor-relief institutions Poor-relief institutions are regarded as the traditional heart of the field. This is why there are countless studies on hospitals in individual towns. From the point of view of local history, the gains are indisputable and, in part, these investigations offer a broad insight into the world inside hospitals.33 Systematically speaking, it would be interesting to concentrate on the services offered by these institutions. At present, attention is being focused increasingly on the development of the medical services (Hatje, [1998], 121).34 As far as hospital food is concerned, the only German study on the subject shows which health schemes existed and what was eaten (Krug-Richter, 1994; Hatje, [1998], 150 ff.). Even in the case of the bedridden sick in Hamburg, the hospital provisions were only subsidiary (Hatje, [1998], 110). The amounts actually paid out under the English Poor Law in the seventeenth century were in fact at most one-third of the minimum needs of the poor; they were only supplementary (Henderson and Wall, 1994, 18). With this in mind, researchers are now unanimous in judging the disciplinary effects – even of workhouses – as low still at the end of the eighteenth century (Finzsch, 1990, 152–155; Stier, 1988, 215; Kinzelbach, 1995, 398; Wüst, 1996, 121 f.; Aderbauer, 2000; Knefelkamp, 2001; Barth, 2002, 113; Hammond 2002, 69; cf. Flückiger Strebel 2002, 69). There continues to be a dearth of regional studies – apart from research on large towns such as Augsburg, Lyon or Cologne – which might offer us information on the

32

But see Aderbauer, (1997), 121, 160, 192, 218. Cf. interesting individual cases in Hatje, [1998], 122 f.

33

On Ravensburg, for example, see Schmauder, 2000; Hatje, [1998].

34

Hatje, [1998], 121; note the discussion on the “protoclinic”.

38


distribution of poor-relief agencies (Jütte, 1984; Roeck, 1989). Very little work has been done even on mapping the hospital infrastructure, and almost the same applies to leper houses (Brans, 1995, 289, 323 ff.; but see Belker-van den Heuvel, 2000). As a result, how good or bad the chances of receiving support in the countryside actually were still remains unclear.35 Now as ever, one fundamental factor contributing to the migration of the destitute to towns is thus unexplained.36 What is more serious is that there is an almost total lack of comparative studies on poor relief that include both open and closed forms.37 A positivistic assessment of knowledge contrasts abruptly with undeveloped categories of comparison.38 With its size and religious diversity, Switzerland would be ideal for comparative research, all the more as the prevailing linguistic conditions mean that it participates in different forms of public debate on poverty and has a variety of institutional cultures.

Poor relief between the Reformation, denominations and the formation of the state At the close of this tour d’horizon, I should like to return to the “big questions” mentioned at the beginning. 1. Medieval poor relief was by no means completely random, but reacted to new requirements by specializing, e.g. after the Black Death in Florence (Henderson, 1994b, 176). In this latter case, this is shown particularly in the way widows and orphans from families disrupted by the epidemic were favoured over the working poor. In other words, it is a myth from the time of the Reformation, handed down in part historiographically, that poor relief in the Middle Ages was thoroughly badly organized.

35

The systematic data in Brans, 1995, are the exception.

36

On the use of specialized municipal hospitals by country dwellers, cf. Kinzelbach, 1995, 338 f., 352, 361; there are single documented instances of charity offered by the nobility as an alternative for country dwellers; cf. e.g. Spiegel, 1997, 480 f.

37

The exception is Kinzelbach, 1995, especially 300–390, from the (central) point of view of care for the sick poor; cf. the attempt to assess a household receiving poor relief in Dinges, 1988, 473.

38

On the possibilities of such a comparision, see the attempt of Dinges (1994), 19–51, as well as the critique of Kinzelbach, 1995, 237 ff.

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2. North of the Alps as well, reform impulses in poor relief originate at the latest in the fifteenth century and are in effect before the Reformation.39 A comparative study of towns in the Netherlands has recently proved, for example, that the following structural changes were effective as early as the late Middle Ages: the regulation of begging; the distinction between those capable and those incapable of work and the worthy and unworthy poor; the effectuation of civil rather than ecclesiastical control of poor-relief systems and, often, a centralization of these systems under the supervision of the council; and, finally, the restriction of aid to local residents (Parker, 1999, 70, 94, 107). The only new thing in the second wave of reform is the workhouse, which, however, was not to institutionalize disciplinary work measures for the able-bodied until the end of the sixteenth century – thus distinguishing it from the medieval tradition. 3. The basic developments in the processes of institutional reform are very similar, regardless of country and denomination. Historiographically, it should be noted that concentrating on hospitals and forms of poor relief organized by the public authorities has led to a disregard of intermediary forms of welfare; this is shown with increasing clarity by, for example, studies on Turin, on the confraternities in Catholic Europe, on testamentary practices and on community poor relief (Cavallo, 1995, 253). Otherwise, all over Europe, the ideas of parochial poor relief as practised by the medieval church still exercised a strong influence on the corresponding practices of public authorities in the seventeenth century (Parker, 1999). The change caused by the Reformation should thus not be overrated. 4. The significance of institutional differences, particularly those based on denomination, i.e. poor-relief systems with or without confraternities, with or without parish poor relief, with communalization or decentralized local poor relief, still has not been sufficiently investigated with regard to what I consider to be the only decisive question, that of their output. What matters is how high the material and symbolic efficiency of the poor-relief system in its “fight against poverty” was. Estimates of poorrelief budgets per inhabitant do exist for some German and English towns in the early modern period (Jütte, 2000). However, there is still a great lack of budget analyses.40

39

Cf. most recently Rexroth, 1999, 338 f.

40

On the budgets of (small- and medium-sized) towns, now, however, see Bingener et al., 2000; on the underestimated poor-relief provision of (English) monasteries, see Rushton, 2001, 9–44.

40


In my opinion, research into policies regarding the poor must be accompanied far more often by the corresponding financial analyses. 5. As far as confessionalization is concerned, the more interesting question is: What good does poor relief do the denominations? It is known that it strengthens group cohesion vis-à-vis the competition. This is particularly true in the case of religious minorities.41 We still have far too little information about the conflict-laden recruitment of members of other denominations with lucrative offers of poor relief, although it has long been known that all religious groups were quite active in this field (Cavallo, 1995; Dinges, 2001, 157 f.; Dinges, 1988, 467; Fehler, 1999, 225 ff.).42 6. From the point of view of political history, the question “What good does charitable activity do the wealthy and the ruling class?” has been answered. It is an excellent method of creating a local clientele, whether for the nobility in the country or for the patricians in the town. When the make-up of elites changes, it offers a stage for self-presentation. The hospitals of the Baroque period represent particularly good opportunities; however, they are not an invention of this epoch (Cavallo, 1995, 99 ff.). Apart from that, it is banal to state that the development of poor relief provides resources for the extension of authority or assertion of the public authority or state. 7. A pattern for the way in which combating poverty is of use to the various political levels within an emerging public authority or a “central state” is also visible. Research results, for example on fourteenth and seventeenth century London, on sixteenth to eighteenth century Turin, on Holland in the sixteenth and seventeenth centuries and on France in the early modern period, are quite plain (Cavallo, 1995, e.g. 44; Slack, 1986; Macfarlane, 1986; Parker, 1998): leading local groups of greater or lesser strength contend continually with one another or with the elites of the emerging central state for predominance in this sphere of politics and influence. Sometimes it is the local group, sometimes the central authority that achieves its objectives and succeeds in increasing its power; after the middle of the seventeenth century, the higher authorities were often in a better position to enforce a centralization of the institutions and simultaneously to deprive the decentralized poor-relief systems of their power. However, even in the

41

Poor-relief activities are also useful in arranging employment, for example; cf. Dinges, 2001, 168.

42

On Jewish poor relief in the early modern period, see, most recently, Reinke, 1999, with further references, particularly 11 ff.

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allegedly absolutist France, active local elites, in smaller towns as well, were able to keep control of poor-relief institutions and, in the eighteenth century, expand them as their own power bases against the interests of the central government (Hickey, 1997). Hickey’s comparison of several towns and regions proves that this was no exception. 8. This area of research has established one noteworthy finding: policies concerning the poor always develop step by step and locally; they are empirical and gradualistic. Nowhere do they follow any kind of master plan for social disciplining or other similar measures (Mörke, 2000). As Gribaudi states, it would be heuristically far more interesting to examine discontinuities rather than the history of state forming (1998, 89). In this way, each poor-relief system could be placed in its respective social context. The configurations and conflict situations disclosed in this way show that poor relief could mean very different things depending on gender and social position. 9. In particular, differences based on gender would be worth following up. In this context, women created room to manoeuvre and carried out financial transactions and public activities that were sometimes at odds with family demands and other genderspecific characteristics ascribed to them (Cavallo, 1995, 167 ff., 175 ff.). Examples can be found in Hüchtker’s study on gender relations and policies regarding poverty in Berlin between 1770 and 1850. She shows strikingly how gender images and the politics of poverty are linked. Both in the way women and men are declared eligible or ineligible for poor relief as well as in male and female participation in activities to alleviate poverty, women and men are in very different positions (Hüchtker, 1999, 103 ff.). Evidently, poverty and poor relief are useful (and, of course, harmful) to women and men in quite different ways. Hüchtker’s proposal that poor relief be investigated on the basis of the particular conflicts waged around it could lead to an advance in the field.43

Conclusion 1. We can observe more differentiated approaches to the concept of poverty inspired by social history. The subject of poverty re-appears in social histories of the household, women etc. The following three shifts in the focus of research are notable:

43

This was also the approach of Cavallo, 1995.

42


•

• •

from global causes and forms of poverty to an investigation of variable states of poverty dependent on the life cycle, paying greater attention to sickness, in particular, as a cause of poverty; from an analysis of states of poverty to the self-help strategies of the poor and destitute; from an examination of institutional poor relief to the question of different appropriations of poor relief: how does it serve those who suffer and how does it add to the prestige of those who distribute it?

Thus, research into poverty has developed sub-disciplines that focus more on practices than on structures. 2. This is duplicated by a deconstructivist impetus, which is particularly strong in gender history. Tendencies to a vague discursive historical approach seem to adopt this. However, it will always be necessary to examine what actually distinguishes these soidisant discursive studies from the old history of ideas. 3. There is remarkable general and growing reserve towards the more general approaches of social disciplining, confessionalization and modernization. At the same time, the “acid test of comparison” should certainly not be forgotten. 4. Accordingly, it seems to me to make sense to consider the various approaches as contributions to a history of defining and dealing with poverty: both the paupers and the citizens, and even the public authorities and kings, with their words and deeds, are all just part of a relationship which others take part in. Each has – of course very different – ways and means of bearing or making use of poverty, of explaining or dealing with it. The resources are material, symbolic (e.g. linguistic) and political. Self-help is the most obvious, poor relief a secondary strategy. The relationship of the two changes over time. How to reach solutions is the cause of many a conflict. This starts with the attributes ascribed to poverty (ranging from blessed to cursed), which predetermine the range of possible actions. There will be different ways of dealing with the godless and disreputable poor than with the “representatives of Christ”. Any institutional solution means excluding some and including others, something that those affected must again deal with. This in turn affects the poor-relief institutions. In such an open conceptualization, the increasing institutional and discursive consolidation of poverty alleviation from the late Middle Ages to the present day may then count as an important development. It does, however, remain open for quite different interventions by the

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historical individuals. In the history of poverty and destitution, as elsewhere, we should accustom ourselves to discontinuities and ruptures.

Acknowledgement Thanks go to P. Lawday, of Stuttgart, for the translation of this article.

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Lubinski, Thomas Rudert and Martina Schattkowsky (eds.), Historie und Eigen-Sinn. Festschrift für Jan Peters zum 65. Geburtstag, Weimar, 485–499. Schmauder, Andreas (ed.) (2000) Macht der Barmherzigkeit – Lebenswelt Spital (Begleitband zur Ausstellung), Konstanz. Schmidt, Christoph (1996) Sozialkontrolle in Moskau. Justiz, Kriminalität und Leibeigenschaft 1649–1785, Stuttgart. Schnegg, Brigitte (1989) “Armut und Geschlecht”. In Anne-Lise Head and Brigitte Schnegg (eds.), Armut in der Schweiz (17.–20. Jh.)/La pauvreté en Suisse (17e–20e s.), Zürich, 9–17. Schnyder-Burghartz, Albert (1992) Alltag und Lebensformen auf der Basler Landschaft um 1700, Liestal. Schubert, Ernst (1990) Arme Leute, Bettler und Gauner im Franken des 18. Jahrhunderts, 2. Auflage Neustadt an der Aisch. Schulz, Knut (1985) Handwerksgesellen und Lohnarbeiter. Untersuchungen zur oberrheinischen und oberdeutschen Stadtgeschichte des 14. bis 17. Jahrhunderts, Sigmaringen. Signori, Gabriela (2001) Vorsorgen – Vererben – Erinnern. Kinder- und familienlose Erblasser in der städtischen Gesellschaft des Spätmittelalters, Göttingen. Slack, Paul (1986) Poverty and Policy in Tudor and Stuart England, London. Sokoll, Thomas (1993) Household and Family among the Poor. The Case of Two Essex Communities in the Late Eighteenth and Early Nineteenth Centuries, Bochum. Sonino, Eugenio (1994) “Between the Home and the Hospice. The Plight and Fate of Girl Orphans in Seventeenth- and Eighteenth-Century Rome”. In John Henderson and Richard Wall (eds.), Poor Women and Children in the European Past, London / New York, 94–116. Spiegel, Beate (1997) Adliger Alltag auf dem Land. Eine Hofmarksherrin, ihre Familie und ihre Untertanen in Tutzing um 1740, Münster. Stannek, Simone (1998) “Armut und Überlebensstrategien von Frauen im sächsischen Zunfthandwerk des 16.–18. Jahrhunderts”. In Katharina Simon-Muscheid (ed.), “Was nützt die Schusterin dem Schmied?” Frauen und Handwerk vor der Industrialisierung, Frankfurt, 99–109. Stier, Bernhard (1988) Fürsorge und Disziplinierung im Zeitalter des Absolutismus. Das Pforzheimer Zuchtund Waisenhaus und die badische Sozialpolitik im 18. Jahrhundert, Sigmaringen.

Stukenbrock, Karin (2001) “Der zerstückte Cörper”. Zur Sozialgeschichte der anatomischen Sektionen in der frühen Neuzeit (1650–1800), Stuttgart. Terpsta, Nicholas (2000) “Making a Living, Making a Life: Work in the Orphanages of Florence and Bologna”, Sixteenth Century Journal, 31, 1063–1079. Titz-Matuszak, Ingeborg (1988) “Mobilität der Armut. Das Almosenwesen im 17. und 18. Jahrhundert im südniedersächsischen Raum”, Plesse-Archiv, 24, 9–338. Ulbricht, Otto (1994) “Die Welt eines Bettlers um 1775. Johann Gottfried Kästner”, Historische Anthropologie, 2, 371–398. Vanja, Christina (2000) “Die Versorgung von Kindern und Jugendlichen in den hessischen Hohen Hospitälern der Frühen Neuzeit”. In Udo Sträter (ed.), Waisenhäuser vor und nach August Hermann Franckes Gründung 1698, Halle. Vordtriede, Werner (ed.) (1969) Bettina von Arnims Armenbuch, Frankfurt am Main. Wandel, Lee P. (1990) Always Among Us: Images of the Poor in Zwingli’s Zurich, Cambridge.

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Martin Dinges

Wissenschaftliche Arbeitsgruppe für weltkirchliche Aufgaben der Deutschen Bischofskonferenz (Hg.) (2000): Das soziale Kapital – Ein Baustein im Kampf gegen Armut von Gesellschaften, Bonn. Wüst, Wolfgang (1996) “Die gezüchtigte Armut. Sozialer Disziplinierungsanspruch in den Arbeits- und Armenanstalten der „vorderen“ Reichskreise”, Zeitschrift des Historischen Vereins für Schwaben, 89, 95–124.

50

Poverty as a Resource of Territorial Power: The Case of Late Medieval Geldern Kay Peter Jankrift (University of Münster, Germany)

“It seems to us improper that there are more healthy people in hospitals and leper houses than pilgrims, poor or sick. Fraudulently they benefit from the alms intended for the relief of the poor,” stress the decrees of the Council of Paris in 1212 depicting the actual situation in hospitals and leper houses.1 Thus, the description continues, healthy people would fraudulently benefit from the alms intended for the relief of the poor. This picture of the medieval welfare system drawn by the Council of Paris in 1212 hardly fits with the common image of hospitals as institutions of poor relief and – in the broadest sense – health care. With regard to the countless scientific studies that have portrayed hundreds of hospitals all over Europe hinting at the fact that sometimes they were founded with the special intention of housing and nourishing the poor or sick and other times pilgrims, there is nothing new in the conclusion that “the” medieval hospital never existed and that such houses had a more or less multifunctional character. However, based mostly on an analysis of charters and normative sources, such studies often tend to idealize the institutions. The decrees of the Council of Paris, however, should not be underestimated when it comes to the question of the real nature of medieval welfare institutions and their functions. That brings us to the main focus of this paper. It will try to point out the necessity of reexamining certain sources connected to the foundation of hospitals in order to verify the quality of such institutions as well as the motivation for their founding. Within the framework of this limited study, the paper has to restrict itself to just one expressive example that seems to serve this purpose best, as we will witness the intentions of the

1

Johannes Domenicus Mansi (ed.), Sacrorum Conciliorum Nova et Amplissima Collectio, Graz 1961 (Reprint), col. 836.

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founders and also be able to draw conclusions about the function of the institution – the hospital of the Holy Spirit in the city of Geldern.2 This analysis of one particular example, however, should not blind us to the fact that only a comparative regional study would allow us to draw definite conclusions as to the extent of such phenomena. Thus, before we turn to the foundation of the hospital of the Holy Spirit in the city of Geldern, some preliminary remarks about the character of our sources seem necessary for a better understanding of some specific difficulties of a comparative regional study. A large number of documents, mostly of urban administrative origin, reveal the forms, structures and developments of late medieval welfare institutions. So far scholarly research has focused mostly on the situation in big and important cities, because the written tradition often permits a detailed reconstruction of a hospital’s foundation and economic development or even of a city’s welfare structures in total.3 The situation of small towns with less than 1500 inhabitants such as Geldern is still neglected due to a lack of sources.4 A result of this partial view of medieval welfare is that encompassing regional structures – one might call them “hospital landscapes”, which comprise all of the individual institutions as well as the towns’ and cities’ welfare systems as a whole – remain unnoticed. This phenomenon is reinforced by the fact that welfare systems seem to be the more independent from any encompassing network the bigger the city is and

2

Kay Peter Jankrift, “Herren, Bürger und Bedürftige in Geldern. Aspekte kleinstädtischer Hospitalgründungen im Spätmittelalter”, in Hans-Jörg Gilomen, Sébastien Guex and Brigitte Studer (eds.), Von der Barmherzigkeit zur Sozialversicherung. Umbrüche und Kontinuitäten vom Spätmittelalter bis zum 20. Jahrhundert, Zürich 2002, 117–126.

3

To name but a few out of a large number of studies in German: Brigitte Pohl-Resl, Rechnen mit der Ewigkeit. Das Wiener Bürgerspital im Mittelalter, Wien 1996; Hermann Queckenstedt, Die Armen und die Toten. Sozialfürsorge und Totengedenken im spätmittelalterlich-frühneuzeitlichen Osnabrück, Osnabrück 1997; Ralf Klötzer, Kleiden, Speisen, Beherbergen. Armenfürsorge und soziale Stiftungen in Münster im 16. Jahrhundert, Münster 1997; Gros Beate Sophie, Das Hohe Hospital in Soest (ca. 1178–1600). Eine prosopographische und sozialgeschichtliche Untersuchung, Münster 1999.

4

Hektor Ammann, “Wie groß war die mittelalterliche Stadt?”, in Studium Generale 9 (1956) 503–506. Peter Johanek, “Landesherrliche Städte-kleine Städte. Umrisse eines europäischen Phänomens”, in Jürgen Treffeisen and Kurt Andermann (eds.), Landesherrliche Städte in Südwestdeutschland, Sigmaringen 1994, 9–25. Franz Irsigler, “Städtelandschaften und kleine Städte”, in Helmut Flachenecker and Rolf Kießling (eds.), Städtelandschaften in Altbayern, Franken und Schwaben, München 1999, 13–38. Carl Haase, “Stadtbegriff und Stadtentstehungsgeschichten in Westfalen”, in Carl Haase, Formen der Stadtentstehung im Spätmittelalter, in: Heinz Stoob (ed.), Forschungen zum Städtewesen in Europa, vol. 1: Räume, Formen und Schichten der mitteleuropäischen Städte. Eine Aufsatzfolge, Köln/Wien 1970, 225–245.

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the more institutions of various specialized character it comprises.5 Therefore, an analysis of the founding of hospitals and their circumstances in small towns seems to be important for an approach to the structures of such hospital landscapes and – if there are such – their overall conceptions. It should be stressed that the number of small towns and cities in a territory was much larger than that of big and important ones. Geldern is situated in the northwestern part of Germany on the Lower Rhine and was part of the former dukedom bearing the same name that extended far into what is now the Netherlands. Between the second half of the fourteenth and the end of the fifteenth centuries a remarkable concentration of hospital foundations in small towns in the Lower Rhine area can be observed.6 While bigger towns and cities at that time already possessed a more or less extensive and still growing poor relief system, smaller communities such as Rees and Sonsbeck, Uedem and Roetgen – to name but a few – all situated within the territories of Jülich or Cleves, established their first hospitals. The sovereign, the Church, sometimes the well-to-do or the town council as a whole were involved in these foundations. While in Jülich and Cleves the foundation activities reached their peak after 1400, the establishment of hospitals in Geldern reached its peak a few decades earlier. Doesburg, for example, got its first hospital before 1354, Wageningen in 1357, Goch in 1358, Doetinchem before 1364 and Groenlo in 1387.7 It seems obvious that all of these foundations are closely linked to the impact of the Black Death and the following plague epidemics.8 Ravaging the small towns just as they did the big ones, they created the need to establish institutional care. Due to the loss of younger family members, the care for the elderly within the frame of the family was no

5

“Basic Reflexions on Medieval Institutionalisation” in Gert Melville (ed.), Institutionen und Geschichte. Theoretische Aspekte und mittelalterliche Befunde, Köln/Weimar/Wien 1992.

6

Jutta Grimbach, Das mittelalterliche Hospitalwesen in den niederrheinischen Territorien Jülich und Kleve. Arbeit zur Erlangung des Magistergrades, Universität Trier, Trier 1999 (unpublished). I thank the author for her kind permission to see her manuscript.

7

Klaus Flink/Bert Thissen, “Gelderns Städte im Mittelalter. Daten und Fakten – Aspekte und Anregungen”, in Johannes Stinner Johannes and Karl-Heinz Tekath (eds.), Gelre – Geldern – Gelderland. Geschichte und Kultur des Herzogtums Geldern, Geldern 2001, 211.

8

Die Limburger Chronik des Tilemann Elhen von Wolfhagen, Arthur Wyss (ed.), Hannover/Leipzig 1883, S. 90. Kay Peter Jankrift, Up dat god sich aver uns verbarmen wolde. Formen, Strukturen und Entwicklungen der Auseinandersetzung mit Seuchen in westfälischen und rheinischen Städten. Habilitationsschrift. Westfälische Wilhems-Universität Münster 2001.

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longer guaranteed.9 Thus elderly but not necessarily poor people found a new dwelling in these hospitals. The first hospital in Geldern was established relatively late. Approximately 1600 inhabitants lived in the 22 hectares that were enclosed by the city walls of Geldern.10 Until 1343 Geldern had been the principal residence of the counts and later dukes of the dukedom. Now, on 10 January 1415 the foundation charter of the hospital of the Holy Spirit was drawn up in the name of the Mayors, the council, the judges and all the citizens.11 The document reflects the intended multifunctionality of the new institution, which is termed both a “hospital” and a “guesthouse”. According to the text, pilgrims, beggars, the poor of the city itself and the sick should be housed there and benefit from works of charity. The statutes, which were drawn up on the same occasion, do not differ from common patterns. For the sick whose physical condition did not allow them attend mass in one of the city’s churches, a chapel was to be erected near the hospital. At the time when the document was sealed the chapel still did not exist. The construction of the hospital building itself had already started, as proved by the request to Mary of Harcourt, Duchess of Jülich and Geldern, to affix her seal to the charter. The text clearly states that Mary “laid the first stone with her own hands”, thus already suggesting the involvement of the territory’s ruler. A priest, who was installed by the city council and was paid for his services by the founders as long as the financial means of the newly created institution remained insufficient, was to say mass for the souls of their dead family members and the poor. Each year the founders were to choose two honest and pious citizens who would be responsible for the financial administration of the building and who would report on its revenues and expenses to the Mayors and the city council. Thus, it seems at first sight as if the city council itself initiated the foundation of the hospital at Geldern. A critical reexamination of the details, however, leads to another conclusion. The council’s quite formal demand to their territorial sovereign Duke

9

Leo Noordegraaf/Gerrit Valk Gerrit, De gave gods. De pest in Holland vanaf de late Middeleeuwen, Bergen 1988.

10

Flink/Thissen, 211. Wilhelm Janssen, “Die Geschichte Gelderns bis zum Traktat von Venlo 1543. Ein Überblick”, in Johannes Stinner Johannes and Karl Heinz Tekath (ed.), Gelre – Geldern – Gelderland. Geschichte und Kultur des Herzogtums Geldern, Geldern 2001, 13ff.

11

Stadtarchiv Geldern, A Urk. Nr.26.

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Rainald IV to acknowledge the foundation is accompanied by the humble demand to grant the favour of installing the priest of the hospital’s chapel eternally by themselves and without the sovereign’s further interference. It seems as if this right, which was finally granted to the local authorities, was achieved by intensive negotiations. While the city may have been able to defend this right for quite a while, there can be no doubt that the duke influenced the financial administration of the new foundation. John of Vossum, for example, Mary of Harcourt’s treasurer, appears besides Mayor Gerit Opstrait as one of the hospital’s administrators.12 Moreover, several elements of the foundation charter do not seem to fit into the picture of the local authorities as initiators of the establishment of the hospital. The participation of the Mayor and the members of the council as representatives of the inhabitants of Geldern is manifested solemnly by the city’s seal. However, neither the Mayors themselves nor any other citizens attached their seals to the charter. On the other hand, the charter bears the seal of Mary of Harcourt, a relative of King Charles VI of France, and the seals of ten members of knightly families. All of them belonged to the close circle of the ducal family, in fact of Mary of Harcourt, among them her above-mentioned treasurer, John of Vossum.13 The reason for the establishment of the hospital as explained in the foundation charter seems characteristic of a match between the territorial interests of the sovereign and urban selfperception. The text states that for a distance of two miles around the city of Geldern there is no dwelling for poor pilgrims, migrating beggars or simply the humble poor as one can find elsewhere in the dukedom or around other towns. This phrase is like a spotlight on the shape of the hospital landscape in the Lower Rhine area at the beginning of the fifteenth century. Despite its small size, the town of Geldern was at least of some importance for the surrounding countryside. Theoretically this also meant that it had to provide facilities to care for the poor. Moreover, we find here a definition of the composition of hospital networks in the Lower Rhine area. For the migrating poor – beggars and pilgrims – it was necessary for there to be enough institutions along their way to enable them to reach them within a day. Hinting at the situation in other towns and cities and thus depicting its self-perception, the small town of Geldern sets itself –

12

Stadtarchiv Geldern, A Urk. Nr. 35 u. Nr. 37. Leopold Leopold, Das alte Geldern. Gesammelte Schriften zur Stadtgeschichte, Geldern 1971, 112.

13

Stefan Frankewitz, Die geldrischen Ämter Geldern, Goch und Straelen im späten Mittelalter, Geldern 1986. Ralf G. Jahn, “Die Genealogie der Vögte, Grafen und Herzöge von Geldern”, in Johannes Stinner Johannes and Karl Heinz Tekath (ed.), Gelre – Geldern – Gelderland. Geschichte und Kultur des Herzogtums Geldern, Geldern 2001, 36f.

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regardless of its size – in the circle of other urban communities inside and outside the dukedom that possessed the full rights of a city. However, the existence of a hospital in a small town seems to have been of more importance. While elsewhere the administrators of hospitals were members of the local council who made their career by fulfilling several consecutive administrative tasks, in Geldern it was the Mayor himself who took over the administrative control of the hospital. At the same time, it becomes obvious that from the fifteenth century at least the institution called a hospital became a constitutive element of a town, an element that stood alongside the town hall, the church and the wall. So the sovereigns upgraded the smaller towns by establishing hospitals as part of their concept of internal territorial development. As a matter of fact, poverty relief in practice seems to have been of minor importance in connection with the circumstances of the hospital foundation in Geldern. The hospital charters underline this thesis. With the sole exception of the foundation charter, no document ever mentions the poor. It seems as if in reality poverty figured as a resource to nourish territorial power. The hospital of the Holy Spirit in Geldern was a small institution that might provide space for just a handful of persons. But, as is the case of hospitals in small towns in neighbouring territories, it is at least questionable whether poor people or the sick ever received food, clothing and housing in the institution. If the institution – as is obvious in other cities than Geldern soon after the first waves of plague – functioned only as a dwelling for elderly but not necessarily poor citizens, one might even dare to speak of fictional rather than really existing poverty. Forms of charity, even if they were covered in the above-mentioned form, strengthened urban self-consciousness and demonstrated the sovereigns’ power. Such interests were sometimes so overwhelming that the authorities suppressed demands by certain groups to be allowed to organize forms of self-help. In sixteenth century Münster in Westphalia, for example, the council did not permit the musicians to create their own brotherhood, which among other functions was intended to care for surviving members of the families of plague victims.14 Other brotherhoods such as the big Elendenbruderschaft at Trier were more successful. By the middle of the fifteenth century this brotherhood had hundreds of members from all over the Mosel area, many of them belonging to well-to-do families and the lower nobility.15 Even inhabitants of

14

Stadtarchiv Münster, A XI Nr.278.

15

Stadtarchiv/Stadtbibliothek Trier Ta 2/5.

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the hospitals mentioned in the list were members of the upper class. If the hospital in Geldern did care for some inhabitants, nothing is known about the daily life in the hospital. Without any doubt there was no medical assistance. With the sole exception of the Hospital of the Holy Spirit in Nuremberg, where from 1486 a special donation meant that the residents received regular medical treatment, none of the late medieval hospitals in the German Empire employed a doctor or surgeon.16 It took ten years from the foundation of the Geldern hospital before it developed into a functioning institution in all aspects, jurisdictional, economic and ecclesiastical. The territorial sovereigns and members of the knighthood secured an economic basis for the survival of the foundation. Duke Rainald acknowledged the establishment and asked in his charter of 29 April 1415 for financial support of the new house.17 At the beginning of the following year the construction of the hospital building was completed. On Pentecost 1416 it was consecrated by the Archbishop of Cologne.18 It took two years longer to finish the chapel. On 27 November 1418 Dietrich of Moers, the Archbishop of Cologne, acknowledged the foundation of the hospital together with its newly built chapel.19 At the same time that religious services started in the chapel, the first donations were made in favour of the hospital, all of them by the sovereign himself and by his knights. The greatest gift, ensuring long institutional survival, was made by Mary of Harcourt, who in her will, drawn up in December 1419, handed over flourishing estates to the administrators of the hospital.20 However, no charter indicates that a single citizen of Geldern ever made a donation to the new house. The account books prove that the city’s contribution was limited to paying the wax to seal the charters and the messenger to bring them back.21 After some time the council lost its right to install the priest of the chapel and the will of Mary of Harcourt shows that from as early as 1420 the sovereign

16

Ulrich Knefelkamp, Das Heilig-Geist-Spital in Nürnberg vom 14.–17. Jahrhundert. Geschichte, Struktur, Alltag (= Nürnberger Forschungen 26), Nürnberg 1989. Martin Kintzinger, “Status medicorum. Mediziner in der städtischen Gesellschaft des 14. bis 16. Jahrhunderts”, in Peter Johanek (ed.), Städtisches Gesundheits- und Fürsorgewesen vor 1800 (= Städteforschung A50), Köln/Weimar/Wien 2000, 63–91.

17

Stadtarchiv Geldern, A Urk. Nr. 29.

18

Henrichs, 112.

19


20

Stadtarchiv Geldern, A Urk. Nr.37–40.

21

Wilhelm Kuppers, Die Stadtrechnungen von Geldern 1386–1423. Einführung, Textausgabe, Register, Geldern 1993, 326 and 330.

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had regained this right. In June 1423 Duke Rainald died. The strong personal ties between Mary of Harcourt and the hospital loosened when she was forced to marry Ruprecht, the only son of Duke Adolf of Berg, and left her former territory. When she died in 1427 she had never seen Geldern again.22 Yet the generous policy of the territorial sovereign remained unchanged. In May 1425 Duke Arnolf endowed a second altar in the chapel.23 In 1450 this was followed by a third one. By 1456 the hospital possessed enough estates to finance itself.24 However, the financial situation of the hospital is symptomatic of hospital foundations in small towns. The founding sovereigns and their knights took care during their lifetimes that the institution obtained enough donations to maintain itself. Like other small communities, Geldern did not have enough well-to-do citizens that could afford the necessary donations to keep the institution alive. Since without hospital occupants even the care for the memoria – the pious memory of the dead, necessary for the redemption of their souls – was not ensured in an appropriate way, almsgiving on behalf of the institution itself lost its interest. With these observations the circle of our analysis comes to a close. As one of the main results we must stress that a critical reexamination of the circumstances of hospital foundations, especially their foundation charters, furnishes detailed information about the relationship of territorial power, urban self-consciousness and the institutionalization of the medieval welfare system. More than before, we have to ask about the form and quality of charity administered by the hospitals as well as the functions of poverty in medieval society. This is linked to the question of whether the fraudulent benefits enjoyed by healthy persons that were criticized by ecclesiastical authorities at the beginning of the thirteenth century did not drift into kinds of fraud intentionally supported by secular powers.

22

Henrichs, 114.

23


24

Stefan Frankewitz/Petra Janßen, Von der Gasthauskapelle zur Heilig-Geist-Kirche in Geldern. Katalog zur Ausstellung des Stadtarchivs Geldern im Foyer des Verwaltungsgebäudes der Stadt Geldern, Geldern 1990, 20.

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Studying all these questions by comparing as many welfare institutions as possible from a regional perspective may help to lift the mists still covering the shapes of medieval hospital landscapes.

59

Organizing Poor Relief and Health Care: The Specificity of the Portuguese Case (16th–18th Centuries) Laurinda Abreu (University of Évora, Portugal)

Introduction One of the most outstanding characteristics of the Portuguese health and welfare system was the maintenance of a model that started to be outlined at the end of the fifteenth century and was kept without major changes for another three hundred years. Although it had been established in the values of reformed Catholicism, it developed its own specificities that made it stand out from the other models followed in Catholic Europe. In this text I intend to present an overview of the main phases of the construction of this process, trying to highlight how political choices, both in agreement and in direct confrontation with the ecclesiastical authorities, shaped it.

The poor relief and health care reform mechanisms in the early modern ages: the establishment of the Misericórdias The effective reorganization of poor relief for the population in Portugal dates back to 1479 when, accompanying the hospital consolidation that was being made in the majority of European states,1 the future King D. João II obtained Papal authorization to

1

Fundamental studies on the subject: Michel Mollat, Études sur l´histoire de la pauvreté (Moyen AgeXVIe siécle), Paris, 1974 and Les Pauvres au Moyen Age, Paris, 1978; Jean Pierre Gutton, La société et les pauvres. L’exemple de la généralité de Lyon, 1534–1789, Paris, 1971; Michel Cavillac, Pícaros y mercaderes en el Guzmán de Alfarache. Reformismo burgués y mentalidad aristocrática en la España del Siglo de Oro, Granada, 1994; Bronislaw Geremek, A Piedade e a Forca - História da Miséria e da Caridade na Europa, Lisboa, 1995; Sandra Cavallo, Charity and Power in Early Modern Italy. Benefactors and their Motives in Turin, 1541–1789, Cambridge, 1995; Robert Jütte, Poverty and

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Organizing Poor Relief and Health Care: The Specificity of the Portuguese Case (16th–18th Centuries)

establish the Hospital Real de Todos os Santos in Lisbon, the first of the General Hospitals created to replace the dispersed and decadent health care institutions which had been founded by private devotion in the late Middle Ages.2 However, it would be King D. Manuel I (1495–1521) who, in the context of an extensive programme of measures for the centralization of political power, would intervene in a systematic way in poor relief mechanisms, creating the foundations of the Portuguese public welfare system. With the aim of responding to the needs of a growing population, devastated by poverty and, consequently, by beggary, vagrancy and overpopulation in the prisons, the monarchy oriented its social politics towards very concrete objectives. In order to optimize the results, specific sectors of the needy were targeted, at least in theory, and the responsibilities were divided among the civil society.3 For the first time, for example, abandoned children had their right to assistance institutionalized by the new code of laws, the Ordenações Manuelinas, which stated that, in the absence of the children’s parents and relatives, they should be cared for, in order of priority, by the local hospitals, the municipalities and the Misericórdia confraternities.4 But the sick, the prisoners and the poor were the main targets of D. Manuel’s welfare policies. With regard to the first, and continuing the hospital reform previously begun by D. João II, in 1499 D. Manuel ordered a general evaluation of the conditions of all pious institutions, which included hospital and charitable institutions.5 The Crown officials who were in charge of this task were to embark on an inventory of the institutions’ patrimony, analyzing the effective accomplishment of the testamentary conditions imposed by the benefactors and punishing transgressors.6 Two years later,

Deviance in Early Modern Europe, 2nd ed., Cambridge, 1996; Ole Peter Grell, Andrew Cunningham, Jon Arrizabalaga, (eds.), Health Care and Poor Relief in Counter-Reformation Europe, London, 1999. 2

Published by António Domingues de Sousa Costa, “Hospitais e albergarias na documentação pontifícia da segunda metade do século XV”, A Pobreza e a Assistência aos pobres na Península Ibérica durante a Idade Média, Actas das 1ªs Jornadas Luso-Espanholas de História Medieval, Lisboa, 1972, I, pp. 259–327.

3

See our text “A especificidade do sistema de assistência pública português: linhas estruturantes” in the Revista Arquipélago-história, volume VI (2002), pp. 417–434.

4

The Portuguese bibliography on this theme is endless. Among the main works, the following books are highlighted: Isabel dos Guimarães Sá, A circulação de crianças na Europa do Sul : o exemplo da Casa da Roda do Porto no século XVIII, Lisboa, 1995; Maria de Fátima Reis, Os expostos em Santarém. A acção social da Misericórdia (1691–1701), Lisboa, 2001.

5

IAN/TT, Chancelaria de D. Manuel I, livro 14, fl. 78.

6

IAN/TT, Chancelaria de D. Manuel I, livro 1, fls. 4v–5.

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the movement towards hospital centralization, until then restricted to the bigger urban centres, started to extend to smaller places. In a large number of cases it was the local Hospital do Espírito Santo – which belonged to the most important medieval confraternity, that of Espírito Santo, which was administered by the urban elites – that received the attributions and incomes from the individual institutions that disappeared. This patrimonial and administrative transfer and, consequently, hospital reorganization, which was followed by significant developments in recruiting new managers and health care professionals, seems to have proceeded quite peacefully. There were two main reasons for this. On the one hand, the hospital reforms answered to a popular desire, expressed by representatives in the 1498 Cortes. On the other hand, the royal intervention was based on the defence of the memories of the deceased, which made it easily acceptable. In fact, according to the civil laws, pious institutions that were not run according to their founders’ rules should have been incorporated into Crown property, then handed over to whoever respected the wishes of the dead. And as the royal inquiry showed, quite soon the interests of the living who managed the pious institutes had become more important than the wishes of the dead.7 In the same year that the hospital survey was carried out, other emissaries left the Court with a very specific aim: to convince the urban municipalities and the local elites to establish confraternities of Santa Casa da Misericórdia in their communities.8 The first Misericórdia confraternity had been created the previous year (15 August 1498) in Lisbon, under royal protection – at the time, that of Queen D. Leonor, sister and representative of D. Manuel, who was absent from the kingdom – and with the support and involvement of the Court nobles. Presented as a charitable confraternity, the Misericórdia’s statutes foresaw the relief of all human needs, both spiritual and corporal, under the designation of the “fourteen works of mercy” – seven spiritual (to instruct the ignorant; to give good advice; to punish those who make mistakes with mercy; to comfort the afflicted; to forgive insults; to bear wrongs patiently; to pray to God for the living and the dead) and seven corporal (to ransom captives and visit

7

Cf. Paulo Drumond Braga, “A crise dos estabelecimentos de assistência aos pobres nos finais da Idade Média”, Revista Portuguesa de História, vol. 26, Coimbra, 1991, pp. 175–190.

8

José Justino de Andrade e Silva, Collecção chronológica da legislação portuguesa, (1613–1619), Lisboa, 1854, p. 318.

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prisoners; to cure the sick; to clothe the naked; to feed the hungry; to give drink to the thirsty; to lodge pilgrims; to bury the dead). Although the early years of the Misericórdias still remain unclear, it seems that they were open to a broad section of society,9 even though only a part of them could be effective members – the confreres, who were supposed to represent the nobles and the non-nobles (termed “officials”) in equal numbers. According to the statutes, the confreres should be men, of pure blood,10 who enjoyed a good financial position and did not perform manual work. The Misericórdia was managed by a committee of thirteen people, elected indirectly within the confraternity, which was called “The Table” (Mesa). This council consisted of the purveyor – a titled noble or one who had the equivalent of noble status – six noble representatives and six “official” representatives; one of them assumed the functions of clerk, another of treasurer and the others shared the control and exercise of charitable and administrative tasks between them. The council of thirteen had effective power inside the institution. The strong royal effort to spread the Misericórdias throughout the whole country had two main aims: to promote, on a national scale and in a uniform way, relief for prisoners and the control of beggars, and to encourage the involvement of the municipal oligarchies in healthcare and welfare issues. Actually, although the Misericórdias’ statutes laid emphasis on the fourteen works of mercy, they also made it very clear that the confraternities’ priority was to help poor, deprived prisoners in terms of judicial support for their release, meals and medical care. So as to achieve this, the first privileges given by the king to the Lisbon Misericórdia allowed the confreres to visit the prisoners and clean the jails and facilitated them in their work to free the prisoners. These privileges were given to each new Misericórdia that sprung up and accompanied its statutes, which were copied from the Lisbon example, but they were nevertheless adapted to local conditions. The competences regarding the beggars granted to the Misericórdias by the provision of 8 July 1503 made them responsible for the distinction between true and

9

It is yet to be proved if the situation registered in the first book of the confreres of the Évora Misericórdia, saying that people from all social levels, including slaves, could be admitted as confreres, was observed in other Misericórdias, or if it was an isolated case. (Cf. Arquivo Distrital de Évora, Registo de Irmãos da Misericórdia, 1499–1540, livro 49).

10

On the restrictions concerning Moorish and Jewish blood, see Isabel Mendes Drumond Braga, “Poor Relief in Counter-Reformation Portugal”, in Health Care and Poor Relief in Counter-Reformation Europe, p. 204.

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false poverty. From then on, only the Misericórdias were allowed to examine the poor, distinguishing between the “undeserving” and the “deserving” – “the crippled, the weak and the elderly with no means of self subsistence”. Only the latter were entitled to a beggar’s licence.11 The involvement of the local elites was facilitated through the attribution of a special status to the Misericórdias. This was a process that had the direct support of the monarch, through privileges and benefits granted to the Misericórdias but also through the attribution of some functions that had a symbolic capital that made them more socially appealing. This applied particularly to the rituals that were connected to assistance work and also to those where the confraternity was exposed to the public.12 As they were responsible for the burials of those condemned to death, the first official public appearance of many Misericórdias was a solemn procession that, “with the coffin raised”,13 went to the gallows to collect the skeletons of the executed and bury them. Also very important for symbolic reasons was the fact that the confreres, especially those of higher social standing, assumed the role of the poor for brief periods, collecting alms that were later distributed among the real poor. D. Manuel’s aims were gradually achieved and the Misericórdias started to attain their place in society. From early on, participation in their governing body meant social prestige and, in some cases, social ascendancy, the first step towards the municipal council. For different reasons, the Misericórdias and the municipal councils became the two main pillars of local power. In fact the link between the Misericórdias and the municipal councils is a feature that is present from the beginning and one that would definitely bind the destinations of the two institutions – not only because the royal letters that contained the appeal for the creation of the Misericórdias had been read in the municipal councils, being a direct summons to the representatives of the civil society, but also because D. Manuel exempted the Misericórdias’ board members from some communitarian obligations and fiscal charges, an honour that placed them above all institutions of the same type and

11

Cf. Fernando Calapez Corrêa, Elementos para a História da Misericórdia de Lagos, Lagos, 1998, p. 183.

12

On the importance of this theme, see Isabel dos Guimarães Sá, As Misericórdias Portuguesas de D. Manuel I a Pombal, Lisboa, 2001, pp. 81–103.

13

Eurico Gama, A Santa Casa da Misericórdia de Elvas, Coimbra, 1954, p. 21.

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made them identical to the municipal councils. But it is important to emphasize that, notwithstanding the fact that the individuals in question might be the same, the Misericórdias were never under municipal control. It is also important to mention that, although royal investment in the Misericórdias was contemporaneous with the hospital reorganization, the king did not hand the hospitals over to these confraternities. Indeed, the welfare system created by D. Manuel I was based on a division between medical care and poor relief. In the system devised by the king, taking care of the hospitals demanded specialized work that involved employing medical professionals and organizing administrative matters, features that were not compatible with institutions that had been planned to administer feelings and affections. Owing to this, “devotion and alms” were enough. The devotion and alms of the Misericórdias’ confreres, of course, were strengthened by the general population, who were now encouraged to give donations to the new confraternities, to whom the king had granted a monopoly of alms in the geographical areas to which they belonged. In this respect, the acquisition of properties was not considered a priority but rather counterproductive, as the king indicated when he refused to annex the incomes of some pious legacies to the Coimbra Misericórdia.14 To sum up, there is no doubt that the welfare reforms made by D. Manuel I followed two distinct but complementary patterns. He tried to revitalize what the Middle Ages knew as “the spirituality of beneficence”,15 guiding the religiousness of laymen towards the Misericórdias, institutions created within the spirit of early Catholic Reform. On the other hand, he continued the reorganization of hospital assistance, trying to face the social problems of a society that was in the process of transformation. It was, in both cases, a nationwide intervention, one that attempted to establish a standard in the area of welfare, at the same time making communities and municipal lay elites responsible for their poor.16

14

António de Oliveira, “A Santa Casa da Misericórdia de Coimbra no contexto das instituições congéneres”, in Memórias da Misericórdia de Coimbra – Documentação & Arte, Coimbra, 2000, p. 28.

15

André Vauchez, La spiritualité du Moyen Age occidental, VIII-XIII siècle, Paris, 1994, p. 118.

16

As can be concluded by the publication of the Regimento de como os contadores das comarcas hã de prover sobre as capellas, ospitaes, albergarias, cõfrarias, gafarias, obras, terças e residos, of 1514.

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The Counter-Reformation and the reinforcement of the Misericórdias’ competences The second phase of the construction process of the Portuguese welfare system, although it continued along the main lines defined at the beginning of the century, was strongly moulded by the influence of the Counter-Reformation. This was a relatively short period, in which Rome made various interventions in order to give the Church a bigger lead where poor relief issues were concerned. Politically it corresponded to the final years of the reign of D. João III, responsible for the introduction of the Inquisition into Portugal (1536), the start of the Censorship and the arrival of the Jesuits (1540),17 and to the political sphere of D. Henrique (1557–1580), who accumulated the functions of Regent and King along with those of General-Inquisitor (1539), Cardinal (1545), Pontifical Legate (1553) and Archbishop of Lisbon (1564). This circumstance helps to explain the fact that the decrees of the Council of Trent were immediately and integrally approved as state laws – by the royal provision of 24 November 1564 – which resulted in a reinforcement of the authority of the Church over the state, which was acknowledged and accepted by the provision of 2 March 1568 that, among other decisions, widened the aid granted to the ecclesiastical courts by the secular courts.18 This was a unique period in terms of joint interests and shared positions between the ecclesiastical and secular spheres (though some friction did exist),19 and one that would never be repeated in the history of the relations between Portugal and the Apostolic See. The first sign of the renewed interest with which Rome faced welfare questions came in a Papal brief of 20 August 1545, in which Paul III authorized the Hospital Real de Todos os Santos to collect all the pious legacies instituted in Lisbon and its outskirts that had not been fulfilled according to the conditions laid down by those who had bequeathed them, and to use them for the sick.20 Nevertheless, it was the indulgences

17

King D. João III was also responsible for a new hospital survey and for legislative measures in order to expel non-native beggars from the communities.

18

Marcello Caetano, “Recepção e Execução dos Decretos do Concílio de Trento em Portugal, Revista da Faculdade de Direito da Universidade de Lisboa, 1965, 19, pp. 7–52.

19

Cf. José Pedro Paiva, “A Igreja e o poder”, História Religiosa de Portugal, dir. Carlos Moreira Azevedo, Rio de Mouro, vol. 2, 2000, p. 150.

20

Abílio Augusto Monteiro, Direito Portuguez sobre Legados Pios, Porto, 1879, pp. 36–37.

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that were sent from Rome to the Misericórdias after 1546 that would be the main proof of the dynamism of reformed Catholicism.21 The first indulgence dates from 30 March 1546 and was forwarded to the Misericórdia of Lisbon. Although its text is unknown – we only have indirect reference to “several privileges and benefits”22 – the indulgence was considered of primordial importance by the confraternity and even excessive by the king, who refused to ratify the whole Papal document.23 As was the case with other institutions, the reception of indulgences also meant public recognition of the Misericórdias’ work, both stimulating the adhesion of the faithful and reinforcing the institutions’ position in their communities. Magnanimous with spiritual benefits to all those who visited the Misericórdia churches to confess and who had holy communion on the most important days of the liturgical calendar, the Popes promised dozens of plenary indulgences, many hundreds of thousands of years of pardon, some partial remissions of sins, and even the possibility of removing some souls from Purgatory, “to all brothers and confreres that are now and will be in the future, men or women (...), and to all the ministers and servers of the confraternity and of its hospital, and to its patients for the time spent there”.24 Among the indulgences we know of, the one sent to the Porto Misericórdia in 1558 by Pope Paul IV, connecting it with the “main charity confraternity” of Rome through arch-confraternity links, deserves to be highlighted because it allows us to evaluate the importance of these documents in the confraternities’ economic structure. Effectively, the Papal brief clarifies that the indulgences were also destined to all those who left the Porto Misericórdia “properties for works of mercy in their wills, or in another way, or

21

About the role and characteristics of the arch-confraternities, see Bernard Dompnier, “Les confréries françaises agrégées à l’archiconfrérie du Gonfalon. Recherche sur une forme du lien à Rome”, Cahiers du GRHIS, Les confréries du Moyen Age à nos jours. Nouvelles approaches, Rouen, nº 211, nº 3, 1995, p. 41.

22

Cf. A. de Magalhães Basto, História da Santa Casa da Misericórdia do Porto, Porto, 1934, pp. 411–412.

23

Specifically, the exemption from the Bishop’s control, which the king considered harmful to the Church as well as to the confreres. Cf. J. Quelhas Bigotte, Situação Jurídica das Misericórdias Portuguesas, 2ªed., Seia, 1994, pp. 93–94.

24

Summario das indulgencias e graças concedidas pelo Santo Padre Paulo IV à Santa Casa da Misericordia do Porto, Porto, 1800.

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bequeathed or instituted the confraternity as their heir”.25 Through donations in wills or other types of legacies, the support of the population increased the economic resources of the Misericórdias, which had serious economic problems until the middle of the sixteenth century. And to have an active role in the charity field it was necessary to have money. It was according to the logic of this reasoning that the provision of 2 March 1568 incorporated into national law the distinction of pious legacies with such a broad interpretation that all settlements with charitable ends, or ends serving the salvation of souls, could fit into it.26 Pious legacies that, under the conditions established in the Papal brief of 20 August 1545, were not respected would be delivered to the Hospital Real de Todos os Santos. In effect, this meant delivered to the Misericórdia of Lisbon, which had been managing the most important Portuguese hospital since 1564.27 As a matter of fact, the Misericórdias turned out to be the great protagonists of the welfare process reform that was now underway. There were two main, apparently contradictory reasons for this. The first one looks forward to the Council of Trent, where the representatives of Portugal obtained for the Misericórdias the status of confraternities “under royal protection”, which meant exemption from ecclesiastical jurisdiction. In the future, only their church and cult activities were under the bishop’s authority. The second reason is related to hospital administration. In fact, after the handing over of the Hospital Real de Todos os Santos to the Misericórdia of Lisbon (27 June 1564), the majority of Portuguese hospitals were transferred to the Misericórdias’ administration, giving them, almost as a monopoly, an assistance role that until then they had rarely played.28 This movement occurred precisely at the moment when assistance was shifted to the bishops’ control and when the Church reinforced its authority over the social welfare system, medical care included.29 How do we explain this? In my opinion, the best way

25

Cf. Indulgências Anexas às Estações de Roma, that the Oporto Misericórdia received in 1551, in Artur de Magalhães Basto, História da Santa Casa da Misericórdia do Porto, Porto, 1934, p. 413.

26

Duarte Nunes do Lião, Leis Extravagantes e Reportório das Ordenações, Lisboa, 1987, p. 83.

27

Gabriel Victor do Monte Pereira, Documentos históricos da cidade de Évora, Évora, 1887–1891, p. 251.

28

Cf. Laurinda Abreu, A Santa Casa da Misericórdia de Setúbal entre 1500 e 1755; aspectos de Sociabilidade e Poder, Setúbal, 1990, pp. 30–31.

29

Cf. João Baptista Reycend, O sacrosanto e ecumenico Concilio de Trento, s/d, s/l., pp. 640–641 and pp. 704–705.

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is through the framework of the political-religious situation of Portugal at that time. This way, the king and the Pope may have tried to strengthen the results where hospital assistance was concerned, even though the role of the state prevailed over that of the Church. It is certain that this moment corresponded to a reorganization of the Misericórdias, from which a change in their aims resulted. From then on they were strongly devoted to hospital care. With the hospitals they also obtained, in addition to the inherent power to manage medical care, the properties and incomes of the attached institutions. Moreover, this strengthened the conditions that led to their being transformed into the privileged recipients of funds for the celebration of perpetual masses, performed in accordance with the spread of the idea that passage through Purgatory was almost inevitable for whoever aspired to eternal salvation and that the saying of masses would be the best way to achieve this salvation.30 In short, in the third quarter of the sixteenth century two of the three main elements that characterized the Misericórdias were already connected: the domain of hospital assistance and ownership of a patrimony of considerable extent, especially in the larger urban centres. The conclusion of this process – an elitist and oligarchic form of administration – would be achieved by the Habsburg dynasty (1580–1640), which put in place an operative matrix that was maintained without substantive alterations for three centuries. It was also under the influence of the Council of Trent that there emerged a diversity of welfare institutions which, in addition to trying to minimize the effects of poverty, concerned themselves with the social moralization and salvation of those who were sheltered there. We might mention here the wave of new foundations specifically destined for women and children, considered risk groups and deserving of particular attention under Counter- Reformation Catholicism. Special attention should be paid to the female conservatoires, almost always organized according to the social condition of their occupants, which limited their expectations for the future. This is a field that is still practically unexplored in Portugal but the individual records of the conservatoires of Nossa Senhora da Piedade and S. Mansos, both from Évora, show that those who

30

Cf. Laurinda Abreu, “As comunidades litorâneas de Setúbal e Lisboa em tempos de Contra-Reforma”, in O litoral em perspectiva histórica (sécs. XVI-XVIII), Porto, 2002, pp. 247–258.

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belonged to a higher social status waited for marriage, which would “free” them from confinement, while those of a lower condition, although also awaiting marriage, generally left the institution through integration in the labour market, almost always as servants.31 Évora had the only mixed conservatoire sheltering women, girls, boys and the aged that we know of, as well as a home for prostitutes. The only indicators that we have show that the first institution became a kind of asylum where old people waited for death, while the House of Saint Marta – the prostitutes’ conservatoire, established by two ecclesiastics (a typical reflection of Charles Borromeo’s example in Milan) during the 1560s – seems to have been an enterprise of little success, since the restorative intentions of its founders seem to have been stronger than the will to redemption on the part of the sinners, always ready to run away and fall into the temptation of the bad life, “perverting other souls that could convert to Our Lord”.32 The foundlings and orphans mentioned above also began to receive a degree of attention that had not hitherto been available to them. In fact, it is probable that the resolutions of the Ordenações Manuelinas relating to the upbringing and assistance of abandoned children were only put into practice after Trent. At any rate, the first documentary registers that we have on foundlings date from this time,33 in most cases linked with the foundation of orphanages that took in children who had no one to care for them after their basic upbringing came to an end at the age of seven.34 An absolutely basic aspect that has also been neglected until the present in Portugal is related to the role of the bishops as agents of charity in the context of the increased

31

According to current research work done under my orientation by the students Marco Loja, Sílva Mestre and Marco Liberato, in the context of the History degree of Évora University. (For Italy see, Brian Pullan, Poverty and Charity: Europe, Italy, Venice, 1400-1700, London, 1994, pp. 177–208, and John Henderson, “Charity and Welfare in Early Modern Tuscany”, in Health Care and Poor Relief in Counter-Reformation Europe, pp. 69–73.

32

Gabriel Pereira, Documentos históricos da cidade de Évora, p. 469.

33

Precisely when the Misericórdias received the hospitals, since several municipal councils had raised the foundlings in the hospitals that they handed over to the confraternities.

34

Ana Isabel Marques Guedes, A assistência e a educação dos órfãos durante o Antigo Regime. O Colégio dos órfãos do Porto, Porto, 1993. The author extended this to other cities in her PhD thesis, Les enfants orphelins: éducation et assistance: les colégios dos meninos órfãos: Évora, Porto et Braga (XVIIe-XIXe siècles), Florence, 2000.

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powers that Trent gave them.35 In this respect, the case of D. Teotónio de Bragança, Archbishop of Évora – the richest diocese in the country – between 1578 and 1602 continues to have an exemplary character. A descendant of the leading Portuguese noble house, the house of the Dukes of Bragança – the dynasty that replaced the Spanish in 1640 – D. Teotónio de Bragança, a novice of the Company of Jesus and doctor of the University of Bordeaux in 1574, corresponded to the model of a Catholic bishop that had been outlined in Trent. Among the many activities he developed in order to reform his diocese, he tried to return the Church to the faithful, investing in the teaching of the catechism and in the social moralization of his parishioners, and he was a champion of the strengthening of episcopal authority, recovering the jurisdictional and patrimonial powers that had been lost.36 But he was also responsible for a wide range of initiatives in the area of poor relief, one example being the two above-mentioned conservatories (S. Mansos and Nossa Senhora da Piedade). He described his functions as follows: “As prelate he had the obligation to see to the spiritual and secular welfare of his subjects, and especially of the poor beggars and the unfortunate.” He defended his unquestioned power over institutions “doing pious work and being useful to the needy, [a power] that according to the law belongs to the bishops”.37 Statements of this nature could only create conflicts with the royal measures put into practice by the Spaniards newly arrived in Portugal. Initiators of very important reforms not only in the state administration but also in many spheres of social life, the Habsburg monarchs confronted the bishops’ authority several times, the field of welfare being one of the most open to the affirmation of the supremacy of the state over the Church.

35

Subject referred to by José Pedro Paiva, “D. Fr. Luís da Silva e a gestão dos bens de uma mitra: o caso da diocese de Lamego (1677–85)”, Estudos em homenagem a João Francisco Marques, Porto, 2002, pp. 245–255.

36

See Federico Palomo, “La autoridad de los prelados postridentinos y la sociedade Moderna. El gobierno de Don Teotonio de Braganza en el arzobispado de Évora (1578-1602)”, in Hispania Sacra, vol. XLVII, nº 96, 1995.

37

Registered in the conservatoire’s statutes of 1702, according to the transcription done by Marco Loja.

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The Misericórdias under the Habsburg government The privileged instruments of this process were the Santas Casas de Misericórdia, owing to their character as “confraternities under royal protection”. Already definitely shaped as local power centres when the Spanish kings arrived – at that time the existence of a Misericórdia was already considered an indicator of the development of a place and of the power and autonomy of certain social groups – the Misericórdias were seen by the Habsburgs as having great potential as elements of a reorganization of the social and political space. At the same time, they could serve as a means of increasing control over a welfare system that was now clearly politicized.38 The Habsburgs introduced several initiatives along these lines, particularly by founding new Misericórdias – at least forty of them were created between 1580 and 1640, reinforcing the net of confraternities that by then extended through the small rural towns – and granting new benefits to already existing ones. By this means they tried to prevent the constitution of very powerful centres, to strengthen local powers and to increase their personal links with local populations, profiting from the fact that the Misericórdias were in direct contact with the king. Meanwhile, the Misericórdias and the municipalities were called upon to participate in the construction of the new social and political order that the state intended to establish. This was accomplished by a reform of access to their leading posts, which in the former case culminated in a law of 1611 and in the latter in statutes of 1618. Both had as their outcome the institutionalization of similar procedures that led to the crystallization of a “group of noblemen responsible for government”,39 closing it off as a limited group of people that controlled both institutions. At the same time, and in addition to receiving the hospitals that had been outside of their control,40 the Misericórdias were distinguished by new privileges that brought additional competences. This procedure was followed by the functional emptying of the

38

Development on this subject is found in our text “As Misericórdias portuguesas de Filipe I a D. João V”, in the 1st volume of the Portugaliae Monumenta Misericordiarum, Lisboa, 2002, pp. 47–77.

39

Maria Helena da Cruz Coelho; Joaquim Romero Magalhães, O poder concelhio. Das origens às Cortes Constituintes, Coimbra, 1986, p. 43.

40

At the same time that Philip II practically concluded the annexation of the hospitals to the Portuguese Misericórdias, he moved ahead in Castile with successive provisions – 1581, 1583, 1586 and 1589 – promoting hospital consolidation.

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other confraternities, which were gradually reduced to cult activities. Renewed or founded after Trent, they were confined to spiritual assistance and their charitable functions were also confined to their confreres and families, very often through dowries for girls. Most of them were so poor that the alms and the annuities were not sufficient to pay for the annual celebration of their patron saint. Throughout the period of Spanish rule in Portugal, confrontations between state and episcopate over the confraternities were frequent; these became particularly violent following the publication in 1604 of the Quaecumque Constitution, the first codification of Church competences and rights with regard to the confraternities. There is much documented proof of the affirmation of the king’s power over confraternities founded by laymen, especially over the Misericórdias and their hospitals – as was the case, for instance, in Arraiolos in 1619 41 – as well as threats to bishops who dared to interfere in areas beyond their sphere of competence. However, one cannot therefore conclude that the reinforcement of the Misericórdias’ power in Portuguese society occurred in an atmosphere of complete freedom and autonomy. In fact, although they functioned in a decentralized system, during the period of Spanish rule the Misericórdias felt the weight of royal intervention as it had never been felt before. Of the various measures that tended towards an increase in control over them, three stand out: control of the accounts (the 1593 law was effective for ten years retrospectively, and it was followed by similar laws); intervention in electoral processes; and an end to the possibility of the Misericórdias autonomously modifying their statutes without informing the central power.42 With regard to the structure of the welfare system, the most important fact to recall from the time of Spanish intervention is the reinforcement of the central place of the Misericórdias in the entire welfare system, and in medical care in particular. This did not mean that the Misericórdias had the exclusive right to administer all the hospitals. Indeed, there were some confraternities that managed to keep their hospitals, either because they were of ecclesiastical foundation or because they had administrative

41

Santa Casa da Misericórdia de Arraiolos, Inventário do Hospital, 1619.

42

Collecção chronologica de leis extravagantes posteriores á nova compilação das Ordenações do reino publicadas em 1603, Coimbra, 1819, pp. 245–246.

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autonomy. Other hospitals were built in periods when there were food shortages. There the needy could spend the night and have meals. Normally, these hospitals were places destined to resolve cyclical crises, or “to be a refuge for sufferers from the plague”,43 when the sick and the beggars, who arrived in “herds” in the great urban centres, became serious threats to public health and the social order.44 They were not under the Misericórdias’ control but were rather administered by the municipalities and financed by extraordinary taxes from the resident population, even though the citizens preferred other alternatives such as the confinement of the undesirable in ghettos – “in a street or a quarter they cannot leave” – or their removal to the colonies, as in a proposal that was presented to The Lisbon municipal council in the crisis of 1598–99.45 Once the crisis was over, these hospitals were closed down.46 These short-term hospitals appeared as a result of the limitations of the Misericórdias’ hospitals. In fact, if their main targets were the poor, some studies carried out in relation to the hospitals’ admissions records show that those who benefited most from medical care – even if this meant firstly food and shelter and only after that medication – were servants and daily workers, mainly migrants without a family to look after them. The latter could easily become poor, while the servants worked for employers who refused to pay their hospital expenses. Beggars were only rarely taken care of in these hospitals.47 Despite the burden, often suffocating, that hospital assistance represented in the Misericórdias’ budgets, they continued “their” other mercy works, even though they had a less significant economic value. These included help to poor prisoners, a task that was more and more contested by municipalities, which did not allow prisoners to be freed unless their expenses had been paid by the Misericórdias; the orphans’

43

Eduardo Freire de Oliveira, Elementos para a História do Município de Lisboa, Lisboa, 1887, vol. III, pp. 107–108.

44

On the importance of this subject, see Robert Jutte, Poverty and Deviance in Early Modern Europe, pp. 178–190.

45

Eduardo Oliveira, Elementos para a História do Município de Lisboa, vol. III, p. 120, p. 122 and pp. 124–125.

46

It was also in these situations that the religious orders, above all the Franciscan, became more important, especially in domiciliary help to plague victims. This was because only in exceptional cases did the Misericórdias accept pestilent and incurable diseases.

47

See examples indicated in the abovementioned text, “As Misericórdias portuguesas de Filipe I a D. João V”.

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endowment, a welfare service that had proper funds, left as bequests by individuals who stipulated that they be given to women from their family or from their servants’ families;48 support for foundlings, a welfare service that was sometimes financially aided by the municipal councils; and alms to the humble poor, to widowers and to poor women on their own.49 Also of some significance was outpatient medical assistance, another addition to the budget of the Misericórdias’ pharmacies, where the poor could get free medications prescribed by Misericórdia doctors. In small communities, the Misericórdias were the only ones to assure the basic structures of charity and welfare.

A system in crisis Since they had exclusive or shared responsibilities for assistance to a variety of groups, there is no doubt that more was demanded from the Misericórdias than they were capable of providing. By the end of the seventeenth century the general contours of the Misericórdias’ problems had already taken shape: too many patients – civilian and military50 – very high mortality rates, inadequate hospital facilities, an excessive number of employees and enormous pressure from groups traditionally helped by the confraternities, which saw a decrease in the amount of aid that had been promised to them, and sometimes even its complete suspension. In addition to this, they had to deal with bad financial practices, rents not charged, embezzlement of capital, extravagant expenses, and the disappearance of most religious responsibilities.51 These were longterm problems that were not solved, but were rather aggravated by the escape of the elites, who had long since taken over the confraternities’ incomes and did not now

48

See Maria Marta Lobo de Araújo, “Pobres, honradas e virtuosas : a distribuição de dotes de D. Francisco pela Misericórdia de Ponte de Lima (1680–1850)”, 2000.

49

See Maria Marta Lobo de Araújo, Dar aos pobres e emprestar a Deus: as Misericórdias de Vila Viçosa e Ponte de Lima (séculos XVI-XVIII), Barcelos, 2000, pp. 233–245 and pp. 607–630.

50

The contracts that the state signed with the Misericórdias for the treatment of soldiers in the confraternities’ hospitals, in the context of the wars with Spain, after 1640, which the Misericórdias accepted in the hope of receiving state financial support, ended up by turning into a serious financial problem as the state did not cover the expenditures for the soldiers.

51

The Misericórdias had a body of religious people (their numbers depending on the size of the particular institution) to celebrate masses for the souls of their benefactors, in addition to one or more chaplains who attended the sick and the dying in hospital. Nonetheless, as soon as the hospitals started to bring pressure on the Misericórdias’ budget, less and less investment was observed in the spiritual functions, which meant the non-payment of salaries to the chaplains and the reduction of religious ceremonies to the minimum.

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want to be compromised by institutions in debt, by the decline of the foundations of perpetual masses and by the decrease of pious donations. It was in the context of financial collapse that, from the second decade of the eighteenth century, an old practice came to light – that of hospitals were being financed by the money left for the celebration of masses for souls in Purgatory and that, consequently, the institutions had tens of thousands of delayed masses to be celebrated. The conditions for the commutation of pious legacies with regard to other charitable works were established at Trent52 and it was on the basis of the wording of the Council minutes that those in charge of the Misericórdias managed to legitimize their disregard for the last testaments of the faithful and, simultaneously, to reduce the number of masses instituted by them. Without much difficulty, the Pope authorized the first by issuing briefs of pardon, and the second by agreeing to briefs of reduction. In unison, the administrators of the Misericórdias justified their acts by claiming that “large numbers of poor did not perish.”53 After all, they added, “the deceased did not require patrimony in the land as they no longer lived in it,” and nobody could deny that the interests of the living were more important than those of the deceased. In their briefs, the Popes complied: to cure the sick was as meritorious as to pray for the souls of the deceased.54 While the majority of the Misericórdias were authorized to devote money from masses to caring for the sick and poor, the Misericórdias of Porto, Évora and Braga55 received the same privilege the Hospital Real de Todos os Santos had received on 20 August 1545: all the pious legacies instituted in the respective archbishopric that were not fulfilled within the periods and according to the conditions imposed on the executors of the wills were to be handed over to them. If the trials related to disposing these incomes disclose fabulous amounts of money – or in the words of the legal texts, “very profitable amounts” – they are reveal damning

52

Cf. João Baptista Reycend, O sacrosanto e ecumenico Concilio de Trento, p. 702.

53

Arquivo da Santa Casa da Misericórdia de Setúbal, Livro de Redução de Legados Pios, fls. 1–4.

54

Laurinda Abreu, Memórias do Corpo e da Alma. A Misericórdia de Setúbal na Modernidade, Viseu, 1999, pp. 153–178.

55

In 1693, 1712 and 1713, respectively. Cf. Abílio Augusto Monteiro, Direito Portuguez sobre Legados Pios, Porto, 1879, pp. 36–37.

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evidence that exposes “agreements” between ecclesiastics, administrators and executors, united in embezzling souls in Purgatory for their own pecuniary advantage. This is perhaps why from the early eighteenth century in, for example, Modena56 as in Setúbal, the opposing voices of those who had witnessed the malfunctioning of this system began to be heard. A priest from the Church of S. Julião, Setúbal, said in 1745 that even though he did not question the virtue of similar acts of mercy, he never advised his parishioners to institute perpetual masses. Experience showed him that such acts did not lead its originators to Heaven, but were also responsible for taking many souls to Hell – in particular administrators of last wills and testaments who, through “negligence” or greed, did not fulfil the wishes of the deceased, as well as the souls of priests who, also through “negligence” or friendship, did not take the necessary measures to condemn the sin and the sinners. Meanwhile, “the miserable institutor suffered in Purgatory without remedy.”57 The decline of the establishment of perpetual masses, already clearly visible from the end of the seventeenth century, would affect, for the reasons mentioned above, the performance of the Misericórdias, and in particular the hospitals’ management. This was due not only to bad administration, but also to an increase in the number of the needy, especially after 1750. The way in which the welfare system developed, keeping the municipalities at a distance, meant that they were free from responsibilities in this field. The weakness of their finances and the idea that the Misericórdias had economic means to support the hospitals contributed to distancing the local authorities from a problem that they should have shared. The same happened with the state, which did not even contribute to the enlargement or remodelling of the hospitals, which practically came to a standstill during the first decades of the seventeenth century. However, these were not the only reasons for underdevelopment in Portuguese medical practices and overall public welfare. The dominant role of the Jesuits in public education and, in the wider vision of Jonathan Israel, "the indirect [and negative] intellectual effects of the Counter Reformation”,58 also played an important role.

56

Brian Pullan, Health Care and Poor Relief in Counter-Reformation Europe, p. 33.

57

Arquivo da Igreja Paroquial de São Julião, Livro das obrigações das missas desta freguezia de S. Julião, anno de 1740.

58

Ibid., p. 45.

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A rigorous and very critical picture of the state of medical training and faculties and the education of medical experts in Portugal in the first half of the eighteenth century was painted by Luís António Verney in 1746 in his Verdadeiro Método de Estudar (True Method To Study).59 A well-travelled man of the Enlightenment and connoisseur of the realities of other European countries, Verney – like the Valencian doctor Juan de Cabriada, writing in 1687 60 – ran up against the practice of medicine based on the humours, which was rooted in the ideas of Hippocrates and Galen, and in its place proposed structural changes that opened the country to research and to an eminently practical education. However it would be necessary to wait for the expulsion of the Jesuits (1759) and for the secularization of education until major reforms could be initiated, embodied – in terms of university education – in the Statutes of the University of Coimbra in 1772. These reforms were initiated but not completed, partly because the political career of the governor who gave rise to them (Marquês de Pombal, 1777) came to an end, but also on account of the particular political circumstances, which necessitated postponement of major reforms in the field of the Portuguese health and welfare system for another century.61

Final considerations In conclusion, the only coordinated activity carried out in Portugal with regard to the system of poor relief during the entire early modern period occurred between the end of the fifteenth century and the beginning of the sixteenth century. During this period, the foundations were laid for a relatively centralized and unified system that established well defined borders between poor relief and proto-medical assistance. In the second half of the sixteenth century, especially after the end of the Council of Trent, political power, in agreement with the religious power, reoriented the “programme” delineated by D. Manuel I, joining what the king wanted to keep separate. The hospitals were handed over to the Misericórdias at the same time as their economic conditions were strengthened to enable them to fulfil the fourteen works of mercy. This path was shortly

59

Luís António Verney, Verdadeiro método de estudar, Lisboa, s/d.

60

Jonathan Israel, Health Care and Poor Relief in Counter-Reformation Europe , p. 41.

61

See Maria Antónia da Silva Figueiredo Lopes, Pobreza, Assistência e Controlo Social em Coimbra (1750–1850), Viseu, 2000.

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afterwards closed by the Habsburg monarchy, which was largely responsible for minimizing the role of the other confraternities in fields related to material welfare by curtailing access to alms of the population while at the same time reinforcing the competences of the Misericórdias in this sector. Among the specificities of the welfare model created in Portugal is the fact that, although it was in principle controlled by the state, the local elites were accorded conditions which meant that they could manage it in a decentralized way, with a high degree of autonomy. This meant at the same time that the municipalities, as power centres, were not involved in this process. Another particularity is related to the sources of financing. Excluding taxing of the population – only authorized to assist foundlings or to cope with situations of extreme crisis – Portugal, following the guidelines provided by Trent, limited health care and poor relief strictly to the field of charitable provision. And in this sense, the commutation of the pious legacies to incomes for the hospitals was an old practice that allowed the Misericórdias greater audacity, later ratified by the Popes through briefs of pardon and briefs of reduction. With such a fragile economic base, the badly constructed system soon collapsed. At the beginning of the eighteenth century the Misericórdias already showed difficulties in replying to the welfare needs of the population, and during that century they continued to weaken, without support from the state. However, we cannot evaluate the whole welfare system from the Misericórdias’ perspective alone. The role of complementary and non-official structures of charity and welfare, for instance, still remains unknown. The competences of the municipalities in the sector of public health and poor relief have not yet been clearly identified. The same applies to the mechanisms of self-help and the various manifestations of private charity.62 There is slightly more light concerning the role of the churchmen who, during the Counter-Reformation, created a multiplicity of conservatories and orphanages directed to a larger sector of society. In this sense, only researching more deeply into to the matter will allow us to evaluate what type of influence the Portuguese bishops had in the application of state directives. For example, we do not have any information on the role of the Misericórdias as controllers of beggary, a function given to them by the

62

On the importance of these types of assistance, see Martin Dinges, Health Care and Poor Relief in Counter-Reformation Europe, pp. 240–279.

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above-mentioned law of 8 July 1503 but one that they may never have exerted.63 And it may not have been mere chance that the project for welfare system reform proposed by Pérez de Herrera was not implemented in Portugal, although the author had advised Philip II to extend it to all territories under the Spanish crown.64 In addition to these legal and administrative aspects, a great deal of research is still necessary if we are to achieve a complete view of how the Portuguese health care and welfare system functioned at the level of everyday practices.

Acknowledgement This paper resulted from research carried out as part of a project financed by the Fundação da Ciência e Tecnologia (POCTI/1999/HAR/33560): “The Role of the Misericórdias in the Portuguese Society of the Ancient Regime: The Case of the Évora Misericórdia”.

63

In fact no cases of forced internment of the poor have been discovered to date, and the proposal presented in the Lisbon municipal session to ostracize the beggars, referred to above, seems to have been an isolated case, without any attendant consequences.

64

Cf. Jon Arrizabalaga, Health Care and Poor Relief in Counter-Reformation Europe, pp. 161–164.

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Medicine, Philanthropy and the State: The 1817–19 Fever Epidemic in Ireland Laurence M. Geary (University College Cork, Ireland)

“God help the poor! I often wonder why any of them who can afford it should remain in this land of poverty and misrule” (Dr William Stokes, Dublin, 17 September 1826, in William Stokes, William Stokes: His Life and Work, 1804–1878, London, 1898, 45)

Fever and fever hospitals in Ireland The great despoiling infections in eighteenth- and nineteenth-century Ireland were bacillary dysentery, Asiatic cholera, smallpox, tuberculosis and fever, a generic term that embraced typhus, relapsing fever, and enteric fever or typhoid. Fever had been endemic in Ireland for centuries, and had killed and terrified countless thousands. There were major fever epidemics in the years 1708–10, 1718–21, 1728–32, and 1740–41. Epidemic fever, dysentery and smallpox, propagated by hordes of wandering beggars, swept the country in the summer of 1740 and became even more virulent in the following year. One anonymous pamphleteer wrote that these three diseases “swept off multitudes of all sorts; whole villages were laid waste by want and sickness and death in various shapes; and scarce an house in the whole island escaped from tears and mourning”.1 Estimates of the mortality from starvation and famine-related diseases in the years 1740–41 vary from 80,000 to five times that number. Demographers and

1

The Groans of Ireland in a Letter to a Member of Parliament (Dublin, 1741), quoted in Michael Drake, “The Irish Demographic Crisis of 1740–41”, in T. W. Moody, ed., Historical Studies VI (London: Routledge & Keegan Paul, 1968), p. 103; F. Barker and J. Cheyne, An Account of the Rise, Progress and Decline of the Fever Lately Epidemical in Ireland, Together with Communications from Physicians in the Provinces, and Various Official Documents (Dublin: Hodges and McArthur, 2 vols., 1821), vol. 1, pp. 1–7; John Rutty, A Chronological History of the Weather and Seasons, and of the Prevailing Diseases in Dublin (London: Robinson & Roberts, 1770), pp. 82–3.

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historians now lean towards the upper reaches, suggesting that between 300,000 and 400,000 people died during the two years of crisis. In relative terms, the famine of 1740–41 was at least as severe and probably more so than the Great Famine a century later.2 There were further outbreaks of fever in the mid-1740s, in 1762 and 1771, while a major epidemic between 1797 and 1802 was at its most virulent in 1800 and 1801. Fever spread among civilians and troops in the wake of the 1798 Rebellion. Climatic extremes, deficient and poor-quality harvests, and rapidly rising food prices exacerbated the situation. The state of the poor in the principal towns in Ireland at the turn of the nineteenth century was said to be “wretched in the extreme”.3 Their situation became even more desperate in the immediate post-Napoleonic years, when war time buoyancy was followed by a severe economic depression, a downturn that was accompanied by the most extensive fever epidemic that occurred in Ireland between the great famines of the 1740s and the 1840s. Between 1817 and 1819 as many as 1,500,000 Irish people may have contracted the disease. The organisms that cause fever were not identified until early in the twentieth century, but it was generally conceded from a much earlier period that hunger, poverty, dirt and overcrowding were predisposing factors.4 The Irish people had an unrivalled knowledge of fever, its symptoms and its consequences. They were empirically aware that the disease was contagious, and fear of infection drove them to quarantine the sick. It is impossible to say when the practice began, but it was firmly established by the opening decades of the nineteenth century. The so-called “fever huts” in which the sick were placed were probably a variation of the “scailps” or “scalpeens” that gave refuge and shelter to evicted tenants and other homeless people. These shelters consisted of a

2

Drake, “Irish demographic crisis”, pp. 101–124; David Dickson, “The Gap in Famines: A Useful Myth”, in E. Margaret Crawford, ed., Famine: the Irish Experience, 900-1900. Subsistence Crises and Famines in Ireland (Edinburgh: John Donald, 1989), pp. 97–8; David Dickson, Arctic Ireland. The Extraordinary Story of the Great Frost and Forgotten Famine of 1740–41 (Belfast, 1997).

3

Barker and Cheyne, Fever, vol. 1, pp. 7–17.

4

Anne Hardy, “Relapsing Fever”, and Victoria A. Harden, “Typhus, Epidemic”, in Kenneth F. Kiple, ed., The Cambridge World History of Human Disease (Cambridge University Press, 1993), pp. 967–970, 1080–4; William A.R. Thomson, ed., Black’s Medical Dictionary (London: Adam & Charles Black, 34th ed., 1984), pp. 758–9, 920; William P. MacArthur, “Medical History of the Famine”, in R. Dudley Edwards and T. Desmond Williams, eds., The Great Famine: Studies in Irish History, 1845–1852 (Dublin: Browne and Nolan, 1956; reprinted Lilliput Press, 1994), pp. 265–8.

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Medicine, Philanthropy and the State: the 1817–19 Fever Epidemic in Ireland

few stakes, covered with long sods called scraws and a small portion of straw or rushes.5 These wretched structures were hastily thrown together, at the side of a road, the corner of a field, or the verge of a bog. The middle and upper classes, whose housing and resources were superior to those of the poor, attempted to isolate the infected within their homes. A common practice appears to have been that described by a Castlecomer, County Kilkenny doctor in 1844. He reported that when fever appeared in the homes of “comfortable farmers”, the door of “the sick room” was “built up with sods, and a hole made in the back wall, through which the doctor must scramble in the best way he can upon all fours into an apartment which is almost invariably dirty, dark and damp”. He added that such contortions were generally fruitless, as domestic segregation did little to check the spread of disease.6 Popular attempts to address and mitigate the impact of fever were paralleled by institutional ones. Fever hospitals, for the more effective isolation of the infected, were opened in Dublin, Cork, Waterford, Belfast and Limerick under special acts of parliament in the late-eighteenth and early-nineteenth centuries. These institutions in the main urban centres were complemented by county, district and workhouse fever hospitals, which were established following legislation in 1807, 1818 and 1843. The workhouse fever hospitals derived their financial support from local taxation; the others were either partially or wholly dependent on philanthropy for their funding. The motives for establishing and supporting fever hospitals and other medical facilities for the sick poor were complex. Some individuals were prompted by the precepts of their religion, to discharge the biblical injunction to heal the sick. For others, philanthropy, idealism or social concern provided the impulse. Medical charity conferred moral and other intangible benefits on the sick poor, and if intervention of this type prevented individuals and their families from sinking into pauperism, such assistance strengthened and promoted the legitimate and desirable concepts of independence, pride and respectability among the poor. For the more worldly, fever’s ability to leap class and social barriers was a powerful motivating factor in establishing institutions where the infected could be isolated and treated. The enabling of medical relief to the poor helped to protect the persons, families and financial interests of the

5

See, for instance, Reports and Returns Relating to Evictions in the Kilrush Union, British Parliamentary Papers (Hereafter BPP), 1849 [1089] xlix. 315, pp. 47–8, 144.

6

Dublin Medical Press, 22 May 1844, p. 325.

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middle and upper classes. William Disney, a prominent social activist in early nineteenth-century Dublin, claimed that fever hospitals were established when society realized that the health of the poor was the security of the rich. In Disney’s words, “motives of self-preservation and public policy operated to enforce the suggestions of benevolence”.7 Similar sentiments were expressed by others who shared Disney’s social background. For instance, in the 1840s, the governors of one Dublin voluntary hospital argued that it was “no less prudential than incumbent on the rich to support institutions for the relief of the destitute sick”, observing that infectious diseases “invaded with fatal impartiality the hovel of the beggar and the mansion of the opulent”.8 In the late-eighteenth and early-nineteenth centuries laissez faire ideology dictated minimal state intervention in economic and social affairs, in addressing either poverty or disease. Successive Irish governments viewed their social role as essentially paternalistic, to encourage and complement self-help and private endeavour rather than subvert or supersede them. It was only when philanthropy and local initiative proved inadequate that central government tended to intervene. The official approach to public health in Ireland was reactive rather than preventive, and owed little to a clearly defined or coherent policy.9

The 1817–19 fever epidemic and the government response The winter of 1815–16 was unusually prolonged, and was followed by a cold, wet summer, which resulted in a very late and depleted grain harvest. The quality of the corn that was saved was very poor, as was the straw used for bedding. Potatoes were small and wet. Turf could not be harvested because of the incessant rain and the shortage of fuel resulted in imperfectly cooked food, damp clothing and bedding, inadequately ventilated rooms, and a deterioration in personal and domestic hygiene.

7

William Disney, “Extract from an Account of the House of Recovery, or Fever Hospital, in Cork Street, Dublin', in Seventh Number of the Report of the Society for Promoting the Comforts of the Poor (Dublin: Wm Watson & Son, 1805), pp. 1–3; A Report upon Certain Charitable Establishments in the City of Dublin, (Dublin, 1809), pp. 49–51.

8

Thirteenth Report of the City of Dublin Hospital, Upper Baggot Street, for the Year 1845, with a List of the Subscribers etc. (Dublin, 1846), p. 9.

9

Gerard O'Brien, “'State Intervention and the Medical Relief of the Irish Poor, 1787–1850”, in Greta Jones and Elizabeth Malcolm, eds., Medicine, Disease and the State in Ireland, 1650–1940 (Cork University Press, 1999), pp. 195–207; T.P. O'Neill, “Fever and Public Health in Pre-Famine Ireland', Journal of the Royal Society of Antiquaries of Ireland, 103 (1973), pp. 7–8, 25.

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Similar climatic conditions, with the same distressing consequences, prevailed in the following year. The hardship caused by inclement weather and poor harvests was compounded by the bankruptcies, growing unemployment and falling wage rates that characterized the post-Napoleonic period. The price of potatoes, oatmeal and bread, the staples of the poor, increased alarmingly, particularly in Dublin. Almost inevitably, the age-old pattern of fever succeeding food shortage was repeated. The disease appeared epidemically in some places in late 1816 and was prevalent throughout Ireland by the spring of the following year, diffused to the country’s outermost reaches by multitudes of wandering beggars. In the early stages of the epidemic, it was left to private enterprise and charity to feed the hungry and to control the outbreak. Relief committees were established in Dublin and in the provinces, and the funds that were raised were used to purchase oatmeal and other provisions for sale to the poor at reduced rates. The steps that were taken in the Quaker village of Ballytore, County Kildare were typical of many local relief efforts. A residents’ committee circulated explanatory notices on the perceived causes of fever, and stressed the need for personal and domestic hygiene. The poor were advised not to admit beggars into their homes or to enter infected houses. They were discouraged from attending wakes and funerals, and those who had recovered from fever were recommended not to visit their neighbours’ houses or any place of public worship for fourteen days. The committee offered lime for whitewashing free of charge, sold windows to the poor at subsidized prices, and refused to employ individuals who did not keep their homes clean, whitewashed and ventilated, and the area in front of their doors free from dunghills and refuse heaps.10 Local efforts to suppress fever were probably more successful in small towns and villages than they were in larger centres. Dublin was a case in point. Only three of the city’s nineteen parishes – St Catherine’s, St Peter’s and St Thomas’s, with a combined population of about 46,000 – attempted to control the epidemic. In late January 1818 a committee was formed in St Peter’s parish to suppress the fever epidemic locally and to serve as a model for the other Dublin parishes. In a public appeal for funds, the committee emphasized that contributions to relieve the poor would lessen the danger from infection to which all classes were exposed. Almost £730 was subscribed within

10

Barker and Cheyne, Fever, vol. 2, pp. 148, 361–6. For the Baltinglass, County Wicklow, and Waterford relief efforts, see vol. 2, pp. 142–3, 326–60.

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the parish, and over a period of ten months advice and aid were proffered and various remedial measures undertaken. Houses were cleaned and whitewashed; more than 22,000 persons were supplied with food, many with clothing and bedding, and some 1,500 suits of clothes were washed and disinfected. The committee disbanded in sheer frustration in early December 1818, claiming that they had received no co-operation from the other Dublin parishes, and while their efforts had helped to relieve much distress and remedy much disease the epidemic had not abated in the parish.11 The lesson was clear, at least for densely populated urban areas. Ad hoc and local responses could at best alleviate distress and contain fever but the epidemic could only be suppressed by a centralized and concerted initiative. According to Dr William Harty, a Dublin medical practitioner with considerable professional experience of fever, St Peter’s was simply another example of the “futility and insufficiency of unconnected efforts for the subjugation of contagion in a large city”.12 Another commentator, writing from the south-west of Ireland, phrased it more colourfully: “While a board of health is attempting to bound its ravages in one quarter of the country, it is striding with seven league boots in another. What is woven one month is unwoven the next.” 13 It was not until the epidemic spread to Dublin at the beginning of September 1817, several months after its appearance in other parts of the country, that the government became actively involved in the crisis. It did so reluctantly and with considerable misgivings. Fever broke out in the north inner city, around Barrack Street and Church Street, an extremely depressed and deprived area that was characterized by overcrowding and high unemployment. Migrant labourers from Connaught and Ulster were blamed for the outbreak. On 3 September 1817 the governors of the Dublin House of Industry, or poorhouse, informed Robert Peel, the Irish Chief Secretary, that fifteen individuals suffering from fever had just been admitted to the fever hospital attached to

11

Ibid., pp. 314–25.

12

William Harty, An Historic Sketch of the Causes, Progress, Extent, and Mortality of the Contagious Fever Epidemic in Ireland during the Years 1817, 1818, and 1819: With Numerous Tables, Official Documents, and Private Communications, Illustrative of its General History and of the System of Management Adopted for its Suppression (Dublin: Hodges and McArthur, 1820), appendix xviii, pp. 88–109.

13

Philanthropus, A Letter to the Right Hon. Charles Grant, MP, Secretary for Ireland, Representing the Causes of the Alarming Increase of Contagious Fever, with the Outline of a Plan for its General Suppression, Not Hitherto Carried into Effect, by the Adoption of Which It is Presumed the Progress of Fever Would Not Only be Arrested but Finally Eradicated in the Country (Limerick, 2nd ed., 1819), p. v.

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the institution, and that this was probably the beginning of a severe epidemic in the city. Numbers increased rapidly during the following week and Peel arranged for additional fever accommodation in a number of the city’s hospitals. On 9 September the Irish administration requested the governors of the House of Industry to perform some of the functions of a board of health: to inspect, clean and disinfect the dwellings of the sick; to remove nuisances, a term that might be defined as offensive matter, ordure and refuse of every kind; and to ensure that there was adequate hospital accommodation to meet the crisis. The governors were instructed to implement these public health measures at minimum cost. They were to incur no more than “reasonable expense” in suppressing the epidemic and to limit assistance to areas where there was little likelihood of effective measures receiving local funding.14 As the epidemic progressed, it became increasingly clear that there were fundamental differences in the government’s policy towards Dublin and the rest of the country. In the capital, with the exception of isolated private relief efforts, like those in St Peter’s parish, the various measures that were adopted to tackle the epidemic were publicly funded, whereas the government was extremely niggardly in assisting similar initiatives in the provinces. The Chief Secretary’s response to appeals for aid was curmudgeonly and graceless. On 30 September 1817 Peel announced that state aid was limited to areas where it was both “necessary and expedient”, where fever was “still prevalent to an unusual extent”, and where local subscriptions had enabled hospitals to be opened or accommodation provided for the relief of the sick.15 However, the sheer scale of the epidemic forced the government to moderate its stance and to assist localities where there were no existing fever hospitals or dispensaries. The public response to government intervention appears to have been one of gratitude, certainly if the reaction of one provincial fever hospital committee was in any way representative. On 18 October 1817 Dr Charles Sughrue, Catholic Bishop of Ardfert and treasurer of the Killarney fever hospital in County Kerry, thanked Peel for his “charitable recommendation to the committee”, adding that the poor of the town and its neighbourhood were “extremely grateful” to him. Sughrue informed the Chief Secretary that “a more regular, peaceable and well conducted race of paupers does not

14

Barker and Cheyne, Fever, vol. 1, pp. 114–121, vol. 2, pp. 159–162.

15

Report from the Select Committee on the Contagious Fever in Ireland; with an Appendix, BPP 1818 (285) vii, p. 2.

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exist and their sense of gratitude to the government for its solicitude for their wants during this year of uncommon difficulties will be long remembered by them”.16 Visitations of disease, such as fever in the immediate post-Napoleonic years and Asiatic cholera in the early 1830s, were invariably marked by public excitement and popular panic in Ireland.17 The Catholic clergy and hierarchy, who ministered to the peasantry and the disadvantaged in Irish society, were concerned about the well-being of their flocks, and with the maintenance of law and order. In times of social crisis, the Catholic church acted in concert with the civil authorities, and the clergy used their office and their pulpits to preach the government’s public health message, to advise, admonish and warn, not least against the custom of extending hospitality and accommodation to beggars and vagrants, who were commonly regarded as responsible for spreading fever and other infectious diseases.18 Sughrue’s communication with the Chief Secretary was part of this general pattern, but it also reflects the public’s low expectation of official assistance, of government intervention in the lives and affairs of the governed.

The response of the medical profession Some medical practitioners applauded the government’s limited intervention, arguing that it was highly judicious, that it encouraged and promoted associations for the relief of the sick poor that would not have been established otherwise. They claimed that the most effective way to manage public monies was to limit state aid to those who had made private contributions, that it was wasteful to disburse public funds indiscriminately, and that such a policy stymied community endeavour.19 Other medical practitioners were far less complimentary. They characterized the government's response to the fever epidemic as tardy and inadequate, and suggested that official policy in relation to infectious disease was reactive rather than preventive. They blamed the government’s medical advisers, the Irish Medical Board, which consisted of the

16

OP 474/34, National Archives of Ireland, Dublin.

17

See particularly, Joseph Robins, The Miasma: Epidemic and Panic in Nineteenth-century Ireland (Dublin, 1995); S.J. Connolly, “The ‘blessed turf’: Cholera and Popular Panic in Ireland, June 1832”, Irish Historical Studies, 23 (1983), pp. 216–32.

18

Barker and Cheyne, Fever, vol. 1, pp. 63–4, 325–6, 371, 469, vol. 2, pp. 83, 142, 149–50.

19

Ibid., vol. 1, pp. 41–2, 111–112, vol. 2, pp. 195–6, 199–200, 207–212.

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Physician-General, the Surgeon-General, and the Director-General of Military Hospitals in Ireland, for such a policy, and claimed that the board’s thinking on public health issues was very much at variance with that of the majority of Dublin medical practitioners. The latter believed that the measures for dealing with the fever epidemic that had been recommended to the government up to the close of 1817 were inadequate, and that a much more interventionist approach was required. In late January 1818 a number of concerned doctors and other individuals responded to the perceived inadequacies of the official response to the epidemic by establishing the Association for the Suppression of Street Begging in Dublin, an organization that was generally known as the Mendicity Association.20 Mendicancy was commonly regarded as a primary factor in diffusing fever, and begging was described by Dr William Harty, a founding member of the association, as a disgrace and a serious threat to the population of Dublin. The practice had grown to what Harty described as “a monstrous and alarming height”, and required immediate and decisive measures for its suppression. At the Mendicity Association’s first public meeting, Harty provided a highly-charged but far from exaggerated account of the privations of the city’s poor, which, he said, were directly responsible for generating and spreading disease. He attributed the occurrence of fever and other epidemic diseases in Dublin to the lack of personal and domestic hygiene among the poor. Harty expounded on the circular nature of poverty and illness, one of the recurring themes of contemporary medical discourse. He and many of his medical colleagues argued that fever and other communicable illnesses could not be eliminated until mendicancy and vagrancy were suppressed. As these conditions arose from pauperism, which was primarily caused by unemployment or under-employment, the question of poverty had to be addressed as a priority. Improvements in this area would combat the spread of disease, would “cut up contagion by the roots”, to use Harty's expressive phrase, and would result in the elimination of “a most prolific source of pauperism in this densely inhabited city”.21

20

For this association, see Audrey Woods, Dublin Outsiders. A history of the Mendicity Institution, 1818–1998 (Dublin: A & A Farmar, 1998). For the London Mendicity Society, which was formally launched on 5 January 1818, and for earlier societies in Bath, Oxford, Edinburgh and Colchester for suppressing vagrancy and street begging, see M. R. D. Roberts, “Reshaping the Gift Relationship. The London Mendicity Society and the Suppression of Begging in England, 1818-1869”, International Review of Social History, 36 (1991), pp 201–31.

21

Harty, An Historic Sketch of the ...Contagious Fever Epidemic in Ireland, pp. 51–2, appendix, pp. 122–5.

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One of the first acts of the Mendicity Association was to appoint four Dublin doctors as a sub-committee of health, with the following objectives: to improve and preserve the health of the poor; to prevent the further dissemination of contagious fever and as far as possible to eradicate its causes; to afford medical and surgical aid in cases of noncommunicable diseases; and to indicate the best ways of assisting the sick and their families during the epidemic. Harty’s hand was discernible in the sub-committee’s first report, which was submitted on 14 February 1818. The essence of the document was the close link between poverty and disease. According to the sub-committee, pauperism was one of the main agents in promoting disease, while there was not “a more prolific source of pauperism, wretchedness and mendicity than disease”.22 This was another expression of the widespread belief that in pre-Famine Ireland dearth and disease were closely related, and that one could not be adequately addressed without the other. Such a disregard for the sacrosanct precepts of political economy was too radical for many and the report attracted much unfavourable comment. The Mendicity Association’s sub-committee of health submitted a second report on 28 February 1818, in which they acknowledged the provision of 100 additional fever beds at government expense at Sir Patrick Dun’s Hospital, but added that “this extraordinary and formidable emergency” could not be checked unless preventive as well as remedial measures were adopted. They called for further hospital accommodation, as isolation of the sick was regarded as the most important factor in containing the disease, and they recommended an extensive programme of public health measures to improve personal and domestic hygiene, and to promote municipal cleanliness.23 In early March 1818 the city’s medical practitioners agreed to cooperate in implementing these measures. In a written submission to William Gregory, the UnderSecretary at Dublin Castle, they argued that the epidemic was “propagated by contagion, and diffused among the poor from cold, wet, bad clothing, bad provisions, filth, want of employment, and consequent despondency”, and the outbreak could only be checked by implementing the recommendations put forward by the Mendicity

22

Ibid., pp. 1–5.

23

Ibid, pp. 9–20.

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Association’s sub-committee of health. The medical practitioners thought that the epidemic was unlikely to subside for at least another year, and that it would not be arrested by the mere reception of the infected into hospitals but had to be tackled at source. This could only be accomplished by addressing the economic and social conditions of the poor. They repeated their willingness to work voluntarily, but pointed out that cooperation between the government and the people of Dublin was essential to combat the epidemic.24 This document was referred to the government's medical advisers, the triumvirate who constituted the Irish Medical Board, and they recommended that the government should provide additional fever hospital beds. This increased provision, in tandem with state-financed initiatives at the House of Industry and the voluntary efforts of individuals in different parts in the city, would, they believed, be sufficient to check the progress of fever among the Dublin poor “until it shall please God to remove the scourge”. The board concluded that the epidemic was waning, except in Dublin, where it would continue for some time because of the circumstances of the poor, many of whom had relapsed into fever on returning from hospital to their “wretched habitations, from the want of fuel, of food, and of clothing”. The board recommended that public funds should not be provided to finance the additional preventive measures proposed by the Mendicity Association’s sub-committee of health and supported by the capital’s medical practitioners. They believed that such a programme could only be accomplished “by a combination of vigilance and economy”, such as might be achieved in the administration of private funds, but which was likely to fail if the exertions of individuals were supported from “the resources of the state”.25 The government accepted the board’s advice and Gregory’s response to the city’s medical practitioners, although couched in the elaborate diplomatic language of the time, was an uncompromising rejection of their professional expertise and their offer of assistance. The Under-Secretary asserted that the measures sanctioned by the government were adequate to stop the progress of contagion, and he was not prepared to take any further action. He added that many of the medical practitioners’ recommendations on domestic inspection, hospitalization of the infected, cleansing and fumigation had already been implemented. In a final rebuff, Gregory stated that the

24

Ibid., pp. 25–34.

25

Ibid., pp. 49–53; Report from the Select Committee on the Contagious Fever in Ireland, pp. 11–12.

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Lord Lieutenant, the chief governor of Ireland, could not “connect himself” in any way with the Mendicity Association.26 The medical practitioners believed that etiquette and professional dignity precluded them from making any formal response to Gregory’s statement, although they disagreed with most of it. At a meeting on 25 March 1818 they acknowledged the liberality, benevolence and paternalism of the government, and the initiatives taken to combat the epidemic, but repeated their conviction that these measures were insufficient. The medical practitioners stated that the system of medical inspection and prevention that had been introduced was utterly inadequate, and dismissed the idea that the fever epidemic could be suppressed at parish level as “a fatal delusion”. They blamed the government’s medical advisers, rather than the government itself, for these hopelessly inadequate policies. The medical practitioners decided that the various reports of the Mendicity Association’s sub-committee of health and all existing correspondence should be submitted for publication in the press. They appointed a committee to monitor the progress of the fever epidemic and to convene the medical profession whenever it was thought necessary or convenient, and then adjourned their meeting sine die.27

Parliamentary committee of inquiry In early March 1818 Sir John Newport, MP for Waterford, gave notice of intent in the House of Commons to move for the appointment of a select committee to investigate the causes and progress of the fever epidemic in Ireland, to suggest preventive and remedial measures, and to secure adequate financial support for permanent and temporary fever hospitals. Peel, who seconded the motion, stated that medical reports from all parts of the country attributed the origins of the epidemic to “the great poverty of the labouring classes”. According to the Chief Secretary, several factors were responsible for spreading the disease, including insufficient and poor quality food, bad weather, fuel shortages, mendicancy, vagrancy, wakes and funerals. Peel agreed with Newport on the key role of unemployment, but, he said, “the removal of this cause was beyond the reach of any measure which the executive government could adopt”, and suggested that it would be wise to avoid all discussion on the subject. A similar abdicatory attitude to poverty and unemployment was apparent in government

26

Harty, An Historic Sketch of the ... Contagious Fever Epidemic in Ireland, appendix, pp. 35–8.

27

Ibid., pp. 39–48.

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contributions to the debate that took place in the following parliamentary session, when Newport moved for a revival of the fever committee. On this occasion, Charles Grant, Peel's successor as Irish Chief Secretary, stated that any permanent legislation to provide employment for the poor would be “nothing more than a delusion and could not be long attended with beneficial consequences”.28 The parliamentary select committee that was appointed in the wake of Newport’s motion recommended the continuation of state aid on the conditions outlined in the government’s directive on 30 September 1817, namely that government assistance should be limited to areas where fever was unusually prevalent and where hospitals had been opened or accommodation provided for the sick through local initiatives and subscriptions. The remainder of the committee’s recommendations were incorporated in legislation that was passed on 30 May 1818.29 The committee regarded the separation of the sick from the healthy as the first and most important step in checking contagion. To this end, the act empowered county grand juries to levy funds for the erection and support of district fever hospitals, where the infected could be compulsorily removed on the certificate of any medical practitioner. In addition, whenever fever or any other dangerous disease appeared epidemically, the inhabitants of any parish or district were authorized to appoint a temporary board of health, whose members were given extensive powers to remove nuisances, clean streets, lanes, yards and houses, fumigate and whitewash infected houses, clean or destroy infected beds and bedding, open windows and take any other ventilative measures they considered necessary. As a warning to the public, the act decreed the attachment of “some mark, number or token” to houses with fever-stricken occupants.30 The costs of these proceedings were to be

28

Hansard Parliamentary Debates, 38 (1818), pp. 285–91; 39 (1819), pp. 1427–32.

29

58 Geo. 111, c. 47, “An act to establish fever hospitals, and to make other regulations for relief of the suffering poor, and for preventing the increase of infectious fevers in Ireland”, 30 May 1818.

30

Report from the Select Committee on the Contagious Fever in Ireland, pp. 1–11; 58 Geo. 111, c. 47. Such symbolism was already customary in rural Ireland, although not in the large towns. “In the country,” according to a Munster commentator, “the poor are in the habit through a religious motive of drawing a large red cross upon their doors, either with tar or red paint, when any of the family are afflicted with fever, which answers as a sign to the passengers”, Philanthropus, A Letter to the Right Hon. Charles Grant, MP, Secretary for Ireland, p. 15.

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defrayed by a parochial rate.31 The expense involved and the extraordinary powers given to the boards of health provoked considerable public opposition to the measure.32 The members of the parliamentary select committee were anxious to address the circumstances that gave rise to epidemic fever and other diseases in Ireland. Their decision was influenced by reports submitted by medical practitioners from different parts of the country on the scarcity and poor quality of the food of the poor, fuel shortages, low levels of hygiene, unemployment, and widespread apathy and despondency. The committee concluded that epidemic fever would continue to be a feature of Irish society as long as these conditions prevailed. The country’s crippling poverty, attributable mainly to the rapidly expanding population and stagnancy in the labour market, had to be addressed before fever could be eliminated. The committee wished to pursue a more extensive inquiry into the connection between poverty and fever in Ireland, “with a view to discover adequate means for their radical and effectual removal, as far as may be practicable”. However, the members were compelled to defer any further investigation because of the anticipated prorogation of Parliament. Before disbanding, the committee sought to impress upon government the necessity for additional aid to combat fever in the provinces, where costs had been privately borne, unlike Dublin, where most of the expense had been met from the public purse.33 On 3 August 1818 Charles Grant replaced Peel as Irish Chief Secretary, and one of the first acts of the new administration was to request a report from Dr George Renny, Director-General of Military Hospitals in Ireland and one of the members of the Irish Medical Board, on the extent of fever in Dublin. Grant may have been influenced by a statement published after a meeting of Dublin medical practitioners on 20 August, in which they referred to the inadequacy, inefficiency and expense of the government’s relief measures. The medical men argued that the latter were remedial rather than preventive and would not eliminate fever. They believed that the epidemic could only be suppressed by implementing the proposals put forward by the Mendicity

31

59 Geo. 111, c. 41, “An act to establish regulations for preventing contagious diseases in Ireland”, 14 June 1819.

32

Barker and Cheyne, Fever, vol. 1, p. 113.

33

Second Report from the Select Committee on the Contagious Fever in Ireland, BPP 1818 (359) vii, pp. 15–16.

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Association’s sub-committee of health in the previous February.34 Their observations were corroborated by Renny’s report, which disclosed a steady increase in the disease and in the number of admissions to the city’s hospitals during the previous year. On 8 October 1818 Grant requested the medical staff of the different fever hospitals in Dublin to consider Renny’s report and to suggest appropriate action. Most of the respondents were critical of the measures funded by government. There was general agreement that epidemic fever was spread by contagion and could only be curbed by isolating the infected. To this end, adequate hospital accommodation was required. Once the infected were hospitalized, a thorough system of cleaning their persons, clothing and homes was needed to destroy the infection at source. The fever hospital staff also recommended the exclusion of country fever patients from the city’s hospitals, an improved water supply for the poor, the removal of nuisances, the suppression of wakes, the incineration of old straw beds, a prohibition on the sale of rags, the distribution of clothes and clean bedding to the poor, and support for the Mendicity Association. In effect, they proposed a more efficient and extensive implementation of the measures in force since the beginning of the epidemic.35 In late November 1818 the Chief Secretary established a central committee of health, consisting of one governor and one physician from each of the city’s fever hospitals, to coordinate the various efforts to suppress the epidemic. He ordered the establishment of a soup kitchen in each fever hospital and the provision of “a competent allowance of nutritious food” to convalescent outpatients for a specified number of days. Grant recommended that each of these institutions should appoint temporary medical inspectors to assist in the early detection and removal of fever patients to hospital. Finally, he urged the governors to consider “further measures for cleansing the persons, clothing and bedding of the poor”, similar to those that had been beneficially introduced in some parts of the city at moderate expense.36 At the first meeting of the central committee of health in late December 1818 the number of medical inspectors was increased from four to thirteen, and they were

34

Harty, An Historic Sketch of the ... Contagious Fever Epidemic in Ireland, appendix xi, pp. 66–71.

35

Barker and Cheyne, Fever, vol. 1, pp. 123–5, vol. 2, pp. 240–280; Harty, An Historic Sketch of the ... Contagious Fever Epidemic in Ireland, appendix xv, p. 83, 139–153.

36

Barker and Cheyne, Fever, vol. 1, p. 126, vol. 2, pp. 300–2; Harty, An Historic Sketch of the ... Contagious Fever Epidemic in Ireland, appendix xvi, pp. 84–6.

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instructed to procure “every information on the extent and nature of the prevailing epidemic”. The central committee collected and tabulated weekly reports from the different fever hospitals, and orchestrated the removal of nuisances. “Thus,” according to Francis Barker and John Cheyne in their history of the epidemic, “a system of medical police, well adapted to existing circumstances, was established within the city of Dublin, supported by proper authority, and in every respect calculated to give full effect to such measures as were suggested by observation and experience.” Despite these efforts, fever continued to spread, in Dublin and elsewhere, and it was decided to carry out a general inspection of the whole country to ascertain the extent of the epidemic.37 On 12 February 1819 the government appointed Francis Barker, John Crampton, James Clarke and John Cheyne to conduct a medical inspection of Munster, Connaught, Ulster and Leinster respectively. After a five-week investigation, the inspectors concluded that fever was declining, especially in Connaught and Ulster. The only places where the disease continued to exist to any considerable extent were Cork, Waterford and Limerick in Munster; Belfast, Randalstown and Lisburn in Ulster; and Dublin, the towns of Wexford and Wicklow, and parts of Carlow and Queen’s County (now County Laois) in Leinster. These returns were laid before Parliament by Chief Secretary Grant, and were published on 17 May 1819 as an appendix to the report of the parliamentary select committee on the state of disease and the condition of the labouring poor in Ireland. This committee, which had been disbanded on the prorogation of the previous Parliament, was revived on 6 April 1819 on the motion of Sir John Newport.38 The committee recommended the appointment of unpaid officers of health throughout the country, with powers to remove nuisances, enforce regular street cleaning, ventilate and fumigate houses where fever had occurred, and to wash and purify the persons and clothing of the fever-stricken. These recommendations were given legislative effect on 14 June 1819, by which time the epidemic was waning.39 In its report, the committee described epidemic fever as “that most calamitous indication of general distress in Ireland”, and claimed that the disease could only be controlled by improving the condition of the labouring poor, by providing them in effect

37

Barker and Cheyne, Fever, vol. 1, pp. 126–8, vol. 2, pp. 302–6.

38

First Report from the Select Committee on the State of Disease, and Condition of the Labouring Poor, in Ireland, BPP 1819 (314) viii. 365; Barker and Cheyne, Fever, vol. 1. pp. 128–9, vol. 2, pp. 1–193.

39

59 Geo. 111, c. 41.

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with “useful and productive” employment. The members wished to give further consideration to the practicality of deploying private funds for this purpose.40 However, they were frustrated by the brick wall of doctrinaire political economy and were forced to concede that on the question of providing employment for the poor they were largely “controlled by the unquestionable principle that legislative interference in the operations of human industry is as much as possible to be avoided”. 41

The aftermath of the 1817–19 fever epidemic Barker and Cheyne argued that the mortality arising from the 1817–19 fever epidemic was proportionally less than that associated with previous epidemics in Ireland, a situation they attributed to private benevolence and government relief measures. In particular, they said, the establishment of a nation-wide network of fever hospitals was of “incalculable benefit” in stemming contagion. Undoubtedly, the steps that were taken helped to contain and eventually suppress the epidemic, but the relative diminution in mortality over previous epidemics may have been due to a preponderance of relapsing fever rather than the more deadly typhus, or to the presence of a less virulent strain of the latter. Barker and Cheyne claimed that the benefits of isolating the infected in fever hospitals, and the necessity for personal and domestic hygiene and disinfection had been further demonstrated during the epidemic. They believed that a spirit of benevolence had been fostered and that the different social classes had been drawn more closely together “by acts of charity on the one side and by gratitude on the other”. In accordance with the prevailing doctrine of political economy, they concluded that these developments would “probably lay a foundation for such improvement both in their moral and physical condition, as shall not only benefit the people of Ireland, but add to the resources and prosperity of the [British] empire”. 42 Barker and Cheyne’s hugely optimistic analysis was refuted by the political, religious, economic and social developments of the next thirty years, years that were marked by recurring subsistence crises and fever epidemics in Ireland. There were

40

First Report from the Select Committee on the State of Disease, and Condition of the Labouring Poor, in Ireland, pp. 4–7; Barker and Cheyne, Fever, vol. 2, pp. 5–8.

41

Second Report from the Select Committee on the State of Disease, and Condition of the Labouring Poor, in Ireland, BPP 1819 (409) viii, p. 95.

42

Barker and Cheyne, Fever, vol. 1., pp. 144–6.

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serious outbreaks of disease in the south and west of the country in 1821–22, in Dublin in 1826–27, and in many parts of the country in the late 1830s and early 1840s. The tenacity of fever in Ireland in the decades leading up to the Great Famine, and the deleterious impact of the disease on the lives of the poor, indicate that the desire of the Mendicity Association’s sub-committee of health to improve and preserve the health of the poor and to eradicate the causes of fever in Ireland remained aspirational. The government’s response to the 1817–19 fever epidemic, and to subsequent disease outbreaks, was dilatory, parsimonious and inadequate. Political ideology and the husbanding of public resources were more important than alleviating suffering and saving lives. The 1817–19 fever epidemic did bequeath some tangible benefits, as Barker and Cheyne suggest, including a provision for the establishment of district fever hospitals, and public health legislation that strengthened the hands of the civil authorities whenever epidemics recurred. Medical practitioners shared the fears and broad social concerns of the middle and upper classes in relation to epidemic fever, and they had a professional interest in acquiring a better understanding of the nature, course and treatment of a disease that had affected the country for generations. The medical profession’s unprecedented engagement with fever and with public health issues generally during these years resulted in two substantial surveys of the epidemic, by Francis Barker and John Cheyne, and by William Harty.43 These significant social and medical documents are likely to have contributed to the ongoing and pressing debate on poverty and its relief in Ireland that was conducted during the 1820s and 1830s, a debate that culminated in the introduction of the controversial poor law system in 1838. The 1817–19 fever epidemic triggered the government’s first major involvement in the area of Irish public health, one that was marked by the formation of the General Board of Health in March 1820. The board’s function was to advise the government on epidemic disease and on public health generally. The immediate task was to conduct a national inquiry into the living conditions and living standards of the poor, and their impact on the people's health.44 The establishment of the General Board of Health as a permanent body and the tasks assigned to it indicate a growing awareness of public

43

See footnotes 1 and 12 above.

44

Barker and Cheyne, Fever, vol. 2, pp. 374–7; First Report of the General Board of Health in the City of Dublin (Dublin, 1822), pp. 1–4; O'Neill, “Fever and Public Health in Pre-Famine Ireland”, pp. 8–13.

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health on the part of government and a desire for information. However, there was little real policy change. Crucially, ideological constraints ensured that the underlying problems of poverty and unemployment were not adequately addressed, which meant, on past experience, that epidemic fever would almost certainly recur. When it did, the conservatism of the General Board of Health ensured that the advice offered to government was for remedial rather than preventive action. The fourteen members of the General Board of Health included several well-known philanthropists and public benefactors, as well as a number of prominent medical practitioners, among them the three members of the Irish Medical Board, the government’s former advisory body on health matters.45 Their influence, in tandem with the prevailing laissez faire doctrines, ensured minimal change in public health policy in the post 1817–19 epidemic years, a policy that was exposed during the 1832 Asiatic cholera epidemic, and critically so during the Great Famine, when general starvation and opportunistic diseases decimated the Irish population. Their influence, in tandem with the prevailing laissez faire doctrines, ensured minimal change in public health policy in the post 1817–19 epidemic years, a policy that was exposed during the 1832 Asiatic cholera epidemic, and critically so during the Great Famine, when general starvation and opportunistic diseases decimated the Irish population.

45

The medical members of the board were John Cheyne, Francis Barker, Robert Perceval, George Renny and Philip Crampton. The remaining nine members were Samuel Bewley, Thomas Crosthwaite, William Disney, William Harding, Rev. James Horner, Francis Lear, John Leland Maquay, John David La Touche, Peter La Touche.

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The Introduction of a School Health Service in Stuttgart, 1904 Sylvelyn Hähner-Rombach (Robert Bosch Foundation, Germany)

In the current discussion about the financing of health care and health politics in general the question of private or public, informal or formal institutions for health services has become increasingly significant. Research into the social history of medicine is no exception to this development and has analysed, for example, the development of private or informal institutions and their relationship to public health services. The establishment of school health services was, along with infant welfare (and later the control of tuberculosis), one of the first preventive health care measures in urban and other communities dating from the end of the nineteenth century.1 Very often the initiative for this care came from private individuals or charity organizations. This was

1

For the establishment of infant welfare see for example Edward Ross Dickinson, The Politics of German Child Welfare. From the Empire to the Federal Public, Cambridge, Mass. 1996; Adelheid zu CastellRüdenhausen, Die Bekämpfung der Tuberkulose und der Säuglingssterblichkeit zwischen Reichsgründung und Inflation unter besonderer Berücksichtigung Preußens (1871–1924), Habil. Bochum 1987; Richard A. Meckel, Save the Babies. American Public Health Reform and the Prevention of Infant Mortality 1850–1929, Baltimore 1990; Lara Marks, Metropolitan Maternity: Maternal and Infant Welfare Services in Early Twentieth Century London, Amsterdam 1996; Dominique Dessertine, La Société Lyonnaise pour le Sauvetage de l’Enfance (1890–1960), Toulouse 1990. For the introduction of school medical service in England and Wales see John Woodward, “The School Medical Officer before the School Medical Service: England and Wales, 1850–1908” in John Woodward and Robert Jütte (eds.) Coping with Sickness. Historical Aspects of Health Care in an European Perspective, Sheffield 1995, 121–146. For British Columbia see Mona Gleason, “Race, Class, and Health: School Medical Inspection and ‘Healthy’ Children in British Columbia, 1890–1930” in Canadian Bulletin of Medical History 19 (2002), 95–112.

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The Introduction of a School Health Service in Stuttgart, 1904

the case in Stuttgart, where the so-called “committee for holiday colonies”2 can be seen as a precursor of public care for pupils. After a short overview of the development of private charity organizations in the last third of the nineteenth century in Germany, this paper deals with the role and character of a private and informal society that took care of schoolchildren in Stuttgart. The paper then looks at the relationship between this informal institution and the later official school health service in the capital of Württemberg.

The structure of private charity organizations in the last third of the nineteenth century From the middle of the nineteenth century civil society strengthened initiatives in founding private charity organizations, most of them devoted to childcare. The internal motivation for this involvement can be seen as fear of the working class, especially after the riots of the Vormärz and the Revolution of 1848/49.3 In 1863 Ferdinand Lassalle founded the first Socialist Labour Party (Allgemeiner Deutscher Arbeiterverein – ADAV) in Leipzig. In 1869 the ADVA united with another existing Socialist movement, the Sozialdemokratische Arbeiterpartei (Social Democratic Labour Party), and in 1875 all existing Socialist movements were united in the Sozialistische Arbeiterpartei – SAP (Socialistic Labour Party). The influence of these organizations within the working class was considerable, indeed enough to cause immanent fear of the Socialist movement. But the fear of the middle and upper classes was not the only reason for taking care of the so-called “social question”. A pragmatic approach was accompanied by the Christian or philanthropic claims of the initiators of private charity organizations. A large part of these initiators were women of the bourgeoisie who now had a field of duty that was respectable and deserving.4 This female presence may have

2

The original name was Comité für Ferienkolonien armer kränklicher Schulkinder in Stuttgart.

3

See for example Ute Frevert, Krankheit als politisches Problem 1770–1880 (=Kritische Studien zur Geschichtswissenschaft 62) Göttingen 1984.

4

For the Anglo-American research see for example Linda Gordon (ed.), Women, the State, and Welfare, Madison, Wisconsin 1990; Jonathan Barry and Colin Jones (eds.), Medicine and Charity before the Welfare State, London, New York 1992. For Germany, especially Berlin, see Meinolf Nitsch, Private Wohltätigkeitsvereine im Kaiserreich. Die praktische Umsetzung der bürgerlichen Sozialreform in Berlin (=Veröffentlichungen der Historischen Kommission zu Berlin, 98) Berlin, New York 1999. For France see Jean-Luc Marais, Histoire du don en France de 1800 à 1939. Dons et legs charitables, pieux et philanthropiques, Rennes 1999.

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Sylvelyn Hähner-Rombach

contributed to the concentration on children of every age (babies, infants, schoolchildren) and on women who were pregnant or about to give birth. Generally speaking, it was the reproductive sphere of the working class that became one of the important focuses of private middle-class charity. This choice of target group was supported by the penetration of the middle class with ideas relating to social hygiene (such as tuberculosis control, sanitary housing conditions, etc.), which became more and more public.5 In Berlin, for example, during the German Empire there existed around 800–900 societies of private welfare, of which 61 were societies for the care, supervision and education of children, 153 for school and apprenticeship, and 111 societies for sick people and women in childbed (altogether almost a third of the whole number). Meinolf Nitsch came to the conclusion that “some hundred” private charity societies were engaged in the reproductive sphere of the working- or under-class (in addition to comparably large numbers in other fields like housing or loans).6 As children were seen as innocent victims of unchangeable social circumstances (or of their neglectful parents) it was easier to take care of them than of, say, prisoners and to find some understanding for this necessity within the middle and upper classes.

The Committee for Holiday Colonies The model for the organization in Stuttgart was probably the Zurich committee for holiday colonies, founded in 1876 by pastor Walter Bion. The Stuttgart committee regarded him as the first person to connect healthy and pedagogical objects with these holiday colonies.7 Among the first ensuing foundations were those in Frankfurt/Main and Stuttgart, followed by Dresden, Chemnitz, Berlin (1880)8, Barmen (1881), Leipzig

5

For the development of social hygiene in the Weimar Republic see for example Heinrich Weder, Sozialhygiene und pragmatische Gesundheitspolitik in der Weimarer Republik am Beispiel des Sozialund Gewerbehygienikers Benno Chajes (1880-1938), Husum 2000.

6

Nitsch, Private Wohltätigkeitsvereine..., 4f.

7

This opinion was right. The only reference to Walter Bion we have is in the report of the committee of the year 1936 by the chairman. For the Zurich committee see Walter Bion, Zum XXjährigen Bestand der Ferienkolonien. Entstehung und Entwicklung derselben. Bericht von Zürich 1895, Zürich 1898; Walter Bion, Die Ferienkolonien und verwandte Bestrebungen auf dem Gebiete der Kinder-Gesundheitspflege, Zürich 1901.

8

For the Berlin organization see also Nitsch (cit. above), 130–136.

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(1890), Hamburg (1904), Hannover and Breslau.9 In November 1881 there was a conference in Berlin on holiday colonies, where 24 committees of the German Empire were already represented.10 A year later committees for holiday colonies had already been established in 31 German cities. In February 1879 the medical practitioner Dr Albert Sigel initiated the foundation of the Stuttgart committee, which already began to establish the first colonies in the summer of the same year. The aim of the committee was to grant a stay in the countryside for children between 10 and 14 years who were poor and weak and who had a good moral record. The journey and the stay of between three and four weeks in the summer holiday colony were free; parents only had to provide sufficient clothes and shoes, which always posed a problem. The number of members of the society was rather small: between 14 and 25 people.11 Until the year 1919 all members were male.12 One part of them consisted of physicians and teachers – the two groups that were professionally involved in health care and the school system respectively. The other members were mostly businessmen, academics and individuals who lived from private means. The committee asked the royal house of Württemberg, several ministries13 and the biggest private charity organization of Württemberg, “Zentralleitung des Wohltätigkeitsvereins”,14 for

9

See Bericht des Comités für Ferienkolonien armer kränklicher Schulkinder in Stuttgart. Erstattet für 1880. Stuttgart 1881, 3.

10

See Bericht des Comités für Ferienkolonien armer kränklicher Schulkinder in Stuttgart vom Jahr 1881, Stuttgart 1882, 3.

11

The structure of the committee changed over the years. At the beginning the committee called the active persons “committee-members”. Later, when their number increased, the committee – which then was called “society” (German: Verein) – had a board of directors, then a chairmen, a deputy and the so-called commission (German: Ausschuß).

12

The first female member of the commission was a welfare worker of the public health office who was among other things responsible for the school health service.

13

The Ministry of Culture gave money, the Ministry of War hired out beds to the committee, the Ministry for Transport gave free tickets for the journey to the holiday colonies.

14

The Zentralleitung des Wohltätigkeitsvereins was founded in 1816 on the initiative of Queen Katharina of Württemberg. In the beginning this institution took care of all cases of needs in general like the consequences of floods, hail, fire and famine. From the middle of the nineteenth century the members founded schools for children in which they learned how to work and took care of sick and poor people. For its history see Gerhard Ihme, “Von der Zentralleitung des Wohltätigkeitsvereins zum Landeswohlfahrtsamt für Baden-Württemberg” in Blätter der Wohlfahrtspflege 114 (1967), 28–66.

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patronage and money, which they received to a limited degree. More than 50 percent of the committee’s income came from private individuals, around 43 percent from the city council and national authorities, and slightly more than 2 percent from the royal family.15 In 1886, the committee published for the first time the names and professions of their donors: 830 had a similar social background to the members, among them around 22 percent women.16 The holiday colonies were quite small. Table 1 gives an overview of the quantitative development. The number of children who came to the holiday colonies was quite small: in 29 years altogether around 10,500, on average around 360 children per year. The number of recommendations (17,133 in all,17 on average around 685 pupils per year) was always much higher than the number of admissions. The committee could only afford to send a part of the recommended pupils to the holiday colonies. To be able to increase their number, the committee started in 1886 to establish holiday colonies in Stuttgart besides the ones in the countryside. The holiday colonies in the city only offered bed and board in the morning and in the afternoon. At noon the children went home where they were supposed to be provided with lunch (which was very often not the case) and slept at home. The holiday colonies in Stuttgart were thus cheaper than the ones in the countryside, where full bed and board was granted. The first attempt at a holiday colony in Stuttgart in 1886 was abandoned as the children had gained less than one kilogram in weight during their stay, and it was one of the most important aims of the holiday colonies to help the children gain weight. Three years later they tried again to somehow increase the number of children taken care of during the holidays. However, it took some time before the colonies in the city were accepted by parents and children and in the end it was only the offer of food which made them attractive.

15

In 1908: 420 marks from the royal house (2.3%), 7,800 marks (43.5%) from the city council and national authorities, and 9,700 marks (54.2%) from private persons.

16

See Bericht des Komites für Ferienkolonien armer, kränklicher Schulkinder in Stuttgart. Jahrgang 1886. Stuttgart 1887, 12–18.

17

With the exception of four years for which we have no indication.

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Table 1: Number of participants of the holiday colonies between 1879 and 1907 Year

1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 Sum

Number of recommended pupils Total 200 251 287 315 325

Male 160

497 585 670 740 566 762 706 774 696 719 793 697 727 679 656

217 242 360

850 987 1005 1311 1335 17,133

413 488 523 668 685 4,291

196

339

Number of pupils who were Number of pupils who were sent to the holiday colonies sent to the holiday colonies in Stuttgart in the countryside

Female Total 40 55 100 100 119 120 144 144 169 168 280 168 343 210 310 225 233 264 264 309 320 334 339 316 314 320 317 317 320 365 437 368 499 368 482 369 643 420 650 379 4,120 7522

Male 44 55 55 60 72 72 73 72 72 90 120 129 127 132 158 161 167 172 155 160 159 160 161 183 183 183 183 208 180 3,563

Female 11 45 45 60 72 72 93 96 96 120 105 104 133 132 151 159 167 167 161 154 161 157 159 182 185 185 186 212 199 3,769

Total

Male

Female

64

34

30

100 131 153 155 154 163 154 162 167 164 162 161 163

50 63 67 75 75 96 83 84 89 78 77 79 73

50 68 145 80 79 67 71 78 78 86 85 82 85

184 171 174 198 200 2980

90 87 89 103 117 1,509

94 84 85 95 83 1,525

(Source: Annuals of the Comités für Ferienkolonien between 1879 and 1907.18)

18

As the indications were not complete each year, we have some gaps in the table.

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The girls were under-represented only in the early years. This was due to the presumption of the committee that parents were not prepared to send their daughters to the colonies. When the committee recognized that this was an error, over the years more girls were recommended and more girls came to the colonies (in all 5,294) than boys (in all 5,072). The children who were chosen for the colonies were only a very small part of all schoolchildren in Stuttgart. In 1882, for example, out of 9,060 pupils 120 were sent to a holiday colony, which represents around 1.3 percent. Although their number increased slightly over the years, the children selected always constituted an absolute minority. The recommendations for the colonies were made by teachers.19 This meant that the children were selected individually. The teachers had to look for pupils who were poor, weak and – something which became more and more important – decent. In the first years the order of conditions for children to be accepted was weak physical condition, a poor family and decent behaviour on the part of the child. In 1883 this scheme changed. Now the moral record took priority, second came the poverty of the parents (which had to be proved by the municipal poor relief fund) and third the weakness or (noninfectious) illness of the pupil. Those children recommended had to go to a physician who worked for the committee and who picked out the weakest.20 From the very beginning of the holiday colonies the committee made it clear that beside the weak condition of the children their “diligence and decent behaviour” was decisive for selection. Although the committee regularly declared that almost all those children recommended were very needy, financial means were too limited to send more pupils to the colonies. But the members of the committee obviously did not take further active steps to collect money than “discreetly” asking people in their own social environment or waiting for donations. They never carried out a general collection, for example,

19

The suggestions came from different types of schools (elementary and different secondary schools) whereas when the pupils’ health care came to the public health office in the first years only pupils of elementary schools came under observation.

20

The categories for the physicians were among others the weight of the child and the chest measurement. And the increase of both after the holiday colony was the “proof” of the success. At the end of each annual report there are tables with weight and chest measurement of the children before and after the stay differentiated according to sex and age with average calculations.

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because – as they declared in their annuals – they did not want to affect older charitable organizations.21 In the early years they mentioned the prejudice they had to fight against. The opponents of the holiday colonies put forward two arguments: first, that in the long run it would not really help to send these children for 25 days of holidays, and second, that these children would have difficulties in reintegrating themselves in their old family and social circumstances after the holidays. Unfortunately the committee do not mention anything about the people who were behind these critics so that we do not know the background of such opponents. The committee’s response was to stress, in the first place, the claim of humanity and the gratefulness of the children. Then they emphasised the modesty of the stay in terms of the choice of locality (far away from any city), the simple lodging and the nonluxurious – but sufficient – food. In addition to this, they stressed the educational influence on working-class children, which should not be underestimated. On the one hand, they tried to train the children to adopt middle-class values in hygiene, nutrition and behaviour. In this respect, they kept an eye on regular washing and brushing of teeth, cleaning shoes and clothes, mending clothes (girls), manner of speaking, three times daily prayers, etc. The hope was that the children – or at least some of them – would “teach” their parents (and the rest of the family) after their stay in the holiday colony to do the same. For that purpose the committee not only visited the children during their stay in the holiday colonies, they also tried to stay in contact with the children after the holiday colony to “supervise their manners and behaviour”.22 Furthermore, the schedule of the day was precisely regulated (getting up between half past six and seven o’clock in the morning, washing, cleaning clothes and shoes and praying before breakfast, etc.). The children had to obey accompanying staff to the letter and they had to eat everything put before them. Discipline was almost perfect, as absolute obedience was demanded.23 Children who were disobedient were sent home. As each accompanying teacher had to write a report of the children during their stay, the

21

See Bericht des Komites für Ferienkolonien armer, kränklicher Schulkinder in Stuttgart. Jahrgang 1884. Stuttgart 1885, 4.

22

Bericht des Comités für Ferienkolonien arme, kränklicher Schulkinder in Stuttgart. Jahrgang 1879, Stuttgart 1880, 10.

23

The German terms for the discipline were “Zucht” and “Ordnung”.

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committee had a further measure of control. Nevertheless the committee was not satisfied with some of the children with respect to their moral and social behaviour. To exclude so-called “worthless” children they tried to persuade the teachers to take a closer look at this aspect when they recommended children. The aim was to reject “vicious elements already at the selection”.24 Some girls were criticised for being vain and more interested in looking nice than being properly dressed. The poor domestic education of these girls was very often remarked upon. Eating habits caused further comments on the part of committee members. They could not understand that some children did not like to eat meat simply because they were not used to doing so. In 1882 the committee decided that the accompanying staff should not only write a general report of the stay, but also a moral certificate of each child after the stay. This moral record was handed over to the director of the school, who was given the power to intervene in the further development of the child. Soon the question came up of whether it would be better to send the children individually to the countryside (for example to a family, which could be cheaper) or in a group. But the committee came to the decision that the holiday colonies were more suitable for the pedagogical aims of the whole establishment. The two main aims were to show the children “how to pray and how to work”.25 Committee members could not imagine how continuous observation and education could be carried out when the children were placed individually. In addition to the holiday colonies, in 1903 the committee founded a recovery home for 40 children, which was opened thanks to a private donation in 1904. The home was intended for sick children who needed more care than they could get in their families. With this home the cooperation between the committee and other formal institutions, such as the largest sickness fund in Stuttgart and the Department of Poor Relief, began in a way that later led to their contributions for the maintenance of the home. This was the first time that the committee cooperated with other formal institutions.

24

Bericht des Komites für Ferienkolonien armer, kränklicher Schulkinder in Stuttgart. Jahrgang 1886, Stuttgart 1887, 5.

25

Zwölfter Bericht des Komites für Ferienkolonien armer kränklicher Schulkinder in Stuttgart. Jahrgang 1890, Stuttgart 1891, 6.

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Connections between the Committee for Holiday Colonies and the school health service The connection between the committee and the later school health service began through a series of personal connections between individuals. Since 1883 the physician Dr Alfred Gastpar had been one of the regular donors of the committee. In 1901 he became deputy town physician of Stuttgart and in 1903 a member of the board of the committee. In the same year he gave his expert opinion on the establishment of a public school health service in Stuttgart. Two years later, in 1905, he became the first town physician responsible also for the school health service, in 1914 he became deputy chairman of the committee, and in 1918 its chairman.

The establishment of a school health service in Stuttgart When in 1903 the city council asked Dr Gastpar to give his expert opinion on the establishment of a public school service, it was not the first time that representatives of the city had intervened in this area. In 1898 the city council had considered engaging a school medical officer.26 They asked the town physician Dr K. Knauss to give his expert opinion to that end. In 1900, Dr Knauss voted against having a special school medical officer, arguing that the town physician was responsible for school hygiene anyway. He mentioned the committee for holiday colonies and other charity organizations which already took care of needy children in ways that a medical school officer could not. For him the committee thus “replaced” further care for schoolchildren.27 But the city council was obviously not satisfied with this expert opinion. In 1902 the members again discussed the subject, decided to further pursue the idea and asked the

26

In Wiesbaden and Offenbach there were medical school officers from 1896/97, in Königsberg, Darmstadt, Heilbronn, Gießen and Leipzig from 1898, in Frankfurt/M. and Cannstatt from 1899. See K. Knauss, “Zur Schularztfrage in Stuttgart und Württemberg”, in Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 70 (1900), 45-54, here 46. Some other cities also started to think of that, for example Nuremberg planned in 1898 to engage school medical officers. See Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 68 (1898), 6. For the plan in Stuttgart see Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 68 (1898), 448.

27

K. Knauss, “Zur Schularztfrage in Stuttgart und Württemberg”, in Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 70 (1900), 45–54, here 49.

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organization of physicians in Württemberg, the Württembergischer ärztlicher Landesverein, to give an expert opinion.28 This association delivered their expert opinion two months later in June 1902. They voted for an extension of the duties of the school medical officer: not only the hygiene of the school buildings and of the class, but also the examination – not the medical treatment! – of all pupils and control of the weak and sick children, who should be sent to a medical practitioner.29 With this advice the organization not only showed its support of the novel and almost inevitable establishment of a new branch of public health care but also tried to make sure that its members could contact a new clientele. The organization further voted for a school medical officer who should be engaged by the city council (not a private physician) and who should be experienced and interested in developing good relations with the medical practitioners of the city. In October 1903, the city council decided to ask the successor of Dr Knauss, Dr Gastpar, for his expert opinion. He was ready to undertake the task but he demanded first the opportunity to examine all schoolchildren to see whether, and to what extent, a school medical service was necessary at all. The city council agreed and provided 10,000 Marks for the costs of the medical examination of the schoolchildren. In 1904, Dr Gastpar examined 10,100 children from all the elementary schools. In 944 cases the parents did not allow the examination (which was voluntary) and 478 children did not take part because they were ill or not at home.30 One of the results established was that only 15.7 percent of the examined children were completely healthy, and that 67 percent of the children had problems that would not have been identified without this medical examination. He therefore voted not only for the establishment of a school health service, but also for an extended one with sufficient means to enable the school medical officer to do something for the children.31

28

See Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 72 (1902), 259f.

29

See “Gutachten der von dem Stuttgarter ärztlichen Verein zur Bearbeitung der Schularztfrage eingesetzten Commission”, in Medicinisches Correspondenz-Blatt des Württembergischen ärztlichen Landesvereins 72 (1902), 469f.

30

See Gastpar, Gutachten über die Schularztfrage in Stuttgart zugleich Bericht über die informatorische Untersuchung der Schulkinder im Jahre 1904, Stuttgart 1904, 5.

31

This meant money for the medical treatment of children whose parents had no sickness fund for their children and who were too poor to pay for the physician.

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Gastpar also mentioned the committee for holiday colonies as one of a number of charity organizations in Stuttgart that did something for undernourished children. But he wanted to go beyond such limited assistance, for example to make sure that the child received medical treatment and not only a stay in a holiday colony once a year. And although he appreciated the work of the committee and other charity organizations he also stated that these organizations worked without any connection with one other and that the work could be more efficiently organized by one centre. The city council accepted his demands, and the public school health service with a wider range of measures than in other cities started its work in April 1905. For the first nine months the school medical officer received 10,000 marks for health care measures for the children. This meant paying for the costs of holiday colonies and a stay in a saltwater bath or in a recreation home. The models for these offers were the institutions of the committee, as Dr Gastpar pointed out in 1914.32 In contrast to the committee, Gastpar from the very beginning involved sickness funds and parents (when they were wealthy enough) in the financing of these measures.33 Two years later cooperation between the school medical officer and the committee began. In 1906 the city council started to pay the committee for the board and lodging of 250 or more children, chosen by Dr Gastpar. For the city council it was very convenient to use an already existing private organization, especially at the beginning of its school health service. The committee had the logistics, locations, accompanying staff and experience. Furthermore the people working for its administration did not get any salary. But soon the number of the pupils selected by the school health service became so big that the committee began to turn into something like an appendix – useful but not sufficient!34

32

See Gastpar, “Die schulhygienischen Einrichtungen Stuttgarts”, in Das Schulwesen der Stadt Stuttgart. Festschrift zur XIV. Jahresversammlung des Allgemeinen deutschen Vereins für Schulgesundheitspflege, Stuttgart 1914, 40–60, 40f.

33

In 1905 the sickness fund gave a subsidy of 1,750 marks, the parents paid 514 marks. See Gastpar, “Die schulhygienischen Einrichtungen Stuttgarts...”, 57.

34

The committee existed until the year 1936. On 28 February 1936 the committee dissolved itself with the explanation that its duties had been taken over by the National Socialist organizations Nationalsozialistische Volkswohlfahrt (National Socialist Public Welfare) and Hitlerjugend (Hitler Youth). See Der Stuttgarter Verein für Ferienkolonien 1879–1936, Stuttgart [1936], 3. Up to this year the committee made an annual contribution to the costs of the holiday colonies.

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Table 2: Number of children examined and chosen by the school health service for medical welfare measures between 1906 and 191435 Year

Examined children

Sent to saltwater bath

Sent to the society at the expense of the city

Sent by the society to colonies in the countryside

Sent by the society to colonies in Stuttgart

Sent to the recovery home

1906 1907 1908 1909 1910 1911 1912 1913 1914

1,454 12,817 9,788 13,718 14,325 14,833 15,560 16,577 38,428

560 732 734 828 867 954 922 918 around 950

250 200 195 ? ? ? ? ? ?

420 579 577 579 580 579 579 582 ?

198 200 213 201 236 207 212 252 ?

380 500 400 488 505 489 514 451 around 400

In the last five years (1909–1913) before the First World War the medical school service examined more than 13,000 pupils each year (on average around 17,700), a much greater number than that achieved in the early days of the committee.36 Between 1906 and 1913 the school health service sent around 2,000 children each year to healthcare activities such as holiday colonies and saltwater baths. This meant around 10 percent of all children.37 The annual contribution of the city council in the early years was 25,000 marks and gradually increased. In addition to this money Dr Gastpar broadened his arrangement with the largest sickness fund to include other, larger sickness funds in Stuttgart and later with the social insurance board of Württemberg, who also contributed to the costs of these preventive health care measures. In the first years of medical examinations for children the school medical officer had the support of some assistants from the public health office; in 1910 the city engaged a

35

In 1914 the Great War started; all public and private healthcare organizations worked only at a reduced level. All data from the table are out of the annual Medizinsch-statistischer Jahresbericht der Stadt Stuttgart 1906 to 1913, published in Stuttgart.

36

The physicians working for the committee examined in the first years around 250, between 1890 and 1900 around 710, later on around 1,100 children per year.

37

See Gastpar, “Die schulhygienischen Einrichtungen Stuttgart...”, 41.

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school nurse and three years later a second school nurse who also visited the children at home. In 1907, from Monday to Saturday the city started to offer a daily breakfast (warm milk and bread) at school for needy children that cost the city between 40,000 and 50,000 marks each year.38 Out of 17,600 schoolchildren, around 2,200 took advantage of this offer. For poor children the breakfast was free but others had to pay a part of the costs. In 1909 the city established a dental clinic for schoolchildren as it was claimed by the school medical officer that the teeth of the majority of the children were in bad condition. The money provided by the city council for saltwater baths and holiday colonies increased in 1914 to 28,000 marks. The biggest sickness fund in Stuttgart, the Allgemeine Ortskrankenkasse, provided a subsidy for this purpose of 20,000 marks; parents paid 5,000 marks.39 In all, 53,000 marks were put at the disposal of the school medical officer. The committee had a much smaller amount at its disposal; in 1890, for example, they had an income of around 16,500 marks, with expenses of around 16,000 marks.40 The amount of the expenses for health care measures and the increasing number of pupils who were examined and sent on health care activities were not the only change in private care provided by the committee. Now, for the first time, the city authorities had quite exact figures about the state of health of pupils in Stuttgart. One outcome of this information was the subsequent provision of money for healthcare measures. Furthermore, the school health service extended the medical examination and observed children’s development. Another difference in principle was how children were chosen. There is no remark in the records of the town physician that he or his colleagues applied moral standards when they decided what constituted a needy child. The crucial aspects were state of health, poverty and the cooperation of the parents. As the offers of the school health service came from a public institution, it sometimes was easier for parents to accept it.

38

Ibid., 41.

39

Ibid., 57. To get an impression of the municipal budget: the total expenditures were in 1902 14.7 million marks, in 1913 43.7 million marks. See Paul Sauer, Das Werden einer Großstadt. Stuttgart zwischen Reichsgründung und Erstem Weltkrieg 1871 bis 1914, Tübingen 1988, 120.

40

See Zwölfter Bericht des Komites für Ferienkolonien armer kränklicher Schulkinder in Stuttgart. Jahrgang 1890, Stuttgart 1891, 14.

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Furthermore, some working-class people did not like having to accept anything from a private charity and they did not like being forced to say “Thank you”.41 The relationship between the committee and working-class people was already characterized by deep mistrust. Before the children’s departure to the colony they had to present themselves several times before the committee to show their equipment and clothes. If something was missing – which was very often the case – the parents were always suspected of trying to exploit the committee, especially when the clothes and shoes of the children were in such bad condition that the committee had to look for better quality replacements. This suspicion on the part of committee members continued although, normally, insufficient clothes and shoes were replaced by used clothes of donors to the committee. This shows that the committee did not spend money on buying new things. Parents were thus suspected of trying to get used clothes for their children for free. The school medical officer did not have so many problems with parents – at least to begin with. For example in 1914 only four parents asserted their right to refuse the undressing of their daughters. Two parents complained about the procedure, a problem that was quickly resolved.42 When parents were not present at the medical examination, the school medical officer sent them a note when it turned out that the children needed medical treatment. In 1914 there were 3,502 notes, representing 9.1 percent of all children examined. In 976 of these 3,502 cases in which the school medical officer asked the parents to consult him, 83 percent of the parents accepted his invitation.43 The only problems he regularly complained about were the percentage of the children who appeared at the medical examination, which was voluntary until the year 1912,44 and the reluctance of some parents to send their children to holiday colonies or saltwater baths.

41

The same observation can be made in the tuberculosis control. As long as private charity in form of the already mentioned Zentralleitung für Wohltätigkeit was responsible for the tuberculosis control in Württemberg (1910–1918), patients of the working class tried to hide their illness, or they did not like to have contact with the members of the charity organizations. See Sylvelyn Hähner-Rombach, Sozialgeschichte der Tuberkulose vom Kaiserreich bis zum Ende des Zweiten Weltkriegs unter besonderer Berücksichtigung Württembergs, Stuttgart 2000.

42

See Gastpar, “Die schulhygienischen Einrichtungen Stuttgarts...”, 44.

43

Ibid., 56.

44

The so-called Oberamtsarztgesetz of 12 July 1912 regulated the medical school service in Württemberg, too. From now on the medical examination was not longer voluntary.

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To get an impression of the varied reactions of the parents we can look at the year 1907. Out of around 10,000 pupils 2,215, slightly more than a fifth, were chosen for a saltwater bath or a holiday colony. Their parents got a letter from the school medical officer with a questionnaire and the message that their child should take part in a health care activity. The reactions of the parents were as follows: • The parents were ready to file an application in 1,714 cases (around 77.4 percent). • The parents did not think that a stay in the countryside was necessary and could not be persuaded of the opposite in 361 cases (16.3 percent). • The parents told the school medical officer that their child would spend the holidays at the countryside anyway in 94 cases (around 4.2 percent). • The families moved house without giving the new address in 15 cases (around 0.7 percent). • The parents claimed that they were ill themselves and they needed their children for help in 11 cases (around 0.5 percent). • The parents claimed that they needed their child for work in 8 cases (around 0.4 percent).45 • The parents asked for a postponement in 7 cases (around 0.3 percent). • The parents claimed that at the time in question their child was bedridden and could not travel in 4 cases (around 0.2 percent). • The parents said it would be too expensive in one case. Out of the 1,714 parents who agreed to a health activity for their child, 1,509 received financial support (around 88 percent). Out of these, 77 did not appear on the day of departure, so that altogether 1,432 children went to a saltwater bath or a holiday colony.46 To sum up, around 77.4 percent were willing to sent their child to the suggested healthcare activity, 16.3 percent of the parents rejected the necessity of such a measure and around 0.9 percent could not do without their child. In the end, around 65 percent of all children who received a recommendation for a healthcare measure actually undertook it. But as the school medical officer declared in 1907, the statement of health

45

In the first medical examination of schoolchildren in 1904, out of 10,100 children 2,028 children were working in addition to attending school and 4,000 children were working in the household of the parents. See Gastpar, Gutachten über die Schularztfrage in Stuttgart..., 64.

46

See Medizinisch-statistischer Jahres-Bericht über die Stadt Stuttgart vom Jahre 1907, Stuttgart 1908, 28f.

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damages and the possibility of sending children for healthcare measures was not adequate. More important seemed to be the constant observation of sick children. For that purpose the officer also visited the children at home.47 In 1911 the school medical officer observed that around 25 percent of all schoolchildren did not appear for medical examination at school. One reason for this was – in his opinion – that the school health service was not regulated by law: it was still voluntary.48 The non-appearance of a somewhat large contingent of pupils did not change much in the following years, although from 1912 a law regulated the medical school service. From 1908 to 1913 between 74 and 78.3 percent of the pupils appeared at medical examinations. The percentage of boys was always higher than the percentage of girls (1908: 79.2% boys, 70% girls, 1909: 82% boys, 72.2% girls, 1910: 83.3% boys, 71.5 % girls, 1911: 84.4% boys, 71.3% girls).49 The school medical officer presumed that some of the parents did not approve of their daughters coming to undress for a medical examination. But when the children came to the examination (which took place during lessons) the majority of the parents did follow his medical advice, especially to bring their child to the physician, as the school medical officer noted with satisfaction in 1915.50 Besides the school medical service, the healthcare measures, the school breakfast offered by the city and the recovery home for sick children, the city council established in 1907 a medical welfare centre for tubercular patients that took care of children especially. Within a year the medical examination of schoolchildren was extended to schoolchildren from secondary schools, and later to vocational schools. In comparison with other German cities Stuttgart did quite a lot for its schoolchildren and was prepared to spend money to that end. As the records of the council have not been handed down preserved we do not know whether the care of schoolchildren was a matter spanning all parties or whether it was the concern of a special political fraction. But we do know that discussions about the expenses for childcare were not especially strained. The reason might be that the first medical examination of the schoolchildren made clear that

47

Ibid., 30f.

48

See Die Verwaltung der Stadt Stuttgart im Jahre 1911. Stadtarchiv Stuttgart Bestand Depot A Sign. BX 10 Bd. 6 Nr. 12.

49

See Medizinisch-statistischer Jahresbericht über die Stadt Stuttgart 1908 to 1913.

50

See Medizinisch-statistischer Jahresbericht über die Stadt Stuttgart vom Jahre 1914, Stuttgart 1915, 27.

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84.3 percent of them had health problems, a truly alarming figure that nobody had anticipated.51

Summary It was a private organization that “found” a new desideratum for health measures. The committee for holiday colonies thus, very early on, provided an important impulse for the care of schoolchildren. Furthermore the committee developed a useful form of this offer of health care. In addition, not only was the committee the first institution in Stuttgart to create holiday colonies and a recovery home for children, but it also became the model for a lot of other holiday colonies in the city. These were founded later, on an individual basis and maintained by different organizations such as the Catholic and Protestant churches, the Social Democratic Party, and the city council. Some of them are still in existence today and have not lost their attraction for children and their parents. It was quite often in character with the nature of informal organizations maintained by private charities that they took care of social matters nobody did before. But normally their care was limited and characterized by some special restrictions. The committee’s definition of needy children was often linked to the moral behaviour of the beneficiaries. In other words, the grant of a place in the holiday colony was something like a moral premium for decent children and their parents. This aspect of the benefit could lead to some reticence on the part of working-class people, who did not like being controlled and patronised by the middle and upper classes. It is often mentioned that one reason for taking care of male schoolchildren was to secure the military fitness of the next generation. I would certainly not say that this statement is wrong in general, but in the case of the Stuttgart committee the limitation of its measures implied that military fitness was no motivation for this initiative. Such considerations only make sense when the measures include a much bigger part of the male youth, as was the case when the city council undertook the task of the school medical service.52

51

See Gastpar, Gutachten über die Schularztfrage in Stuttgart..., 20.

52

In the records of the city council we cannot find any remark about the military fitness of the male youth having to be improved. But as Susanne Hahn has pointed out, this consideration was – though also unspoken – the basic motivation of the national support of the establishment of school medical service. This consideration was so to speak in the air. See Susanne Hahn, “Militärischer Einflüsse auf die

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In any case, the work of the committee probably contributed to the rather early establishment of a public school health service in Stuttgart in 1904 as at least one model for possible care measures. Step by step, the school health service took over the tasks of the committee. First it made use of the committee’s offer and sent children at the expense of the city council to the holiday colonies. Then the school health service decided which children should take part in the holiday colonies and later the saltwater baths. Finally the whole organization of the holiday colonies fell into its hands. With this takeover the provision of care for schoolchildren became more extended, professional, reliable, acceptable and therefore more effective. The need for a school health service began to be regarded as something like common sense; voices against the demand that the health of pupils should be under regular observation fell silent. The activities of the committee are an example for the development of new demands or needs for healthcare measures that were initiated by a private or informal organization and later taken over, institutionalized and enlarged by a public institution. In this way the Stuttgart example is more than a particular case and might act as a startingpoint for further comparative studies.

Entwicklung der Schulhygiene im Kaiserlichen Deutschland, 1871–1918”, in “Medizin für den Staat – Medizin für den Krieg”. Aspekte zwischen 1914 und 1945. (Abhandlungen zur Geschichte der Medizin und Naturwissenschaften, 69), Husum 1994, 18–34.

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The Development of School Health Services in Austria Martina Gamper (University of Vienna, Austria)

To write an article about the history of school hygiene in Austria means more than just analysing the development of the profession “school doctor”. It is rather a discussion of pupil’s health and the ways that were chosen to recover and support it in this particular period. In Austria a lot of new attitudes towards pupil’s health and actions adopted with regard to this matter derived from non-governmental societies or individuals. The importance of those measures has remained until today. Several school health services that have their roots in the initiatives of informal societies are still in use today. Therefore it is all the more interesting that to date there has been little research done into the development of school health services in Austria.1 In consequence, many questions concerning the history of “school hygiene”, such as relations between school doctors and teachers or the training of people who work in the school health services, are still open. This article, however, will focus on a rather more basic topic. It concerns the role of non-governmental institutions in school health services and, thereby, their relation to the state. Firstly, it has to be asked what kind of school health services were organized or discussed by informal institutions. As good examples of this the first extensive school health service in Austria and the special subject of school dentistry will be described. The analysis that follows attempts to outline general tendencies and similarities between

1

The last substantial work on the history of school dentistry, for instance, was written in 1942. See Grete Meuren, Die Schulzahnpflege in Wien. Vorgeschichte, Gründung und Entwicklung, Diss. Wien 1942.

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these areas. It will also be necessary to take a look at the motivation of an individual or an association in dealing with the health of pupils. Secondly, the role of the state in school health services needs to be analysed. What was its relation to these informal institutions and to the subject of school hygiene in general?

The changing connotation of the term “school hygiene” As pointed out in the introduction “school hygiene” today includes a variety of different arrangements for the benefit of children’s health. This concept of “school hygiene” has not always existed. In 1873 the Austrian Ministry of Education released for the first time a decree that school hygiene as its subject. This paper dealt mainly with the hygiene conditions of the school building itself.2 The function of the physician, who was in general a public health officer, was restricted to being a consultant with regard to questions concerning the sanitary situation of the schoolhouse. He was not responsible for the health of each child. In later edicts enacted by state ministries or the authorities of several provinces (“Kronländer”) this attitude towards school health basically remained. In general medics worked as “Schulärzte” (school doctors), which means they were in charge of the sanitary conditions of the school building. Apart from a few decrees no further steps in school health services were taken by the government for several decades.3 At the end of the nineteenth century a new approach to school health services is observable. In addition to the task mentioned before, physicians were required to be, primarily, “Schülerärzte” (pupils’ doctors). This means they had to take care of the health of each child. Besides a general medical examination made by a school doctor,

2

“Erlass des Ministeriums für Unterricht und Kultus vom 9. Juni 1873”, in E. Wiener, Die Schularztfrage in Österreich. SA Wiener klinische Wochenschrift (1903), No. 21, 22, 23, 24. 4.

3

The first school doctors paid by the state began to work in a very few “Lehrerbildungsanstalten” (schools for the education of teachers) in 1909/10. In 1923 general rules for practitioners working in state secondary schools were released for the first time. See “Erlaß des Ministeriums für Kultus und Unterricht vom 22. Oktober 1909”, Z. 21986, and “Erlaß des Bundesministeruims für Unterricht vom 1. April 1923”, Z. 5105.

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further initiatives regarding children’s health, such as school-dental services or hygiene instructions for teachers, parents and pupils, started to be taken into consideration.4 This new meaning of “school hygiene” was primarily discussed by informal organizations like the Österreichische Gesellschaft für Schulgesundheitspflege (Austrian Society for School Hygiene). They considered introducing specialists as school doctors or building school hygiene information offices for parents. Congresses and meetings organized by non-governmental societies like the Österreichische Gesellschaft für Kinderforschung (Austrian Society for Research on Children) built a forum for people involved in school hygiene. At these conventions they compared their experience of school health services, expressed their wishes for the future and wrote requests to officials.

The first extensive school health service Associations and individuals not only discussed the topic of school health services, but also initiated them. The first extensive school health service in Austria, for example, was introduced by Arthur Krupp, owner of the factory in Berndorf, a small town in Lower Austria. He was known for supporting its workers and their families in several ways. In 1866, for instance, he introduced general accident insurance.5 Around 1907 he planned to build a new schoolhouse for Berndorf. According to Dr. Carl Lämel, the long-time school doctor in Berndorf, Krupp contacted Prof. Theodor Escherich, who was at this time head of the university children’s clinic in Vienna. Together they created general outlines for the organization of school health services in Berndorf. As a result of these planned school health services a conference organized by the Österreichische Gesellschaft für Kinderforschung took place in 1908.6 At this meeting the results of the first medical examination of the Berndorfer school children in 1907/08 were presented. In addition, several physicians and school doctors presented

4

See Martina Gamper, Die Entwicklung des Schularztwesens in Österreich (Bundesministerium für Bildung, Wissenschaft und Kultur), Wien 2002, 30–46.

5

Peter Muschik, Berndorf. Spuren von Krupp und Kaiser, Berndorf 1990, 26. As a comparison the law for obligatory accident insurance passed in 1886/87.

6

Carl Lämel, Festschrift zu Feier des 25 jährigen Bestandes der neuen Schulen in Berndorf. Gewidmet ihrem Schöpfe und Begründer Sr. Exzellenz Dr. A. Krupp, 20f. The presentations and discussions can be found in T. Heller and Clemens v. Pirquet (eds.), Der Stand der Schularztfrage in Österreich. Wien 1908.

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their research in school hygiene and, of particular significance for the work in Berndorf, expressed their opinions about organizing good school health services. In 1908/9 a regular medical school service was established. All school children from six to fourteen years, including the boys from the school financed by Krupp, were medically examined every year. After their parents had filled out a questionnaire, the school doctor carried out a thorough examination. He not only measured and weighed the children, but also looked at their general constitution and examined them for posture deformities. Their parents received a letter about the results of this examination and a paper called “Kurze Gesundheitsregeln für Eltern nebst einigen Winken für Schulkinder” (“Advice on Healthy Ways of Living for Parents and Schoolchildren”). In general this practitioner did not treat the children. Instead, he referred them to other practitioners. Only for children from poorer families did he offer prescriptions.7 Not only a general practitioner but specialists were involved in the medical school services in Berndorf. A specially educated school dentist, an oculist and an ear, nose and throat specialist took care of the children. In contrast to the normal school doctor, they treated pupils. For this reason all these physicians had their own doctor’s practices in the newly constructed school. This new building also possessed school baths, where children could take a shower once a week. They got a shampoo, swimsuits, towels and hairbrushes for free. The reason for this special innovation was to teach children a clean, healthy way of life. The school doctor hoped that pupils would then transmit this attitude to their families.8 All these services were possible because Arthur Krupp bore the expenses. He also paid for the construction of the new school, which housed rooms for the school medical services, as well as the physicians’ wages. In addition, he financed necessary medical aids, such as glasses. According to Dr. Lämel this system was a role model for other school health services in Austria. In 1909 the Ministry of Education employed general practitioners as school doctors for a few “Lehrerbildungsanstalten”. In these schools physicians used the

7

Martina Gamper, Die Entwicklung des Schularztwesens, 10.

8

For a detailed description of school health services in Berndorf, see Carl Lämel, Schulneubauten und Schulärztlicher Dienst der Stadt Berndorf, Niederösterreich, Berndorf 1910.

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same forms for a medical examination as the doctor in Berndorf and consequently oriented themselves to this system.9

School dentistry In the history of the Austrian school health services, schoolchildren’s teeth have always played an important role. The reason often given for this is that childrens’ teeth were generally in a bad condition. The first examinations in Berndorf, for example, showed that only 21.3 percent of children had good teeth. This does not mean that those 21.3 percent were free of caries. 26 percent of the pupils had more than six teeth with caries.10 One explanation for this situation was a lack of knowledge with regard to basic dental care amongst the majority of the population. Another point was that children, like their parents, did not go to the dentist. According to dentists at this time, supporting school dentistry was not only important for achieving healthy children’s teeth, but also for improving their general state of health. Bad teeth could cause several further diseases, such as stomach illnesses. Dentists even established a link between tuberculosis and caries. Therefore school dentistry did not deal exclusively with dental problems and more importance was attached to this part of the school health services.11 Already by 1887, at the Congress of Hygiene and Demography in Vienna and in 1901, when a note was sent to the Prime Minister by the Presidents of Dentists’ Societies, the meaningfulness of school dental services was a matter for discussion.12 As no initiatives followed these discussions, the first systematically established school dental service was created in 1909. That year Arthur Krupp opened the first school dental clinics in the Habsburg monarchy. At this time the only school dental services

9

Carl Lämel, Einführung in den schulärztlichen Dienst, Wien 1922, 8.

10

Ibid., 8.

11

Zeitschrift für Stomatologie (1910), 95.

12

Austrian State Archive, AVA, Ministerium des Inneren, Ärztliches Personal in genere 1900/01, Z. 16316/1901. See also Ernst Jessen, “Zur Förderung der Zahnhygiene in Österreich-Ungarn. Ein Aufruf an die Collegen”, in Wiener zahnärztliches Monatsblatt (1901), 397–407.

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that existed in Austria were a few examinations and treatments of schoolchildren made by individual dentists or university clinics, sometimes at their own expense.13 That same year a Ständiges Internationales Komitee für öffentliche Mundhygiene was founded at the International Congress of Stomatology in Berlin. Within this committee it was decided to establish associations for school dentistry in several countries. The association’s purpose was to build school dental clinics with the support of communal and governmental authorities and to inform people about the importance of dental care.14 For this reason the Österreichische Gesellschaft für Zahnpflege in den Schulen (Austrian Society for Dental Care in Schools) was founded in Vienna in 1911. As well as dentists, officials from several ministries and teachers also got involved. They aimed at building school dental clinics, organizing popular scientific lectures and trying to found associations in other towns of the Habsburg empire. 15 In 1911 the Viennese association was able to open its first school dental clinic in a barracks of the Red Cross and run it at its own expense. In this dental clinic one dentist examined and treated pupils of a limited area in Vienna for free. In 1912 the association organized and built the first state-run school dental clinic in a boys’ orphanage in Vienna. After finishing its construction and organization, the director of the orphanage also took over responsibility for its running. By the beginning of the First World War the association was running three dental school clinics in Vienna.16 Another purpose of the Österreichische Gesellschaft für Zahnpflege in den Schulen was to educate people in effective dental care. One way of doing this was to teach children the principles of dental hygiene. The members of the association hoped that children would transmit their new attitude to hygiene to other people. Another possibility was to organize lectures for the general public. In these lectures a dentist

13

A resume of this situation can be found in Gabriel Wolf, “Schulzahnpflege”, in Österreichische Zeitschrift für Stomatologie (1911), 137–147, 144.

14

Zeitschrift für Stomatologie (1910), 95.

15

Österreichische Gesellschaft für Zahnpflege in den Schulen. I. Jahresbericht für das Vereinsjahr 1911. Wien 1911.

16

Österreichische Gesellschaft für Zahnpflege in den Schulen. III. Jahresbericht für das Vereinsjahr 1913. Wien 1914.

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talked about the basics of dental care, the structure of teeth and the detrimental effects that neglect of one’s teeth can cause.17 As mentioned above, one aim of the association was to establish local committees of the association in other towns of the Habsburg empire. One such committee was found in Baden, a small town in Lower Austria. In establishing this initiative, officials from the government played an important part. They tried to build and find funds for operating school dental clinics in this area. In 1913 they were able to open one clinic.18 The First World War caused serious, especially financial, problems for the association. One of the clinics had to be closed. After 1918 the financial situation did not improve and the two remaining clinics were taken over in 1922 by the city of Vienna. These clinics provided the basis for school dental care organized by the municipality of Vienna. In their management, the city remained faithful to the basic ideas of the non-governmental organization. Children were examined and treated and also taught effective dental care. Within a few years the municipality of Vienna had extended its system of school dentistry. In 1923 it had already built seven school dental clinics and by 1932 it was running 15 clinics.19 By this time Vienna had become known for its system of welfare for children. In addition to school dental clinics it provided several other services for pupils. One way of improving children’s health care was to organize children’s holiday camps. The Wiener Jugendhilfswerk, founded by the city of Vienna in 1922, arranged, with the help of some informal organizations, a number of holiday camps for schoolchildren. These vacations for children were either provided by the Wiener Jugendhilfswerk itself or by non-governmental organizations. The central committee, where there were members of several associations, representatives of the municipality, and officials from the government, developed some general guidelines. One rule was that the same amount of

17

An example of such a speech is presented by Gabriel Wolf, secretary of this associaion, in Österreichisches Sanitätswesen (1913), 877–881.

18

Österreichische Gesellschaft für Zahnpflege in den Schulen. II. Jahresbericht für das Vereinsjahr 1912, Wien 1913, 8. Österreichische Gesellschaft für Zahnpflege in den Schulen. III. Jahresbericht für das Vereinsjahr 1913. Wien 1914, 4. See also a small notice in Österreichische Zeitschrift für Stomatologie (1912), 23.

19

Erna Greiner, “Die Tätigkeit der Wiener Schulzahnkliniken im Jahr 1923”, in Blätter für die Wohlfahrtspflege (1924), 7. Erna Greiner, Stand der städtischen Schulzahnkliniken mit Ende des Schuljahres 1931/1932. Wien 1932, 1.

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money was paid per child and day to the associations. This was necessary, as each organization had a completely different religious and political background. According to this principle no particular society could be given preferential treatment. The financing of this initiative was shared between the city of Vienna (which paid one third), state associations and parents. 20

Non-governmental associations and the state A description of these school health services highlights a number of similarities and some general conclusions can be drawn. However, for an in-depth analysis of school health services provided by non-governmental associations, it is necessary to look at the state’s role and participation in this matter. As mentioned before, innovations in school medical services were discussed and organized by informal societies. This may have led to the impression that state institutions were not concerned about this subject from the outset, even though extended school health services could have improved the health of future citizens and therefore should have been a matter for the state. Already in 1901, when a note was sent to the Prime Minister, dentists were pointing out the connection between poor dental care and the general health of the population.21 Further contributions to research in this field, however, have led to a somewhat different conclusion. They make it clear that state authorities were often involved in the associations’ activities in one way or another. Firstly, it needs to be taken into account that representatives of state authorities were members of these associations. In the Österreichischen Gesellschaft für Zahnpflege in den Schulen, for example, officials from several state authorities were on the board of the committee. It is interesting to note that, in addition to a representative of the Ministry of Education, officials from the Ministry of Defence and Ministry of War were also involved in this organization.22 Dr. Wolf, the Secretary of this association, had an

20

See Karl Sablik, Julius Tandler. Mediziner und Sozialreformer, Wien 1983, 220. See also Städtewerk (ed.), with the official participation of the City of Vienna, Das neue Wien. Vol. II. Wien 1927, 410.

21

Austrian State Archive, AVA, Ministeruim des Inneren, Ärztliches Personal in genere 1900/01, Z. 16316/1901.

22

Österreichische Gesellschaft für Zahnpflege in den Schulen. I. Jahresbericht für das Vereinsjahr 1911, 5.

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explanation for this. He was of the opinion that the state should have an interest in schools’ dental service because it affected the “Hebung der Wehrkraft des Volkes” (rise in the military power of its people).23 Secondly, the financing of school health services needs to be considered. Some societies, like the Österreichische Gesellschaft für Zahnpflege in den Schulen and the Wiener Jugendhilfswerk, were supported financially by the state. In the case of school dental clinics the society received, besides financial aid from the municipality of Vienna, a subsidy from the state. In 1911 almost 50 percent of the annual costs, such as expenses for the clinics, were paid from this support.24 However, one should not forget that a large part of the necessary money was provided by individuals such as parents or, as mentioned above, factory owners like Arthur Krupp. A good example of this means of financing is an advertisement for the Österreichische Gesellschaft zur Zahnpflege in den Schulen in Arbeiterschut, a magazine published collectively by several health funds. In its call for support and new members the society used the same argumentation as mentioned before. It informed readers that 98 percent of children’s teeth had caries and that many people could not afford a dentist. It also pointed at the link between poor dental care and serious diseases. Such facts, it was felt, would motivate individuals to join the society or at least send a donation.25 This means of financing became difficult during the First World War and the postwar period. Subsidies were cut or individual supporters had financial problems. On account of these circumstances, societies and individuals were not able to keep up their school health services any longer. The Österreichische Gesellschaft für Zahnpflege in den Schulen had to close one of its clinics and the community of Vienna took over its management in 1922. Arthur Krupp also got into financial troubles with his factory and could no longer provide financial support for the school health services. As a result of these developments, the municipality of Berndorf took charge of medical services in schools. Due to the

23

See Gabriel Wolf, in Österreichisches Sanitätswesen (1913), 877–881, 883.

24

Österreichische Gesellschaft für Zahnpflege in den Schulen. I. Jahresbericht für das Vereinsjahr 1911, 10.

25

Der Arbeiterschutz (1911), 85.

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generally weak state of the economy in the 1920s and 1930s the community was forced to reduce its activities for schoolchildren.26 The end or gradual reduction of private associations’ activities in this sphere was not only due to financial difficulties. It also has to be kept in mind that the framework for social welfare changed after the First World War. In Vienna, for instance, an extensive new system of welfare was created by the municipality after the war. It established new amenities for children, such as public swimming pools. Conditions pertaining to informal welfare also changed. Firstly, the associations’ activities came partly under the control of state and local authorities. The municipality of Vienna, for instance, was able to regulate matters more effectively through the Wiener Jugendhilfswerk societies, organizing children’s holiday camps. Every child, for instance, needed a certificate to show that vacations were necessary for the improvement of its health. Evidence of this had to be provided by a school doctor, who was employed by the city. Therefore the municipality could influence the choice of participants in holiday camps.27 Secondly, as in the case of school dentistry, privately funded and organized school health services seemed to be in opposition to general trends in welfare at this time. Now their activities started to be provided or taken over by communities or the state. Nevertheless, the initiatives of informal organizations provided the basis or were role models for institutional school health services.

Why get involved with school health services? In the course of doing research on this topic, another question became obvious. What was the motivation of these informal institutions in getting involved with school hygiene and organizing activities? It has to be considered that most of this work was unpaid and connected with various difficulties, in particular looking for sponsors. It is rather complicated to find a clear answer and several possibilities exist. Philanthropy may be one explanation. The poor condition of children’s health and of

26

Carl Lämel, Festschrift zur Feier des 25 Jährigen Bestandes der neuen Schulen in Berndorf. Berndorf 1934, 23.

27

Städtewerk (ed.), with the official participation of the City of Vienna, Das neue Wien. Vol. II. Wien 1927, 410.

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teeth in special might be another reason for dealing with the development of school health services. This conclusion seems to be logical, as physicians were especially involved in the establishment of school health services. They were confronted with children’s problems in their daily work so they might have had the feeling that they had to do something about them. The Österreichische Gesellschaft zur Zahnpflege in den Schulen, for example, was initiated mainly by dentists. Nevertheless one also has to consider some of the more selfish reasons of people involved in school hygiene. When Arthur Krupp, the owner of the local factory in Berndorf, supported school health services, he might have been intending to influence the health of his future workers in a positive way. In the case of school dentists too a more self-interested reason can be established. As dentists at that time drew attention to the connection between dental care and a good general state of health, their profession gained in importance. They became responsible not only for children’s teeth, but also for the whole bodies of a future generation.

Conclusion In conclusion, one can state that private societies and individuals were somehow supported by the state and communities in their school hygiene activities. Nevertheless, it was up to non-governmental societies to start the initiative, build a structure and organize such activities. However, we still lack a clear answer as to why the state did not show more commitment in this matter. As with many other questions concerning the history of school health services in Austria, a question mark remains and further research is necessary.

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Section 2 Social Welfare Policy and Changes in the Health of the Population Presented by Jan Sundin

The papers from this session deal with examples of socio-economic and political changes that affect health, both historically and in today’s Europe. The society’s socioeconomic structure and the strength and willingness of its social winners to share their resources with vulnerable groups decide the nature, timing and speed of these processes. The paper on Sweden by Jan Sundin and Sam Willner and two from Portugal by Teresa Rodrigues Veigaand and Maria João Guardado Moreira and by Joaquim da Costa Leite illustrate how different groups and different countries got access to the negative and positive aspects of social transitions at different times. In Sweden, which was spared wars and collective violence after 1809, the authorities managed to implement a policy that reduced infant, child and middle-aged female mortality almost constantly after 1810, while the social and economic machinery was unable to bring down adult male mortality before the second half of the century. The same late progress was also documented for the survival rates of vulnerable illegitimate children. Although with winners and losers, the demographic transition started in Sweden by the beginning of the nineteenth century, and by 1900 life expectancy was significantly higher in Sweden than in Portugal. At the beginning of the nineteenth century this difference is not caused

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mainly by economic prosperity so much as by a climate less favourable for gastrointestinal diseases, the absence of wars, political problems and a less feudalized society. Economic prosperity, caused by good terms of trade in Scandinavia, was, on the other hand, probably the most important reason for Sweden’s successful performance towards the end of the century. In both Portugal and Sweden, industrialization, urbanization and migration caused health problems during the nineteenth century, especially among children, but this changed for the better after a couple of decades due to the improved sanitation of the cities and other reforms. The demographic transition started relatively late in Portugal, but during the twentieth century it entered on a successful path towards high expectancy of life, enhanced by economic growth and welfare policies. Petr Svobodný discusses the cholera epidemics during the eighteenth century and their effects on the medical and political systems in the Habsburg monarchy with special reference to the Bohemian situation. There as elsewhere, cholera became a “model disease” for efforts to understand and fight epidemics at that time. Svobodný shows how two major competing theories about the disease lead to different conclusions about ways to fight it, each leading to partly sensible recommendations, most of which were, however, often not capable of stopping the epidemics. The scientific conflicts were in many ways an obstacle to an efficient intervention by the authorities, illustrating the close relationship between scientific “truths” and political action. Environmental reforms, in this case especially to provide clean drinking water and an efficient system to get rid of dirt, was for a long time the most efficient instrument, supported by one of the theories, but given final prestige by Robert Koch’s discovery of the cholera agent. Even after Koch’s discovery, however, local political bodies were impressed to varying degrees by the need for reform, which is elegantly described by Richard Evans.1 By a couple of decades into the twentieth century, the “cleaning of the cities” that started on a large scale during the second half of the nineteenth century had changed the urban milieus from being “gateways to death” for infants and young children into forerunners enjoying lower mortality rates than rural areas in most parts of Europe. For adult males, however, the urban life has often continued to be more dangerous for their survival than living in the countryside, while the same phenomenon does not usually exist among women.

1

Richard Evans, Death in Hamburg: Society and politics in the cholera years, 1830–1910. Oxford: Clarendon Press 1987.

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Section 2 – Social Welfare Policy and Changes in the Health of the Population

Sam Willner’s analysis of regional mortality differentials among middle-aged men and women in twentieth century Sweden shows that certain geographical patterns are relatively consistent over time. They can, however, change as a result of profound socio-economic transitions. During the first decades of the twentieth century, the most discriminating variables turned out to be industrialization, urbanization and migration, factors that are strongly interrelated, creating unhealthy milieus and increasing inequalities between social groups during the initial phases. By the 1930s, the Swedish provincial data showed no such correlation and “unemployment” and “rates of dependency on social assistance” turned out to be the strongest potentially active factors to create shorter life expectancies. All the time, male excess mortality was the factor most strongly correlated with overall mortality and, in 1990–95 “single living” also turned out to predict higher mortality rates. For both men and women, poor relief and ishaemic heart disease were strongly correlated. This disease is hardly connected to absolute destitution but to psychosocial factors and certain lifestyles. Willner’s study shows that social equality is an important field for public health policy beneficial for the vulnerable parts of the population. It also demonstrates that social destitution does not have to be close to the line of survival: it occurs as a relative force even in a welfare society with safety nets far above the level of subsistence. Janos Sandor analyzes regional mortality differentials in Hungary during the last decades of the previous century. He finds that, although national mortality figures went down, the regional differences increased, especially in areas hit by structural change without a relative benefit from the new economy. These differences are especially found among causes of death that are sensitive to public health factors. Strokes were strongly linked to socio-economic status, which is confirmed in many other studies of different contexts. Sandor relates the general decrease of stroke mortality to improved medical technology, which was only available to the upper strata on the social scale, owing to their ability to purchase good health service. His argues that the restructured health care system, which demands the active participation of the people in prevention and in healthcare usage, created obstacles for the socially disadvantaged, vulnerable groups, while the advantageous persons could benefit. In this case, as in Sam Willner’s example from Sweden, we do not have to expect total destitution before these negative tendencies occur, which may give some ammunition to theories pointing at the impact of psycho-social stress on a number of health problems. Whatever the causes, the results suggest that any society must pay special attention to prevent or minimize potential negative effects of social change producing both winners and losers.

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The report on the present-day health situation and future strategies in the Basque Autonomous Community by Emma Sobremonte strongly indicates that economic growth can produce or be used for a healthier and longer life and expresses a belief in the ability of politics to define goals for improved health within a number of areas. It deals specifically with the problem of inequality in health outcome by social class and educational status and the need to give the whole population equal access to health services. The article identifies the mortality differences in the middle-aged population, particularly in cardiovascular diseases and external causes of death to the disadvantage of males. This phenomenon is widespread in many societies in time and space and one of the distinguishing patterns of rapidly changing societies. The particularly strong effect of the social gradient among men is also common in other cases mentioned above. The Basque Health Plan for the years 2002–2010 mentions as a specific goal improving the health of the most disadvantaged persons and diminishing social inequalities in health. Such a task must of course also involve a wide area of the social fabric with a better health system and information about high-risk lifestyles, including informed awareness of the deep-rooted processes that are reproducing the inequality factors and ideas on how to minimize this inequality. To sum up, during the nineteenth century medical knowledge concerning the causes of infectious diseases and public health interventions, especially on the local level, was able to reduce infant and child mortality in Western Europe. Industrialization, urbanization and migration caused health problems for the poorest part of the urban dwellers in uprooted communities with bad hygienic conditions. In the long run, however, this process proved to be positive, giving local communities and individuals the economic and social resources for improvement of the environment and their personal welfare. Political democracy and voluntary associations gave all citizens a new tool to influence their destinies and gave birth to the ideas and realization of the twentieth century welfare state. Hence, after a crisis with many losers during the nineteenth century, economic progress, medical science, social coherence and social policies joined together in a historically unique expansion of the standard of living and life expectancy. The narrowing of the mortality gap in European countries after the Second World War also embraced the Soviet Union and its satellites, at least until the 1970s. After that, life expectancy stagnated in present-day Russia and some other countries, a health crisis that became even more visible immediately after 1989. That lesson shows that an ever-increasing healthy life is not won once and for all: it has to be continually protected and reclaimed by sound economies and efficient social and health

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policies for all. A sound policy towards this goal must rest on the combined knowledge produced by medicine, the social sciences and the humanities. Ignoring the complexity of the problem leads to the risk of simplification and misdirected interventions or noninterventions.

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Health and Social Transitions: The Need for Comparative and Multidisciplinary Knowledge Jan Sundin and Sam Willner (University of Linköping, Sweden)

Introduction Serious health problems create psychological and material burdens for individuals, families and societies. Conversely, good health helps individuals to fulfil their goals in life and contributes to the wealth of an entire society. Most welfare societies invest about one-tenth of their budgets in curing disease and caring for the sick. They spend less than that to promote health and prevent disease (Porter 1999). One reason for this imbalance between prevention and cure is the complex relationship between social factors and health, which often makes it difficult to evaluate, or even estimate, the costs and benefits of public health policies. Yet policymaking and institutional structures greatly influence the well-being of populations and individuals, especially during periods of rapid social change. Economic development affects public health. There is a positive correlation between the prosperity of nations and social groups and health and high income and good education reduces the risks for almost all types of disease (Kawachi et al. 1999; Leon et al. 2001; Marmot et al. 1999). Large social differences do not only produce large differences in health, but may also have a negative impact on the health of those who are better off (Wilkinson 1996, 1 and 2). A healthy population, with low mortality among children and adults and a balanced age structure, is correlated with economic growth (Herzman and Siddiqi 2000; Lindh and Malmberg 1999 and 2000). All countries need to protect the health of their populations. Culture and politics influence the timing and speed of improvements in health. Gender – the culturally and socially constructed distinctions between female and male resources, rights and duties – causes striking differences in adult mortality, especially when marital status is taken into account. This story starts in nineteenth-century Sweden and ends with a discussion

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Health and Social Transitions: The Need for Comparative and Multidisciplinary Knowledge

based on a brief comparison with contemporary South Africa and Eastern and Central Europe, three examples of profound social change which affected or affects health.

Sweden – a historical example An analysis of the relationship between health and social transitions during the last centuries in Sweden must, due to the availability of sources, rely mostly on mortality figures and history has to be divided into partly artificial periods, making the social change visible: 1. The classical agrarian society, until c. 1800 2. The transition of the agrarian society before industrialization, c. 1800–1860/70 3. Industrialization and the classical industrial society, c. 1860/70 – c. 1980 4. Towards the IT society? c. 1980 – Each of these periods was characterized by specific mortality patterns, in certain ways linked to socioeconomic factors. In addition, however, due consideration must be taken to medical techniques and interventions by local and national government. In this story, the emphasis is put on the second period. It will be argued that the rapid transitions during the first half of the nineteenth century could, for some groups and especially for adult men, create what is today described as social stress. This was reflected in a mortality hump strikingly similar to the one that has been observed to a varying degree in the former Soviet empire after 1989. Such a comparison, however delicate because of all the differences, might help to identify and understand some of the more common connections between health and rapid social transitions, but also underline the influence of specific contexts.

The classical agrarian society – a starting point Until the nineteenth century, Sweden can be defined as a classical, ancien régime agrarian society. The vast majority of the population earned its living from farming and, especially in the forest areas in the north, from hunting, fishing and forestry. The minority, about 10 percent, lived either in the little towns in the households of craftsmen and merchants or in relatively small iron foundries. War, infectious diseases and years of crop failures kept population growth at a modest rate. The age of marriage fluctuated according to the possibilities of becoming a farmer, craftsman or foundry worker and forming a new family. Hence, with few illegitimate births, the size of a new generation was limited by its opportunities to marry and by its high mortality, especially among

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children but also among adults in their middle age. Upward or downward social mobility between generations was an exception. (Edgren 1987; Harnesk 1990; Hörsell 1983; Lundh 1997; Winberg 1977). Luther’s Haustafel stated that each person had a given place on earth, which seemed to be in line with the existing social order (Pleijel 1970). The Bible, interpreted by the orthodox Protestant clergy, and Luther’s Catechism, read and memorized by everybody, were the official guidelines for a good Christian life. These rules were internalized by a system of home education where the parents were obliged to teach their children to read and to memorize the central religious texts. Yearly catechetical examinations of all persons above the age of seven took place in order to check that these duties were fulfilled and that nothing was forgotten later in life. In the countryside, parish meetings and village boards handled both spiritual and secular affairs. The minister, whose task it was to make sure that the decisions were in accordance with religious norms and secular laws, chaired these meetings. Special attention was paid to church discipline, not only concerning purely religious shortcomings but also juvenile delinquency, family disputes, drunkenness and other disorderly behaviour that was not serious enough to be brought to the civil courts. Many parishes appointed village guards who were to report on all kinds of “unrest” among their neighbours (Johansson 1977; Sundin 1981, 1991 and 1992). In this “tight” local society, being obedient to the authorities and cooperating with one’s neighbours was the sensible way to become accepted and to avoid many problems. A majority of the population belonged to these “insiders” while those who broke the rules and challenged the order became “outsiders”. As an insider one could also hope that relatives, neighbours, guilds and other more or less informal institutions and networks would intervene and try to assist in difficult situations. Outsiders were looked upon with less compassion. Being an insider was even more important since survival was always at risk. A harvest failure meant that the next year had to be endured at or sometimes even below the level of subsistence. Such years were often accompanied by an increase of migration and the spread of epidemics. During wars, generations of young men were drafted and many never came back to their home parishes. War consumed money and extra taxes put burdens on the whole population. War was also a source of epidemics, affecting both soldiers and civilians. Smallpox, measles, whooping cough, diarrhoea and other infections killed 20–35 percent of the infants and large numbers of those who survived their first year of life. In addition, dysentery, typhoid fever and other epidemics hit at all ages, making life more difficult for the survivors in the family. Death had to be accepted

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as the result of God’s mysterious will. Seen from the point of view of the individuals, there was little they could do to prevent these events. Living a Christian life and relying on the “Gemeinshaft” and social capital invested in kin and neighbours could, however, be a source of support for the sick and in other ways unfortunate. And, in the end, the Bible promised eternal life for the faithful. While unpredictable in one sense, society was governed by simple rules and traditions (Sundin 1994, 1995 and 1996(2)).

The transition of the agrarian society, c. 1800−1860/70 The transition of the classical agrarian society accelerated during the first half of the nineteenth century. Enclosure and new techniques in agriculture increased productivity. In the more densely populated rural areas, for instance in the plains in the south of Sweden, the number of farms and the workforce needed to cultivate the land was reduced. The decline of infant and child mortality after 1810 produced a rapidly growing population and a larger proportion than before became crofters, on marginal plots of land, or day-labourers or had to look for work in the small pre-industrial cities (Brändström and Tedebrand 1995 and 2000; Brändström, Sundin and Tedebrand 1999 and 2000; Eriksson and Rogers 1978; Hofsten and Lundström 1976; Jonsson 1980; Lundh 1997; Lundsjö 1975; Martinius 1977; Nilsson and Willner 1994; Olsson 1999; Sundin and Tedebrand 1981 (1); Sundin 1992 and 2001; Söderberg 1978; Söderberg et al. 1991; Winberg 1977). These cities could offer work as servants for young women and men. Traditional crafts in the cities were at the same time stagnating, which meant that the opportunities to find steady, long-lasting employment were limited. The little town of Linköping and its surroundings can serve as an example of the social changes taking place. In its agrarian hinterland, about 30 percent of the men above 14 years of age had been farmers in the year 1750. In addition, many young servants reached that position later in life. In 1850 this figure had been reduced to less than 20 percent. In the city itself, the percentage of male apprentices, workers and servants increased from about 50 percent in 1800 to 70 percent in 1850, while the proportion of master craftsmen and other members of the established groups decreased accordingly. The labour market offered more jobs for female servants than for males, which created a 25 percent female surplus. Consequently, a considerable number of women never married. When they had reached the age of 40, most of these female servants were fired and replaced by younger candidates. Together with the widows, this group had to rely on casual work or poor relief. Similar circumstances were common among many men when they had reached

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what we today consider upper middle age. The difficulties to find steady jobs and form a family caused the average age of marriage to rise to about 30 years for both sexes among the lower classes. This, and the female surplus, contributed to a rapidly increasing illegitimacy rate. In Linköping, almost 30 percent of the children were born outside marriage during the 1820s. Fig 1. Social structure of the agricultural population. Sweden 1751 and 1850. Number of male heads of households (1,000)

peasants landless

1,000 male heads of household

250 200 150 100 50 0 1751

1850

Source: C. Winberg, Folkökning och proletarisering (1975), 17

Another reason was the rapid population turnover. Migration was intensive and only a minority of the inhabitants had spent most of their lives in Linköping. The majority arrived as young adults and stayed for one or a few years. Some remained longer, but they often lacked the important ties to relatives in the neighbourhood. Informal social control was not as tight and effective as it had been in the stable traditional society and many men could choose to deny fatherhood or refuse to marry the mother without being stigmatized by local opinion. For some of the contemporary commentators this was seen as a general slackening of morality among the poor women. However, considering the hardships for the unmarried mother, we have no reason to believe that her situation was chosen voluntarily or wished for. Without the support of a husband, parents or other relatives these mothers had great problems to work and take care of their newly born children at the same time. As a result, infant mortality was extremely high in this group

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while it remained close to the general average if the mother could rely on the support of her closest kin (Artaeus 1992; Bengtsson 1996; Carlsson 1977 and 1978; Edgren 1994; Sundin 1991(1) and 1997). Thus, the cities became the focus of many social problems connected with the changes taking place. For a minority these changes meant new opportunities. Besides the traditional four stånd (estates: nobility, clergy, burghers and farmers), each with specific privileges and representation in the Parliament, a new middle class emerged consisting of persons of standing and wealth outside the nobility: owners of iron foundries, successful merchants, members of the expanding civil bureaucracy and others who had managed to climb the social ladder. The social and economic gaps widened and the political influence in local affairs were to a greater extent concentrated in the hands of the elite, whose members created their own “Victorian” system of cultural values and felt less related to their poorer neighbours. Occasionally these social tensions manifested themselves in riots but never of a magnitude that could seriously threaten the establishment. Everyday signs of the tensions were registered in the court’s records of minor violence. In Linköping, as in other cities, petty fights and quarrels had been very common for centuries. Traditionally they were conflicts between social equals, starting at the pub or in other circumstances when honour was at stake and, according to the tradition, had to be defended with the fists. Such events occurred even during the nineteenth century but a new type of conflicts became more common than before: verbal or physical aggression against representatives of the upper classes or the guards responsible for the keeping of the peace at public places. This registered upsurge of social tensions was caused by an intensified campaign for law and order initiated by the local elite and the counter-resistance from those who were the targets of this control. The prosecution of drunkenness in public places is a striking example. The number of recorded cases rose year by year during the first half of the nineteenth century, to some extent reflecting an increased consumption of alcohol. It was, however, also an effect of the elite’s growing sensitivity to what it considered disorderly behaviour in the lower classes. Other criminal offences became more frequent as well during the first half of the nineteenth century. The number of thefts and other property crimes increased. As the result of a more peaceful society and “civilization”, homicide rates had dropped steadily in Sweden since the end of the seventeenth century, but started to rise again after 1800.

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In the case of manslaughter, alcohol was often said to be a trigger effect. While some contemporary commentators pointed at poverty and socioeconomic factors as the main cause, others described this new proletariat as a depraved and immoral group, a dangerous class that had to be further controlled and educated (Petersson 1983; Sundin 1976, 1992 and 1994).

The mortality decline During this period, mortality trends differed depending on age and sex. For infants the figures started to decline steadily after 1810. Usually, the greatest decline took place in areas where the mortality had been exceptionally high, i.e. in the towns and certain rural areas. In places where the infant mortality rate (IMR) had been relatively low (close to 10 percent) there seemed to be a threshold preventing the figures from dropping much before the end of the nineteenth century. From 1810 to 1860, however, the national figure went from 19 percent to 12 percent and in the city of Linköping it went from 37 percent in 1810 to 16 percent in 1860. Several factors contributed to this positive achievement. The growth of the production of food, for instance the introduction of potatoes on a large scale, may account for a limited part of the decline. Total starvation, the effects of which have been observed in parts of the world today, was unusual during this period and minor reductions of the food supply did not seem to have a great impact on the infants’ mortality. Improved nutritional status of the mothers was beneficial for the foetus. However, the greatest contribution to the decline occurred after the first month of the infants’ lives when other factors were more important. Furthermore, real wages for the day-labourers did not increase and the growing production was unequally distributed in the population. (Bengtsson 1996; Brändström 1984; Brändström and Tedebrand 1993; Brändström, Edvinsson and Rogers 2002; Castensson et al. 1988; Högberg 1986; Nelson and Rogers 1997; Puranen 1984; Sundin 1981 (1), 1995 and 1996(2); Sundin and Tedebrand 1981(2)). Swedish authorities had access to mortality rates by sex, age and causes of death for each parish from 1749 (Sköld 2001). They noticed the high number of incidents among infants and children and the great regional differences, a problem since a large and healthy population was supposed to be a necessary asset for the wealth of the state. One Swedish authorities had access to mortality rates by sex, age and causes of death for each parish from 1749 (Sköld 2001). They noticed the high number of incidents among

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infants and children and the great regional differences, a problem since a large and healthy population was supposed to be a necessary asset for the wealth of the state. Figs. 2 a–c. Sex- and age-specific death rates and male/female ratio in Sweden 1750−1900. 250

140

Infants

m ale fem ale ratio

200

ratio

deaths/ 1,000

120 150

100 100 50

0

1750

80

1800

20

1850

1900 140

30-34 years

male female ratio

15

ratio

deaths/ 1,000

120

10

100 5

0

80

1750

1800

1850

1900

140

140

70-74 years

male female ratio

120 100

ratio

deaths/ 1,000

120 80 60 100 40 20 0

1750

80

1800

1850

1900

Source: G. Sundbärg, Bevölkerungsstatistik Schwedens 1750–1900 (1907)

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One way to improve this situation was to invest in health care, especially by increasing the number of district physicians appointed and partly paid by the state. This was necessary in a sparsely populated country where the market for private practitioners was weak. The reform started modestly with one physician sometimes responsible for a large area where he could only visit each parish a few times during his years of service. After 1800, however, the number of positions increased steadily. A school for the training of midwives had also been established in Stockholm during the eighteenth century (Brändström 1984). The curative and therapeutic effect of these investments may have been limited. The physicians, however, looked upon themselves as the agents of health in a wider sense, trying to observe the patterns of disease in their districts and to suggest preventive remedies. As a well-recorded example, Carl Josua Wretholm, the physician in Nedertorneå on the northern border with Finland, noticed the high infant mortality in his district, often above 30 percent during the first decades of the nineteenth century. He was convinced that the reason for this detrimental condition was to be found in the total lack of breast-feeding among the mothers. In the 1830s he started a campaign in order to change their habits. It was not easy to change a long-lasting tradition, but after he had managed to convince the farmers to hire an educated midwife, the campaign became easier. In letters to his superiors in Stockholm he could proudly report the gradual success, with considerable reductions in the mortality figures before his death in 1866. Nedertorneå was one of the extreme examples, but unsatisfactory breast-feeding patterns were also reported from other, if not all, parts of Sweden. Other colleagues of Wretholm’s were also engaged in similar campaigns. Hence, prolonged and more consistent breast-feeding, and perhaps also generally more hygienic child care, made its contribution to the decline of infant mortality in a number of areas of nineteenth century Sweden. During the second half of the eighteenth century, many Swedish physicians were engaged in attempts to inoculate against smallpox, using contagious matter from an infected person. The extent of inoculations and their effect on the overall mortality rate has been seriously questioned. At any rate, inoculation paved the way for the very quick introduction of the vaccination method demonstrated by Edward Jenner. During the first decades of the nineteenth century the big smallpox epidemics of the previous century disappeared and the mortality figures went down drastically. The success was made possible by the collaboration between national authorities, district physicians and local administration in each parish and town. The local church was responsible for the

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vaccination of children, carefully recorded for each individual in the catechetical examination registers. Based upon this organization, the campaign met relatively little resistance from the parents’ side even before it became compulsory by law. For infants, but even more for children above their first year of age, the elimination of major smallpox epidemics was an important factor behind the mortality decline. Despite the social problems described above, Sweden could therefore rely on a growing number of health agents, an efficient local administration and new medical technology (vaccination) implemented within these institutional frameworks (Sköld 1996). Infant mortality was usually high in urban areas, even in small towns with less than 1,000 inhabitants (Sundin 1995 and 1996(2)). Small aggregations of people were enough to create a milieu that was favourable for the spread of air-, water- and foodborn diseases – “the urban penalty”. In Linköping, IMR was, for instance, often above 30 percent before 1810. After that year, the figures went down almost uninterruptedly. Even in this case, more consistent and prolonged breast-feeding and smallpox vaccination were important factors behind the positive development. It is, however, also plausible that the campaigns for general orderliness, as recorded in the court’s lists of fines, had a positive effect on people’s health. From 1810 and onwards we find a growing number of convictions for neglecting to clean the gutters, spreading dirt in forbidden places, washing cloths in the river close to the place where the drinking water was fetched and other offences that worsened the hygienic conditions. In 1817, the town council decided that the place where the fresh water was taken should be moved upstream, where it could not be contaminated by the dirty surface water from the town. Limited as they were, such measures preceded more extensive attempts to clean up the cities during the second half of the century, and played a role in reducing the exposure to gastro-intestinal diseases (Sundin 1992). In Sweden, as well as in Linköping, mortality also declined after 1810 among children above their first year of life, particularly as an effect of smallpox vaccination. When the infants faced fewer serious infections during their first year of life, they may also have been stronger and more resistant to new attacks when they grew older. One sign of a positive synergetic effect between different diseases is seen among the infants in Linköping, where the reduction of food- and waterborne causes of death was accompanied by a similar decline of deaths by airborne diseases without any reasonable explanation of why the exposure of the latter had diminished. Increased geographical mobility and population density would have created an increase of exposure, but such

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an effect can only be observed in the temporary rising mortality in scarlet fever and diphtheria during some decades around the middle of the century. So far, some factors have been pointed at which contributed to the early nineteenth century decline of infant and child mortality. Some of these factors were age specific while others, such as a general improvement of hygienic conditions, would also have been positive for adults. Positive health experiences in early life have a tendency to promote good health and higher life expectancy later in life (Barker 1994). Actually, the mortality of young and middle-aged women followed the trend of the children with a visible decline after 1810. The assistance of trained midwives may also have been positive for the mothers. Maternal mortality was reduced, probably due to improved hygiene in general and especially during the deliveries. It declined earlier in the city of Linköping, where assisted childbirths were more common, than in the surrounding countryside, where midwives were used less frequently during the beginning of the nineteenth century. For women in the oldest age groups, however, mortality did not start to decline at the same time, probably because of the materially vulnerable situation of many poor spinsters and widows (Högberg 1986; Willner 1999). Summarizing the mortality experience of children and women, we find that the increased survival rates are to an extent caused by conscious interventions of health agents (physicians and midwives) supported by national agencies in cooperation with local institutions. It was, in a sense, a happy meeting between mercantilism, which gave the state a reason to invest in healthcare institutions, and the Enlightenment, which believed in the possibility of studying, discovering, understanding and influencing what had previously been usually seen to be God’s unchangeable will. Although Sweden was a sparsely settled and relatively poor country, historical traditions of paternalism and local self-government based on participation and negotiation with higher authorities made these interventions successful. Of course such a statement does not mean that total harmony and consensus always ruled the relations between local society and the Crown. Conflicts did occur, but compared to many other countries at that time, Sweden was still an almost monolithically organized political society with one state religion, infiltrating the minds and institutions locally (Nelson and Rogers 1992; Sköld 1996).

The male puzzle For adult men, however, we face an intriguing question. Why were these men not affected by the same positive factors as children and women? Or was there another

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negative factor, specific for men, “overshadowing” the positive effects? This negative trend for men was still strong even if we take the female reduction of maternal mortality into consideration. Hence, among the men mortality stagnated at a high level or even increased for certain age groups until the middle of the nineteenth century (Edvinsson 1992; Söderberg et al. 1991; Willner 1999). Compared with women of the same age, male surplus mortality existed for almost all of the contemporary registered causes of death. Among the most striking differences were deaths related to excessive alcohol consumption, accidents and violent deaths, suicides and tuberculosis. There was an urban/rural surplus of mortality for both sexes, but male urban mortality and the urban male/female surplus was particularly high. As has often been the case over time and space, married persons had the lowest figures within their respective sex. Local studies in areas where proletarianization had started indicate that men in the lowest social strata had the highest mortality figures, while the social gradient was not visible to the same extent among women. Consequently, the highest mortality risks existed among urban unskilled male workers without a wife at their side. These variations over time, space and class and between persons with different marital status mean that the male/female differences cannot be explained by simple biological factors. We must, instead, look for social and cultural determinants, i.e. gender differences. In most societies, and also in early nineteenth century Sweden, men and women have been invested with culturally constructed “rights” and “duties” (Johansson 1991). Rights and duties can be either positive or negative for a person’s health. One important positive right is of course the access to material resources: food, clothing and good housing. In this respect, we have no indication of early nineteenth-century Swedish men being generally worse off than women. The official salary for male servants was, for instance, twice as big as the salary for females and the labour market for women was limited to low-paid work. One difference was, however, that most women were, as housemaids, members of a household and guaranteed a minimum supply of food and shelter. Women were also, through their work roles, more accustomed to cooking, keeping clean surroundings, etc., something that has been mentioned as a positive factor when explaining the lower mortality among unmarried women compared to unmarried men. It could also be assumed with good evidence that men in general and unmarried men in particular were allowed, or allowed themselves, to engage in more disorderly lifestyles, something we could call a – for health – culturally defined negative right.

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Deaths caused by accidents have, for instance, usually been more common among men than among women, even if the accidents are not connected with a certain occupation. This difference already exists among boys at an early age, when nongender-related risks for the two sexes ought to be relatively equal. Adding the testimonies from statistics on violent deaths, deaths caused by alcohol, and the fact that men were more often involved in violent events according to the crime registers, the male role appears to be more prone to risk behaviour in nineteenth-century Sweden as well as in many other cultures. Women seem to have had more “duties” and expectations to lead an orderly, quieter life, which contributed positively to their health. One way, however, to protect the men from negative health behaviour was through marriage. The differences by marital status were, as was pointed out above, greater among men than among women. Part of these differences can probably be explained by negative selection, i.e. a larger than normal part of the persons who do not marry are handicapped, physically or mentally, or in other ways belonging to a negatively selected group even in relation to health risks. This hypothesis finds some support in data, but it cannot explain why the differences vary in strength over time and space. Émile Durkheim’s theory, that marriage is an institution providing the partners with a sense of meaning and both external and self-inflicted social control, seems to be worth taking seriously. This was, according to Durkheim, especially the case for men (Durkheim 1991). We could therefore make a stereotype of the unmarried men as more prone to risks and unhealthy behaviour, while unmarried women due to their internalized gender roles were more careful and found more constructive networks. In Swedish preindustrial cities it has, for instance, been found that certain houses were occupied by lonely mothers and widows where they could live in some kind of symbiosis, elderly widows taking care of the children while the mothers were working and younger women “paying back” with other types of help. Thus, women should have been more efficient in using what is now often referred to as social capital. The married man was supposed to be the major breadwinner in the household, his most important and statusloaded duty. He could fulfil this responsibility as long as he had work, giving him money to feed the family (Sundin 1997). So far, we have been discussing factors that could explain mortality differences between men and women and by marital status. Two key questions remain to be discussed further: Why was the male surplus mortality primarily an urban phenomenon and why was it so high during the first half of the nineteenth century? The urban penalty for males has been observed in several historical contexts, which indicates that the

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urban milieu may – at least under certain conditions – have characteristics that are negative for the men’s health. Secularization came earlier to the towns and the form of social control represented by Church discipline was therefore less efficient. Male servants and apprentices were still often living in the households of their masters, but the husband’s paternalistic influence over his employees was hard to uphold when they were off duty and entertaining themselves. The court records tell us that female servants were not at all engaged in what was defined as unruliness and debauchery to the same extent as the males. Finding oneself in a new milieu easily lead to a sense of being uprooted. Old rules from the agrarian society no longer worked. Often lacking networks of kin and neighbours made the immigrants more vulnerable in case they was looking for a new job or for some other reason in need of help. Fig. 3. Acute alcohol intoxication (deaths or autopsies) per 1,000,000 in 1804–1870

25

per 1 000 000

20

15

10

5

deaths

autopsies

0

1800

1810

1820

1830

1840

1850

1860

1870

Sources: Sundhets-Coll. Ber. 1851, BiSOS A 1851–60, BiSOS K 1852–70.

Alcohol was an obvious mediator of illness and mortality. Although we lack reliable data on the consumption per capita during the first half of the nineteenth century, several factors strongly indicate a substantial increase and culmination during this period, contributing to the rise in excess male mortality. Among other things, the development of the registered deaths due to alcohol intoxication culminated in the

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1840s. The out-shipping of alcoholic beverages from certain production districts to other parts of Sweden increased substantially and culminated during the period. Contemporary estimates of alcohol consumption as well as the official reports of county governors also support this view. Alcohol could be bought at a relatively low price and the restrictions of production and sale were lenient. In urban areas, the range of temptations was much greater than in the countryside. In towns, the number of legal pubs was large, not counting the “speakeasies”, giving extra incomes to widows and other members of the poor population. Certainly, the mortality impact of alcohol consumption was much larger than the relatively few registered cases of acute alcohol intoxication. Heavy drinking affected health-related living conditions with regard to nutritional situation, housing conditions, hygiene, etc. and diagnoses such as lung consumption, stroke and external causes (primarily accidents and suicides) were to some part caused by excessive drinking. The pioneering work, Alcoholismus Chronicus, published in the 1840s by the Swedish physician Magnus Huss, pointed out the negative medical effects of excessive drinking, an opinion that was often seen in the medical literature as well as in the official reports of vital statistics during the second half of the century. Fig. 4. Labour force structure. Sweden 1750–1990 –

Agriculture Industrial Service 90 80 70 60

%

50 40 30 20 10 0

1750

.

1800

1850

1900

1950

2000

Source: J. Melin et al., Sveriges historia. Koncentrerad uppslagsbok (1997)

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The great socioeconomic and cultural transformations of the time, which gave uncertain prospect for the future among the rapidly growing proletarian groups, contributed to a climate that stimulated excessive alcohol consumption, as did a weakening of informal social control. For contemporary commentators the male surplus mortality was not a major topic. As we have seen, the unruly and immoral proletariat was supposed to be a dangerous “disease”. Drunkenness in public places was primarily seen as disturbance of the peace. The early version of the temperance movement, in many cases initiated and led by clergymen, was already established before 1850. Some of them tried to form “associations” in their parishes in which the members promised not to produce, sell or consume alcohol, while other associations limited their ambitions to moderation. The success of these early versions of temperance movements is of course impossible to assess in detail, but the main impression is that it was limited. One of their weaknesses was that they were usually governed “from above” and were not spontaneously created movements. The society was not quite ready for real mass movements before the second half of the century (Willner 1999 and 2001).

The early phase of industrial take-off – c. 1860–1900 It is of course impossible to give an exact year when industrialization started in Sweden. In some cities, signs of industrial activities were already seen before 1860. In Norrköping, for instance, the textile industry was founded before the middle of the century. The production in traditional iron foundries peaked in the 1850s and the first steam-driven sawmill in Sweden was built in 1849. Looking for the final take-off, however, we have to move to the 1870s. Due, for instance, to wars and a general boom in the construction of ships, factories and machines and other goods in Europe and North America, the demand for wood and iron products gave Sweden favourable terms of trade on the world market. After two years of bad harvests and a shortage of food at the end of the 1860s, the labour market for industrial workers grew rapidly and real wages rose steeply. The demand for food for the workers meant that agriculture could also flourish. The majority of the population was still engaged in agriculture, the boom did not last forever and less prosperous periods sometimes interrupted the growth. From a secular perspective, however, Sweden had definitely entered the road towards the industrial society.

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Fig. 5. Consumption of alcohol (litres 100% per 1,000 aged 15+). Sweden 1870–1995. Moving 5-year averages.

12

litres per 1,000 aged 15+

10

8

6

4

2

0

1870

1890

1910

1930

1950

1970

1990

Sources: L. Lenke, Alcohol and Criminal Violence (1989); Alkoholstatistik 1985–93 (Socialstyrelsen). Stockholm, the capital, and the industrial areas, for instance the sawmill districts in the north, became places of in-migration while emigration to America was an alternative for those who did not find the future in Sweden attractive. During the first decades, the labour force was mainly recruited from the countryside and, in some of the new communities, the supply of decent housing had problems keeping up with the demand. In the sawmill areas, for instance, the result was overcrowding and unmarried young men often lived in barracks where bad hygienic conditions created an inviting milieu for tuberculosis and other infectious diseases. During the last decades of the century, pipelines for fresh water and sewerage were built in the cities and contributed to a reduction of diarrhoea and other gastro-intestinal causes of death. However, it often took some time before the new settlements of workers could get the same facilities. Overcrowded houses and bad hygienic conditions affected everybody negatively, especially the children. Years of high demand for labour, rising real wages and an in-migration of young unmarried men resulted in an increase in

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the consumption of alcohol, rising numbers of arrests for drunkenness and higher mortality among adult men. The negative effects of industrialization on life expectancy was, however, only visible in the mortality figures during a decade or two. (Brändström and Tedebrand 1993; Edvinsson 1992; Nelson 1988, 1994 and 1995; Nelson and Rogers 1992 and 1994; Nilsson 1994; Taussi Sjöberg 1981). Industrial production demanded that the workers should arrive sober and in time at work every day. This has been said to be a factor creating a more disciplined workforce than in the traditional crafts, where time was not regulated in the same way and the employees could sometimes take a “free Monday” off (Edgren 1987; Horgby 1986). This new discipline also became part of the workers’ own ideal, often expressed by their trade unions and political organizations. Many workers joined the temperance movement and the new “free churches”, associations which, in a sense, re-established the church discipline of the agrarian society in a formally less compulsory version. These popular movements were not only instruments for shaping the disciplined worker with bourgeois values of orderliness. They also provided people with new ideologies and interpretations of the world. The labour movements tried to explain the economic order and suggested how the workers should defend their rights, the temperance movement drew up the rules for a sober person and the free churches appealed to those who were religious, but rejected the hierarchical structure of the traditional state Church. Being a member in one or several of these associations was a ticket to social networks, which could help in times of hardship. Trade unions started voluntary sick insurance systems for their members and the free churches supported their members in times of unemployment or illness. The voluntary associations offered the workers a place in the new social order. The emergence of a new society, materially better off and socially more stable, offered more opportunities and less risks than early nineteenth century Sweden. Sanitary reforms in the cities contributed to the continued decline of mortality and prolonged life expectancy at all ages, the greatest relative winners being middle-aged men. Restrictions in the production and sale of alcohol, introduced already during the 1850s, together with self-inflicted temperance, was reflected in a reduction of the type of causes of death that were directly or indirectly linked to excessive drinking. It is also highly likely that a more stable society reduced the need to use alcohol as a “pain-killer” against social stress. These are some important causes of the improvement of the

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population’s health, especially among adult men, during the last decades of nineteenthcentury Sweden. During the first part of the nineteenth century, old institutions on the community level were still at work contributing to the general decline of mortality and this trend continued during the early phase of industrialization with short interruptions due to problems to cope with the rapid growth of urban areas. No active and effective welfare policy was, or could have been, introduced in order to minimize the negative effects of structural economic change and the problem of the rapidly growing proletariat before 1850. The positive effects of a more stable labour market were, on the other hand, demonstrated during the second half of the nineteenth century. Economic progress was, after some decades, accompanied by more stable family structures, social networks and informal associations for the working classes, i.e. new forms of social capital in the industrial society. Life expectancy rose in both sexes and in all age groups, especially among the previously high-mortality groups of urban adult men.

A comparative perspective The male penalty, observed in early-nineteenth-century Sweden, shows striking similarities with what has happened in Eastern and Central Europe during the recent decades (Carlson 2000; Cockerham 1999; Cornia and Paniccià 2000; Dzúrova 1999; Meslé and Vallin 1998; Shkolnikov et al. 1998; Wallberg et al. 1998). A common pattern in almost all parts of the former Soviet empire was that adult mortality increased after the political changes in 1989, especially in causes such as heart diseases, accidents, alcohol-related diseases and, for instance in marginal groups in Russia, diphtheria and tuberculosis as well. In some countries, mortality also increased among women, but not everywhere and not to the same extent as for men. Mortality increased more among those who were not married, had a brief education, and/or were unemployed and the negative trends were more marked in certain regions and in urban areas. Among the factors that are thought to have influenced the development are political and social disintegration; a weak state; deterioration of systems of welfare and health care; rapid privatization of the economy, which created unemployment; increased migration and uprooted groups; a weak civil society (family structure, other types of social networks, etc.); alcoholism; lawlessness and criminality. This has been summarized under the concept of “social stress”.

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The degree to which this was the case varied from country to country. In Russia life expectancy declined from the 1970s to the middle of the 80s. Then it increased between 1985 and 1989, probably as a result of Gorbachev’s campaign against alcohol abuse. After 1989, life expectancy declined rapidly, especially for men (6.6 years between 1989 and 1994!). The mortality rates then stagnated or even decreased for a short time, bur seem, according to the latest figures, to be rising again. The Czech Republic represents a more positive case. No decline of the life expectancy took place before the political changes in 1989. For a short period (1990–91), male life expectancy declined by less than a year and after the middle of the decade it started to rise again and is, according to the latest available figures, higher than it was before the short crisis. Among the factors that have been mentioned in order to explain why the mortality crisis was so modest compared to many other countries in Central and Eastern Europe are an active policy against unemployment; a limited increase in income gaps; the preservation or even some improvement of the health care system and a basic system for social security; limited migration streams and the preservation of stable family patterns and a civil society. Social stress also marks many developing countries, notably African nations. Even in South Africa, the most affluent country south of the Sahara, socioeconomic, cultural and epidemiological factors combine in ways that are unhealthy for both sexes and all ages. The legacy of apartheid is still a heavy burden, and “Freedom Day” in 1994 did not immediately realize a Rainbow Society with social security and equality for all, a frustration for the most vulnerable (Barbarin 2001; Bassett 2000; Bhorat et al. 2001; De Beer 1986; Möller 1998; Pillay and Sargent 1999; Unterhalter 1982). Opening South Africa’s borders to the global economy led to de-industrialization and unemployment (Bond 1998; Loewenson 2001; Midgley 2001; Studies … ILO 2001). Shantytowns are growing in the suburbs of big cities as poor people migrate from the countryside. They endure difficult social and hygienic conditions, extremely high unemployment, violence, crime and drug abuse (Glantz and Spiegel 1996; London 1999; Parry and Bennets 1998). Morbidity and mortality from infectious diseases have remained high, or have even increased, with the advent of HIV and AIDS (South African Health Review 1999–2002; Tollman 1999; Whiteside 2000). The health care system is often least developed in areas with the most urgent needs (Baldwin-Ragawan 1999). Wellfunctioning local communities are hard to establish, although non-governmental organizations and the state are trying to alleviate the conditions.

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Exact and reliable figures are hard to find, but – according to South African studies – HIV and AIDS are more common among young and middle-aged women than among men in the same age groups (Bassett 2001; Jaffrey 2001). This is partly caused by women’s higher physiological risk of being infected by the virus. The risk of infection is exacerbated because popular misconceptions do not acknowledge that HIV is sexually transmitted. However, most South Africans seem to know about HIV/AIDS and the ways to remain HIV negative, but culturally defined gender roles intervene and make it difficult for many women to stand up for their right to voluntary and safe sex (Ackerman 2002; Campbell 2000; Dolby 2001; Jewkes et al. 2001; Kaler 2001; Mac Phail and Campbell 2001; Ramphele 2000; Reddy 1999; Wood et al. 1998). People suffering from AIDS are vulnerable to other diseases such as tuberculosis and children either become orphans and/or die themselves at an early age because of transmission from the mother or sexual abuse (Donald 1998; Guest 2001; Madu and Pelzer 2000; Packard 1990). Some of the points of departure for a presently ongoing cross-national comparative research programme within the PhoenixTN in cooperation with the Milbank Memorial Fund are that: • Transitions that are fundamental and rapid have immediate, profound effects on health. • Changes in the labour market, social structure and social security systems put a heavy burden on people’s occupational flexibility, social adaptability and ability to find economic safety for themselves and their families. • In times of rapid change, old rules, norms and institutions no longer function as efficiently as they did before. • If social and geographical mobility increases, some people benefit while others lose out. • “Social capital” is one factor that determines who will become winners and losers. • Welfare and health also depend on gender, age and social class. • Cultural and gender factors within a particular epidemiological setting often have different effects on the health of men and women. • The negative effects, even when change is positive in the long run, can be summarized as “social stress”. • The impact of change is always filtered through formal and informal institutions. • Public institutions can distribute and redistribute material resources, welfare, and social capital.

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•

Informal institutions – such as voluntary associations, social networks in the workplace or among neighbours, the family and other primary groups – and the way civil society functions can enhance social capital and are essential for social stability and security.

Certain theoretical concepts and foci may help to form part of a platform for comparative studies. One of the concepts used in this article is social stress, which signifies the negative psychosocial effects upon individuals, groups and societies living through rapid change. For individuals, it can result in psychological and physiological health problems, reduced capacity to cope with difficulties, frustration, lack of hope for the future, violence, drug abuse, etc. Using Émile Durkheim’s term, even social and political systems and discourses can be affected by the same “anomie”, which strengthens the negative consequences of change. The three cases above serve as illustrations of the potential content and meaning of “social stress”. There is a link between social change and biological responses affecting health. It can be described as the interplay between the individual’s “biography” and her “biology”. Social stress may cause disease according to two main pathways. One is unhealthy lifestyles: depressed people tend to drink more, eat more unhealthy food and be more overweight both at work and in daily life (Stonks et al. 1996). The other pathway is through effects of changes in the stress-systems and the immune system, leading to an increased susceptibility to disease (Syme at al. 1976). Especially, checks at work have predicted future risk of coronary heart disease (CHD) death in Eastern and Central Europe (Bobak et al. 1998 1–2). Likewise, the quality and quantity of social networks has predicted CHD (Orth-Gomér 1994). Individual characteristics, especially feelings of depression, hopelessness and vital exhaustion, have all been related to risk of CHD (Everson et al. 1996; Appels et al. 1998). In an earlier cross- sectional comparison of Swedish and Lithuanian men in two cities, a higher frequency of negative psychosocial factors was found among Lithuanian men, who had more job strain, more social isolation and more depression and exhaustion in comparison with Swedish men. In both cities, men with low social status had higher rates of unfavourable psychosocial characteristics than men with high social status (Kristenson 1998). Other Eastern and Central European studies have also shown that high levels of depression are linked to social stress and illness (Weidner et al. 2000). If health is the capacity to realize – in a given context – reasonable, fair and vital goals of life (Nordenfelt 1995), “social capital” seems to be one of the useful concepts

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for comparative analysis. More than, for instance, a “social network” or the “civil society”, it is directly related to the empowerment and resources of individuals and groups. “Social capital” has been defined, demonstrated and discussed in countless numbers of reports with different scope and aims, some of them focused on historical change (Bourdieu 1980, 1985, 1994; Dasgupta and Sergaldin 2000; Field and Schuller 2000; Hawe and Schiell 2000; Kennedy et al. 1998; Putnam 1993 and 2000; Rothstein 2001; Rotberg 2001; Szreter 2003; Wosinska at al. 2000; Woolcock 2000 and 2002). Widely defined, “social capital” means – primarily – non-material assets, which are resources for the fulfilment of vital goals such as security, welfare and health. For some authors, social capital seems to mean anything produced by social systems: from individual education to support from one’s own family, neighbours, friends at the workplace, informal and formal associations and public institutions on the local or national level (Abers 1998; Campbell et al. 2002; Gittel and Vidal 1998; Kunitz 2001; Sampson and Morenoff 2001; Szreter 2003). In Pierre Bourdieu’s version, a distinction is made between economic (i.e. “material”), cultural, social and sometimes also political capital, the last three being of an immaterial, often symbolic and more indirectly useable nature. There is, however, a close interaction and possibilities to transform or exchange one capital for another.1 Conversely, it can also be argued that “health” – mental and physical – is a social resource, a form of “capital” with similarities and close interaction with other forms of capital. There is only enough space to raise the issue in this context, but some common definitions and understandings of these terms ought to be established in future comparative studies. “Social stress” or the unequal distribution or diminishing of any type of collective or individual resources is a serious threat to any attempt to realize WHO’s goal of “health for all”. Identifying vulnerable groups who have lost or are at risk of losing material and immaterial capital and the mechanisms behind this process can be a first step towards formal and informal actions and interventions in order to empower them and protect or restore their welfare. Culture and gender are also, of course, basic factors to be studied and understood. The literature quoted and empirical evidence in the three cases above illustrate how an

1

The concept of “human capital” is sometimes also mentioned among the different types of capital, but it will be avoided here, because of the risk of only identifying it as the humans being a capital for “society”, not as a resource for the individual herself.

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analysis of culturally-created gender roles is a necessary tool for understanding differences in power and health as well as gender-related responses to social change (see also Johansson 1991). The Swedish nineteenth-century mortality crisis among adult men was an effect of socioeconomic changes. Politically, Sweden experienced a peaceful coup d’état in 1809, but the social problems were never of such a magnitude that they threatened the political establishment, and Parliament was reformed in the 1860s, giving the majority to the emerging wealthier part of the farmers and the growing bureaucracy. The state and local communities were capable of introducing reforms that improved the health of children and women. They did not, however, have either the economic resources or the political will to give adequate help to the growing proletariat during the first half of the century, which was detrimental to the health of adult men. Industrialization and emigration lifted the yoke of unemployment and drastic poverty during the last three decades of the century, while local communities became wealthier and more efficient in handling environmental problems and “free churches”, temperance movements and the workers’ associations helped to give the common people an explanation of the new world and social networks for support and self-discipline. As a consequence, mortality dropped rapidly. For the first time, even the most vulnerable group, illegitimate children with single mothers, could enjoy a healthier life than before. In the former communist states in Eastern and Central Europe, the crisis showed its first signs during the period of politically and economically stagnating, centralized and authoritarian state socialism. South Africa experienced a similar development during the last stage of the apartheid era, which no doubt speeded up the development towards an unavoidable political revolution. Political freedom has led to the opening of the domestic markets, a painful experience for previously protected economies. Political and socioeconomic crisis led to political change, which accelerated the economic and social crisis for those who had the least resources to cope with the new situation. As a result, the health of the populations, especially adult men in Eastern Europe but also children and adult women, has suffered in both cases. The fatal HIV/AIDS epidemic is partly coincidental, but it has been efficiently fertilized by the effects of apartheid policy, which split families in order to get cheap male labour, the impoverishment of the countryside and the unpreventable mass migration into urban areas after Freedom Day. Men are uprooted, which also affects the health of women and children through sexual abuse, violence domestically and in the public sphere and the spread of infections to the next generation. So far, male lifestyle factors are the most visible signs of the Russian

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crisis, but tuberculosis and sexually transmittable diseases are also fed by poverty and social disintegration. Former Communist states in Central Europe have also been affected negatively, but to a lesser extent, and, so it seems at the moment, have passed the mortality peak. The mere size and heterogeneity of former Soviet Union does of course create political and economic problems of a much greater magnitude than in the previous satellite states. In the Czech Republic, for instance, the social cohesion is said to have been important after 1989, the political system has worked relatively well, the economy has been under strain but not to the same extent as in Russia and more resources have been allocated to systems for social welfare and health. The relative stability of the society has been seen as the key positive factor. Institutionally, the Swedish nineteenth-century crisis took place under more favourable conditions and the economic boom created by industrialization came as the ultimate saviour. The IT-bubble is no longer a safe card for future investors and a great economic and technological boom is not yet to be seen in the world today. Globalization forces economically and socially less fortunate countries to compete with efficient multinational powers, epidemics and a lack of resources. Time is running short before the majority of the population in many countries consists of the elderly and a relatively limited, unhealthy middle-aged generation. People in the rich countries are, at the same time, said to suffer from stress at work and high demands on their skills and flexibility in order to be winners in the race for more wealth and welfare. This paper has highlighted a process of rapid social transition in early nineteenth century Sweden and the improvements of the socio-economic and health situation starting during the latter part of that century. Economic and social exclusion are negative for general welfare and health. In early nineteenth-century Sweden and Russia and South Africa today, gender roles made middle-aged men more vulnerable than other groups. All three cases show that important functions for stability and welfare, produced by formal and informal institutions, can easily be eroded within new economic and social structures. The Swedish case also shows that the activity of such institutions can contribute to substantial improvements for the survival of children during a socially difficult period. Finally, it depicts the first steps on the road towards the welfare society during the last decades of the nineteenth century. This process – which was not unique in Western societies of that time – was made possible by economic growth,

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increased social stability and an adaptation of formal and informal institutions to new circumstances. Such institutions, on national, regional and local levels, are particularly essential for the protection of those who are economically, socially and culturally least resourceful. The economy, social structure and collective actions interact and are mutually dependent on each other. A comparative perspective in time and space helps to understand relationships between health and society. It can disclose the dangers and potentials for good health in periods of profound social transition. It can identify general or context-bound mechanisms that create vulnerable groups and social exclusion. Due to the subtle interaction between biology, the economy, social, cultural and political systems, good interpretations benefit from inter-disciplinary approaches. That means an exchange of knowledge between several disciplines within medicine, the social sciences and the humanities, which provides a more solid basis for present and future policymaking.

Acknowledgement This study started as the result of a discussion with the economic historian Lena Sommestad, previous Director of the Swedish Institute for Futures Studies and present member of the Swedish cabinet. The Institute has given financial support to our work and will publish a more extensive Swedish version of the report in a forthcoming anthology. We are intellectually in debt to all members of the Milbank Memorial Fund/PhoenixTN on “Health and Social Change”, but the authors are of course exclusively responsible for errors and misguided conclusions.

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Lisbon in the Last Two Centuries: An Example of the Difficult Relations between Urban Growth, Migration and Death Teresa Rodrigues Veiga (New University of Lisbon, Portugal) Maria João Guardado Moreira (Polytechnic Institute of Castelo Branco, Portugal)

In 1900 only 14 percent of the world’s population lived in cities and only twelve of them had more than one million inhabitants. This proportion was a new phenomenon in human history and it was strongly related to economic development, in particular the specific phenomenon of industrialization, which increased migratory movements and urban growth to unimaginable levels, changing collective behaviours towards life and death. What no one could expect were the following outcomes: one century later, the urban population forms 46 percent of the total population and in the near future this rate will most probably reach 52 percent.1 Currently, a total of 411 cities have more than one million residents. Urban evolution in the next few decades of the twenty-first century has become an increasing preoccupation of the international community, as it stands as a focus of probable instability. Rates of urbanization are growing, the dependence of urban inhabitants towards essential and basic needs is well known and concern grows as in our contemporary societies the world’s biggest cities are geographically situated in some of the poorest countries.2

1

Estimations made by Population Reference Bureau for the year 2025.

2

By decreasing order: Mexico (30 million), São Paulo (25), Tóquio (23), New York (22), Xangai (21), Pequim (19), Rio de Janeiro (18), Calcutta (17), Mumbai and Djakarta (16).

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Teresa Rodrigues Veiga and Maria João Guardado Moreira

Nevertheless, from a temporal and historical perspective, we can also find the strong persistence of a few trends that act as factors of permanent instability, regardless of the development rates of any particular society. In fact, they emerge independently if one studies the nineteenth-century European urban system or that of the twentieth century and the same applies to comparisons between continents.3 Among aspects of instability we would like to emphasize the importance of the huge number of people living together in a limited space. Higher population densities usually correlate with worse sanitary conditions such as sewerage systems, difficulties in water and food supply and the worst housing conditions for large groups of society. In fact, most of these problems emerge from the simple existence of huge differences between the specific social groups that compose these urban societies, and these are connected to violence and social tensions, sometimes of an ethnic character, at various levels. As we try to look at cities’ internal diversity, it is inevitable to find richer and poorer quarters. Their inhabitants are distinguished by different nutrition regimes, housing and clothing, all of which subsequently influence physical strength. People also differ with regard to the economic possibilities of access to medical care and, very importantly, they present different degrees of access to information, with impacts on general mortality levels and life expectancy as a whole, and with strong differences between each of them that persist for decades. At the same time, if one looks to the composition of contemporary urban societies, it is not difficult to conclude that, along with these factors of differentiation, it is possible to observe an inevitable and intense dependence on migratory movements, present in all aspects of present day urban life. Most migrations are made for economic reasons. They evolve people born in villages who seek new opportunities and expect to find a better life for themselves or their family in the near future. For the year 2000 the United Nations estimated an annual figure of 60 million people leaving their birthplaces. Half of those migrations were made inside the country

3

J. C. Chasteland and J. C. Chesnais, La population du Monde. Enjeux et Problèmes, PUF, Paris, 1997, pp. 481–496.

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Lisbon in the Last Two Centuries: An Example of the Difficult Relations between Urban Growth, Migration and Death

of origin, from villages to urban centres. A total of 125 million people, 3 percent of the world’s population, live outside their birthplaces.4 The current situation in Portugal indicates exactly the same trends, possibly even more clearly, due to the long migratory tradition of our society. An analysis already made for the twentieth century indicates that urban attraction accounts for 89 percent of all internal migration, 79 percent made from small villages to urban centres. The remaining 10 percent belongs to movements from small urban centres to bigger cities, especially Lisbon.5 In fact, in Portuguese history, the capital emerges as the main pole of all national migratory movements. These few lines introduce our theory regarding the difficult relation between population growth and life conditions, although this claim applies more to the nineteenth century than to the twentieth and has its most clear examples in urban centres, especially when they reach a considerable human dimension.

Lisbon in the nineteenth and twentieth centuries The last statement explains the major reason for this article. Our case study refers to Lisbon in the nineteenth and twentieth centuries, and the choice of the Portuguese case seems obvious.6 Lisbon has always been the main Portuguese town, the biggest commercial centre, political and economical capital, “macrocephalous head” of a huge empire. (Table 1)

4

Phillip Martin and Jones Widgreen, “International Migratioon: Facing the Challenge”, Population Bulletin, vol. 57, no. 1, 2002.

5

Teresa Rodrigues and Maria Luís Rocha Pinto, “Migrações no Portugal do Século XX”, Ler História 43, Lisbon, 2002.

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Table 1: Population of Lisbon Year 1527–32

Population

Year

Population

55,000

1890

300,964

1551

112,830

1900

351,210

3rd.q.16th

120,000

1911

431,738

1620

143,608

1920

484,664

1639–40

170,000

1930

591,939

1755

191,052

1940

694,389

1801

181,208

1950

738,226

1815

163,561

1960

802,230

1840

154,861

1970

760,150

1853

166,539

1981

807,937

1864

190,311

1991

663,394

1878

240,740

2001

564,657

From the beginning of the sixteenth century Lisbon became the crossroads of the trade routes between Europe and Africa, later from Asia and finally from America. The town expanded and changed, as the number of people living there increased. It was an enormous city in Portuguese terms. At the time of the first general census of national inhabitants (1527–1532) it had 50,000–60,000 people, about 5 percent of the total Portuguese population. Oporto, the second biggest town, accounted for about 15,000. During the following centuries Lisbon continued to grow faster than any other city in the Iberian Peninsula, reaching 144,000 inhabitants in 1620.7 In size it was comparable to Venice or Amsterdam, although smaller than Paris, London and Naples. Within Portugal, Oporto remained in second place: it had still not reached 20,000 residents. The population increased rapidly up to the first decades of the seventeenth century, but this was then followed by a period of high mortality, marked by outbreaks of plague

6

For this subject see Urban Dominance and Labour Market Differentiation of a European Capital City. Lisbon, 1890–1990, edited by Pedro Telhado Pereira and Maria Eugénia Mata (Kluwer Academic Publishers, Boston, 1996), chapter 3.

7

For the same year Seville was estimated to have a population of 120,000.

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coupled with the consequences of political instability and the loss of independence. The average annual growth rate dropped, falling to a point below zero by the end of the century. Mortality rates rose and the migration balance turned negative, as a result of conscription, violent deaths and the flight of many people. The end of the war with neighbouring Spain and the economic recovery achieved at the end of the century brought a new impetus to the capital, although for an initial period, up to the beginning of the eighteenth century, this merely consisted of making up the shortfall from the previous century. Annual demographic variations stood above 1 percent until the devastation of the 1755 earthquake. The substantial drop in population attributable to this disaster is due to the flight of survivors from the affected area rather than to the actual number of direct casualties. It was not until the last quarter of the century that the number of inhabitants caught up with the figure that had existed on the eve of the tragedy. Strong growth then continued beyond the end of the century. Migration flows were intense. At the outset of the 1800s, Lisbon, with more than 150,000 inhabitants, was among the ten largest European cities but had lost any chance of competing with any European metropolitan centres.8 In national terms, however, the city has continued to stand out as a macrocephalous phenomenon amongst the remaining urban centres. If one compares its history with other urban centres in Portugal, it is easy to see how the capital differs. With slight alterations, this difference has persisted until today. We refer to the absence of an “urban skeleton”, dating back to the sixteenth century, and becoming worse in the last two centuries, as a result of demographic inertia demonstrated by the other towns in the country. Rather than fading out, this imbalance has become more acute during the last three decades. The increased relative importance of the urban population has been achieved at the expense of the two largest Portuguese towns heading the economic development process in the north and south of the country. By the middle of the nineteenth century and more obviously after that, and in line with economic bipolarization, the idea of a

8

Teresa Rodrigues, “População”, in Dicionário da História de Lisboa, Lisbon, 1994.

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macrocephalic situation was replaced by urban bicephala, with Lisbon and its surrounding area standing at the top of national demographic development.9 Over the last 130 years the capital has suffered from an exceptional situation in demographic terms, existing as it does within a sparsely urbanized country.10 With regard to the nineteenth and twentieth centuries, Lisbon’s demographic growth is distinctive in the Portuguese national context, first as an isolated centre and, after the middle of the twentieth century, as the central part of a large area (Metropolitan Area). Nowadays, together with the region known as “Grande Porto”, these account for more than half of all mainland residents. At the beginning of the nineteenth century, Lisbon had about 169,000 residents and there was little change during the next fifty years, as a result of the successive adverse circumstances suffered by the city. The political situation did nothing to encourage growth. The flight of the court to Brazil and the French invasions that followed11 temporarily deprived the capital of its role as favourite residence of the nobility and seat of government, turning Lisbon into a risky place, which the liberal struggles, popular revolts and the Civil War (1846–1847) exacerbated for some time.12 In general terms, the dates correspond to national growth trends, although the attraction of Lisbon was such that demographic recovery was rapid once the indispensable conditions for political and economic stability were met. After 1857, when the last traditional census took place and the last epidemic swept the capital, Lisbon grew moderately. Inhabitants totalled 179,000, equating to an annual growth rate of approximately 0.5 percent. The population then grew at a progressively faster rate, with a very intense period between 1878 and 1890. By the end of the nineteenth century, 7.1 percent of the Portuguese population lived in the capital and this percentage continued to grow until the middle of the twentieth century.13 (Table 2)

9

David Justino, A Formação do Espaço Económico Nacional. Portugal 1810–1913, 2 vols., Lisbon, 1988–1989.

10

Luís Baptista, “Dominação Demográfica no Contexto do Século XX Português”, Sociologia. Problemas e Práticas 15, 1994.

11

From 1807 to 1811.

12

We are talking about a period that starts arround 1807 and only ends in the 1860’s.

13

Teresa Rodrigues, Nascer e Morrer na Lisboa Oitocentista. Migrações, mortalidade e desenvolvimento, Cosmos, Lisbon, 1995.

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Table 2: Lisbon in the context of mainland Portugal (percentages and average annual growth rates) Year

Mainland Portugal

%

Lisbon

1801

–

6.3

–

1821

0.19

6.6

0.26

1835

0.08

7.0

0.36

1851

0.79

4.9

-1.01

1864

1.13

4.9

0.88

1878

0.59

5.6

1.69

1890

0.94

6.4

1.88

1900

0.75

7.0

1.56

1911

0.86

7.7

1.89

1920

0.14

8.6

1.29

1930

1.24

9.3

2.02

1940

1.24

9.6

1.61

1950

0.89

9.9

1.21

1960

0.48

9.7

0.24

1970

-0.21

9.4

-0.54

1981

1.29

8.7

0.56

1991

0.03

7.1

-1.95

2001

0.52

5.7

-1.60

From 1900 to 1960 Lisbon’s demographic dynamic was unique in the Portuguese context, several times above the national average. During the three first decades the number of residents in the capital grew by 1.8 percent each year, while the national average was 0.8 percent. Then, still within the period of an exceptional demographic situation, the rate of population increase slowed down in the capital and tended to come closer to the national average. Between 1930 and 1960 the Portuguese population increased 0.9 percent per year, while Lisbon increased by 1.0 percent. Nevertheless the weight of the city of Lisbon in the context of the future Metropolitan Area remained stable until 1930, but decreased steadily after. In fact, as the second part of the century went on, the city of Lisbon suffered its first loss of rhythm, followed by a rapid decrease in the last two decades. In Portugal growth

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rates were negative in the 1960s and increased artificially during the following decade as a result of people returning from the ex-colonies and from Europe. Mainland Portugal’s population stabilized between 1981 and 1991, then grew mainly for migratory reasons, but the total number of inhabitants of the capital dropped at an annual average rate of 2 percent. Thus during the last four decades one must talk about short phases of irregular growth which are clearly negative for the city, when compared to the remaining territory. This has happened because the relationship between Lisbon and its periphery is now different. Together they form the Lisbon Metropolitan Area, including eleven municipal districts on the north and south banks of the Tagus.14 In spite of all these changes, the numerical advantage of the capital is irreversible, enabling a unique “physical and population framework” to be built up around the city. Altogether, the urban or partially urban areas under Lisbon and Oporto’s influence account for almost half of the Portuguese population. Internally, the process of demographic growth reflects three different zones in the municipality, each of them playing different roles and being composed of several turning points. Until the last quarter of the nineteenth century, the historical zone exerted a clear demographic domination; during the next period there emerged an intermediate area, which dominated from 1930 to 1960.15 Finally, the results of the two last population censuses show a new reality. The peripheral area has gained the advantage, receiving more than half of Lisbon’s residents. This transfer from centre to periphery is also confirmed by density figures and each of these periods corresponds to different relations between stages of economic development, migratory movements and living conditions.

Urban growth, migration and health From here on our attention will be concentrated mainly on the last two aspects – migration and health. We have seen that very early on Lisbon was a magnet, attracting people from all over the kingdom. The idea of the capital as macrocephalous is a facet

14

They are the following: NORTH BANK – Cascais, Loures, Oeiras, Sintra, Vila Franca de Xira, Amadora; SOUTH BANK – Almada, Barreiro, Seixal, Moita, Montijo.

15

For a detailed description of this process see Ana Fernandes Santos and Françoise Royer Cruz, “Crescimento Urbano e Dinâmica Populacional: Análise da Cidade de Lisboa a partir dos Últimos Recenseamentos”, Actas do Colóquio Viver (N)a Cidade, Lisbon, 1990.

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of Portuguese history that has lasted for centuries, right down to the present day, and only temporarily altered.16 Lisbon’s growth was supported by internal immigration from all parts of the national territory, in spite of several conjunctures. Although we can find some differences concerning sources of information,17 when we look at the geographical basis of recruitment of the several administrative regions (distritos) that compose our country for the last 120 years or so, there is no doubt that Lisbon and its district showed a peculiar evolution relative to the national context. The capital’s labour market characteristics and opportunities explain what happened in the last two centuries. The different levels of migratory attraction must be connected to economic differences between districts and their job market evolutions, mainly urban job opportunities. As we already mentioned, until the middle of the nineteenth century there was slow demographic growth, due mainly to political instability. Then, the second half of the century was of moderate growth, although quicker in the last quarter. Until 1960 the rate of growth was unique in the national context, several times more than the average. And from then to our day there has been a loss of rhythm, followed by rapid decrease in the last two decades. (Table 3) Table 3: Lisbon’s migratory trends 1801–1851

reduced

1851–1890

moderate

1890–1960

intensive

1960–1981

moderate

1981–2001

reduced

Along with these specificities, Lisbon has also always showed original demographic behaviour regarding life and death. The Portuguese demographic transition probably started in the capital by the end of the nineteenth century.

16

Management of areas within administrative boundaries. See Urban Dominance and Labour Market Differentiation of a European CapitalCcity. Lisbon, 1890–1990, edited by Pedro Telhado Pereira and Maria Eugénia Mata (Kluwer Academic Publishers, Boston, 1996), chapter 3.

17

Census data have different shapes and consider different aspects for this matter.

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In fact, migratory movements explain Lisbon’s population growth. Altogether 75 percent of total population increase is due to immigration, as shown in Table 4, referring to the birthplace of Lisbon’s residents at the beginning of the twentieth century. Around 1900 52 percent of all registered people were born outside the city and this figure tends to be maintained in the next decades, following the trends of economic conjunctures. One century after (1981), 46.3 percent of Lisbon district inhabitants were born outside, and we must add about 20 percent to this figure where the capital city is concerned.18 For the next decade internal migration affected more than 635,000 people. Table 4: Birthplace of Lisbon’s inhabitants (1900) 52% – born outside 9% – from Lisbon’s surroundings 38% – from other parts of Portugal 5% – from other countries

As expected, migratory movements have a strong impact at different levels of collective behaviour and on the quality of life. 1. The most evident of these is related to changes in the characteristics of the population’s structure. A long-term analysis (from 1864 to 2001) makes it possible to find clear distortions in age structure, with a lack of young people and higher percentages for adults and elderly people. In fact, without migration Lisbon would have had structures reflecting higher age categories from the middle of the nineteenth century, something unimaginable in the Portuguese reality.19 The influence of migratory movements’ intensity provides internal differences in terms of spatial distribution.20 In fact, since the intensification of industrialization we can find a higher percentages of young people in quarters with higher immigrant levels.

18

In Portugal this percentage reached 22.5 percent. Custódio Conim, Portugal e a sua População, vol. II, Ed. Alfa, Lisbon, 1990.

19

Teresa Rodrigues, “Os Movimentos Migratórios em Lisboa. Estimativa e efeitos na estrutura populacional urbana de Oitocentos”, Ler História 26, Lisbon, 1994.

20

Teresa Rodrigues, “O balanço possível de um século de evolução demográfica”, Olisipo, IIª Série, no. 15, 2001, pp.115–122.

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Central and wealthier parishes have more aged people, popular quarters more and more children and young adults, as a result of both migration and the formation of new families. Differences tend to rise as the twentieth century goes on. This phenomenon is clear in the most popular quarters of the historical centre of the capital until 1890, than reaches the peripheral quarters until the 1960s. After that, migration intensity preferences transfer themselves to surroundings outside the town’s administrative area and, once more, the average age of Lisbon’s inhabitants grows. (Table 5). Table 5: Age structure of Lisbon inhabitants (%) Ages

1801

1900

1970

1981

1991

2001

0–14

37.2

35.0

20.0

18.9

14.2

13.0

65 +

7.4

7.8

11.4

14.3

18.8

21.8

2. Migratory movements influence other forms of demographic behaviour, especially those related to fertility and mortality. In fertility terms it explains the reason why the city presents the lowest fertility levels of the whole country. And this happens from the second half of the nineteenth century, when the Portuguese average was 4 children per woman but in Lisbon stood, except in most wealthy social groups, at 2 children per woman. In fact, generations have not been replaced in the capital since the second half of the nineteenth century, so migrations explain all the demographic growth rates of this specific urban population. Nevertheless there have always been distinct forms of social behaviour between groups separated by different income levels and, even more important, by different social status. These last were less influenced by the traditional reasons to migrate and their behaviour towards marital status, fertility and the family as a whole are quite distinct from those which prevailed in most parts of the urban centre. Let us recall some of the specificities of Lisbon’s situation. Among them is the importance of higher illegitimacy levels, which reached about 27 percent of all children born in the middle of the nineteenth century and 34 percent at the end, although some of them were brought from other parts of the country and did not belong to the city. These figures tend to stabilize after that, also because abandoning children receded as a social and generalized phenomenon.

179


Lisbon was the first place in Portugal where we have news about nuclear families formed by common-law couples. Paying guests or other persons in their charge created complicated relationships within these families in spite of the reduced number of members. As we progress in time the frequency of other kinds of marital unions (uniões de facto) rises, quite rare in the national context but representing by the end of the nineteenth century already 6 percent of all marriages, with a higher incidence in popular quarters. Celibacy and divorce rates have always been higher than in any other part of the country and they still are, although we can find in all Portuguese collective behaviour a trend towards uniformity. Some additional remarks should also be made concerning general mortality levels. Until the middle of the twentieth century it was clear that the city of Lisbon had the highest mortality levels of all. The existence of major risk groups such as abandoned children, mendicants and others explains this, as well as differences found in the major causes of sickness and death. Except for epidemic diseases, whose incidence was easily spread as a result of population density, Lisbon’s age structure and the fact that the biggest assistance institutions were close explains the relatively low IMR rates and different causes of death. For the past two centuries the latter have mainly been due to respiratory and circulatory problems (nineteenth-twentieth and twentieth centuries respectively) much more than to digestive causes, which prevailed in most parts of the country. As we reach the twentieth century there is a steady approach to the national average, as well as a change in the main causes of death and a small rise in the global death rate in the last two decades, due to the very high age structure of the population.

Migratory movements and changes in general indicators of mortality Although the following statement is more applicable to conditions in the nineteenth century, it seems clear that migratory movements influenced general indicators of mortality. In fact, there is a clear relation between factors like urban growth rates, the rise of immigration intensity and an increase in mortality. This conclusion can be clearly seen for the period 1878–1890, which witnessed the maximum rates of all indicators considered here. (Table 6)

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Table 6: Urban growth rate, immigration intensity and mortality levels in Lisbon (nineteenth century) Total annual average

Migratory annual average

growth (%)

growth (%)

Mortality global rates (‰)

1801–1857

0.0

- 0.8

24.9

1857–1864

0.8

- 0.1

33.5*

1864–1878

0.9

7.9

33.1**

1878–1890

3.2

16.8

28.1

1890–1900

1.5

11.0

21.2

* 1857: yellow fever; ** 1872–78: typhus.

There is also a connection between lack of information and instruction, lower incomes and lower life expectancy. Table 7 compares average expectancy of life in two urban parishes with different average incomes. The figures are clear. They show differences of 11 years at the beginning of the century, which increase when industrialization has its most spectacular growth. Table 7: Ignorance, poverty and life expectancy in Lisbon (nineteenth century) 1801 Wealthier parishes (Conceição) Popular parishes (Alcântara)

1864

1900

M

F

M

F

M

F

44.3

50.0

51.9

55.0

63.6

67.5

33.9

35.0

42.9

45.0

40.6

43.5

On the other hand, epidemic diseases also show a higher intensity and periodicity in popular quarters. In fact, beginning in the second half of nineteenth century mortality crises became a specific phenomenon of places with stronger percentages of immigrant populations. All the general diseases occurring in the capital were confined to the poor urban population. (Table 8)

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Table 8: Major mortality crises in Lisbon in the last two centuries Diseases

Years

Age groups

Cholera morbus

1888, 1892, 1894

All

Typhus exanthemicus

1871–72, 1875–76, 1885

All

Typhoid fever

1867, 1896

Adults

Yellow fever

1857, 1882

All

Smallpox

1888

Children

Pneumonia

1895

Adults

Flu

1868, 1889, 1895, 1917–19

Adults

As we enter the twentieth century differences between rich and poor persist, and there is no doubt that the residents with the lowest incomes are outsiders (immigrants). Until the middle of the century these differences had effects on the causes of disease and death, mainly with regard to tuberculosis and other contagious illnesses. Nevertheless, as the twentieth century progressed there came a gradual uniformity of ways of dying, as a consequence of a more effective public health system. Some private and public institutions and associations managed to support the cost of medical care and the teaching of preventive behaviour towards specific diseases. This new attitude had its most important effects in poor and less educated residents, who were, and still are, mainly immigrants.

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Health and Living Standards in Portugal in the Early Twentieth Century Joaquim da Costa Leite (University of Aveiro, Portugal)

The available estimates of life expectancy and infant mortality in Portugal at the beginning of the twentieth century constitute a first indication of Portuguese health standards. The first impression is that, in the European context, the situation was certainly not good – Portugal was clearly behind the countries of northwest Europe – but neither was it as bad as might be expected from other socio-economic indicators. For example, Portugal was lagging behind Italy and Spain in terms of literacy and income per capita, but seemed to be roughly on a par with them in terms of health. To what extent is this first impression the result of inaccurate data? What other factors should be taken into consideration? One of the fascinating aspects of vital data such as infant mortality and life expectancy is that they reveal the complex interaction of scientific, political, social and economic factors of a country, from statistical development and bureaucratic organization to medical assistance, infant care within and outside the family, public policy and general economic development. In this introductory discussion of health and living standards in Portugal in the early decades of the twentieth century I will discuss estimates of infant mortality and life expectancy both in terms of their internal consistency and reliability, and in a comparative perspective with other European countries, especially Italy and Spain.

The early twentieth century presents a good time framework to formulate such questions. Portugal had already undergone some significant changes in terms of industrialization and urbanization, but was still basically a backward rural society. This was a time of great disturbances, from record emigration to the violent interruption

183

Joaquim da Costa Leite

caused by the First World War and financial and political instability. It was likely to affect food supply and family incomes. Vital registration was also in a transitional stage, with some accumulated experience in the collection and publication of birth and death statistics, but with the system undergoing conceptual and organizational changes of uncertain consequences. Table 1 gathers some relevant data and suggests the nature of the problem. At the national level, the first data on death by age were published in 1906, concerning the years 1902–4. Ten years later these were published again, including data from 1902 to 1910.1 This means that before the early twentieth century any attempt to estimate infant mortality and expectation of life must either be limited to local studies based on parish registers or be done by indirect methods like population projection techniques. After 1902 it is possible to obtain estimates by direct calculation, other methods being important in order to verify or complement the available data. Table 1: Estimates of life expectancy at birth in Portugal Time period

Life expectancy

Method

Author

Source

1900–1913

M=44

F=48

Direct calculation

Bento Carqueja

(a)

1900–1911

M=43

F=46

Projected model life

J. Costa Leite

(b)

M. Leston

(c)

tables 1902

M+F = 44

1920/21

M+F = 39

Direct calculation

Bandeira

Sources: (a) Bento Carqueja, O Povo Portuguez: Aspectos sociaes e economicos (Porto: Livraria Chardron, 1916), pp. 458–9; (b) Joaquim da Costa Leite, “Population and Emigration: Projections and Estimates” (Mimeo); (c) Mário Leston Bandeira, Demografia e Modernidade: Família e Transição Demográfica em Portugal (Lisbon: Imprensa Nacional Casa da Moeda, 1996), table I.2, p. 438 (the table only gives distrito figures; these were weighted with the percentages of population in 1900 and 1920 to obtain national figures for 1902 and 1920/21 respectively).

Bento Carqueja does not indicate his sources, but he mentions Ricardo Jorge’s work, and he almost certainly had access to the vital data collected under his guidance by the

1

See preface by Ricardo Jorge to Arquivos do Instituto Central de Higiene, Secção de Demografia e Estatística, Tabelas do Movimento Fisiológico da População de Portugal. Decénio de 1901–1910 (Lisbon, 1916).

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Health and Living Standards in Portugal in the Early Twentieth Century

national health institute, probably including some unpublished data.2 Carqueja was well acquainted with the methods of calculation and the problems involved, using his data to discuss the Portuguese situation in comparison with other European countries.3 My own calculations used intercensal population projections based on model life tables – model South of Coale and Demeny – and emigration figures in order to arrive at estimates of net migration and expectation of life at birth. Mário Leston Bandeira used the earliest available published data to calculate infant mortality and expectation of life at birth, comparing the 1902 figures with those of 1920–21 to evaluate the quality of the sources. The three sources mentioned in Table 1 arrived independently at fairly consistent results for the early twentieth century. This is an interesting verification, but although it serves as confirmation of the consistency of the data underlying the calculations, it does not guarantee their accuracy. The problem is exposed by the comparison of Leston Bandeira’s estimates of the expectation of life at birth in 1902 and 1920–21: the same method of direct calculation from the same statistical series would point to a reduction from 44 years in 1902 to 39 years in 1920–21. The author considers such a reduction unlikely, interpreting it as a sure indication of underregistration in 1902. As a working hypothesis we may consider the figures for 1920–21 as fairly accurate.4 This seems acceptable not only in terms of the internal analyses of the Portuguese data, but also in comparative perspective. Table 2 shows that Portugal is well in line with available estimates of expectation of life at birth in Spain in 1920 and 1930, but markedly above them in 1900. This is a strong indication of underregistration and inflated estimates in the earlier date.

2

See Arquivos do Instituto Central de Higiene, Secção de Demografia e Estatística, Tabelas do Movimento Fisiológico da População de Portugal. Decénio de 1901–1910 (Lisbon, 1916) with a preface by Ricardo Jorge, pp. V–VII. Given the fact that Bento Carqueja provides a life table for the period 1900–1913, it is interesting to notice that Ricardo Jorge states that the figures for 1913 had been compiled and were then at the printing stage.

3

Bento Carqueja was a recognized expert of Portuguese statistics; together with Ricardo Jorge and others he was appointed to the Superior Statistical Council created in 1920; see Fernando de Sousa, História da Estatística em Portugal (Lisbon: Instituto Nacional de Estatística, 1995), p. 161.

4

This is in practice the position taken by Mário Leston Bandeira, who compares infant mortality rates in 1902 and 1921 to assess underregistration in 1902, distinguishing three different groups of distritos; op. cit, tables IV.1, IV-2 and IV–3, pp. 143–145.

185


Accepting these general guidelines should not, however, rule out two considerations. One is that the possibility of a temporary setback of health standards should not be completely dismissed. Periods of political instability and war – Portugal had a republican revolution in 1910 and later participated in the First World War – often have unsettling consequences in other areas, including food supply. This and a crisis in agriculture could lead to deteriorating nutrition and health.5 The practical stagnation observed in Spain between 1910 and 1920 points in the same direction. There is also the possibility that Portugal and Spain might experience significantly different conditions; otherwise we would simply bring down the Portuguese estimates to the Spanish level. The fact remains that, in spite of similarities, the two countries were different and there is no a priori reason why they would not have different mortality levels or follow a different chronology in their demographic transition.6 It is enough to notice regional differences within Spain concerning, for example, levels of infant mortality or urbanization to understand that we should not expect uniformity.7 Even if we think in terms of the Iberian Peninsula as a complex of regions cutting across national boundaries, Portugal and Spain would each constitute a territory with different proportions of the same basic regions, developing different socio-economic entities. Once this is understood, however, it is clear that the comparison between them is very useful as a first indication of plausibility when their values are close or as a warning signal when they diverge significantly.

5

There was a likely reduction of grain and meat consumption per capita from the first to the second decade of the century; see estimates in Pedro Lains, A Evolução da Agricultura e da Indústria em Portugal (1850–1913): Uma Interpretação Quantitativa (Lisbon: Banco de Portugal, 1990), tables 5 (p. 14) and 9 (p. 17).

6

This cautionary note is all the more important when we note that, in spite of the apparent precision of the numbers (sometimes with expectation of life calculated to the hundredth of a year), there are different estimates available, sometimes in the same volume; compare, for example, the Italian estimates in JeanPierre Bardet and Jacques Dupâquier, eds., Histoire des Populations de l'Europe. II. La révolution démographique, 1750–1914 (Ed. Fayard, 1998), tables 4 (p. 77), 113 (p. 526).

7

For a brief survey of regional differences in infant mortality and urbanization, see David Reher, “L’Espagne”, in Jean-Pierre Bardet and Jacques Dupâquier, eds., Histoire des Populations de l'Europe. II. La révolution démographique, 1750–1914 (Ed. Fayard, 1998), figures 114 (p. 547), 115 (p. 551).

186


Table 2: Estimates of life expectancy at birth compared

1860

Italy

Spain

32

30

1900 1910

35 47

Portugal 44

42

1920

41

39

1930

50

50

Sources: For Italy in 1862 and 1911 and for Spain, different sources quoted in Jean-Pierre Bardet and Jacques Dupâquier, eds., Histoire des Populations de l'Europe. II. La révolution démographique, 1750–1914 (Ed. Fayard, 1998), tables 113 (p. 526) and 129 (p. 546). For Portugal in 1902 and 1920–21 see Mário Leston Bandeira, Demografia e Modernidade: Família e Transição Demográfica em Portugal (Lisbon: Imprensa Nacional Casa da Moeda, 1996), table I.2, p. 438 (adapted; see note in table 1 above); for 1930 see Maria Luís Rocha Pinto and Teresa Rodrigues, “Mortalidade”, in Fernando Rosas and J. M. Brandão de Brito, eds, Dicionário de História do Estado Novo (Lisbon: Círculo de Leitores, 1996), vol. II, pp. 630.

Thus, we may take the values in Table 2 as an indication of accurate Portuguese estimates in 1920, while those for 1900 are probably wrong, perhaps grossly overestimating the expectation of life at birth. The republican revolution of 1910 proclaimed a new political regime, with an emphasis on education and a secular culture, independent from the Catholic Church. In practice, though, it did not achieve the required stability in order to put its programme to the test. But one of the areas where it acted quickly was vital registration. The statistics of births, marriages and deaths had been compiled and published since 1886 centrally by the state, but in practice this still depended on parish priests and, at the local level, there was no independent civil registration: the official statistics of births, marriages and deaths were based on the religious registration of baptisms, religious marriages and burials.8 This was a state of affairs that the new republican regime would not accept. A civil registration was instituted, and the corresponding statistics for 1911 bear the following note: “The elements relative to marriages, births, deaths and stillbirths were

8

This was not incompatible with some organizational improvements, such as the involvement of health authorities in the compilation of mortality data mentioned above, but the basis remained the religious registry; see footnote 2.

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supplied to this Directorate General (of Statistics) by the General Conservatory of Civil Registry, in harmony with the law of 18 February 1911”. 9 Did the change contribute to an improvement in registration? It would be reasonable to expect the contrary: as with any sudden and dramatic change, it might create disturbances to the old system while the new system would require time to organize itself and settle down on a regular basis; in the specific case of the republican regime, its political instability did not favour administrative regularity.10 Nevertheless, the task seems to have been carried out with zeal, apparently compensating for other shortcomings, because there is evidence of an immediate improvement, at least according to basic indicators. There was an obvious increase in registered births and deaths, but that by itself might be a coincidence. There was also an increase in marriages – which came under the jurisdiction of the new service, but where we would not expect any significant improvements in registration11 – and in emigration, which is explained by other factors. But beyond that, it is possible to note a telling detail: registered female births and deaths increased more than their male counterparts. Leaving aside 1910 as the year of revolution, Table 3 shows the comparison of vital registration in the period 1911–14 relative to 1906–09. While total male births increased by 16 percent and deaths by 4.4 percent, female births increased by 18.6 and 6.9 percent respectively. In both cases, the female registers gained about 2.5 percentage points. This is the sort of development that we might expect as a correction for underregistration. Table 3: Vital registration before and after the republican revolution Males

Females

Total

Births

116.0

118.6

117.2

Deaths

104.4

106.9

105.7

Births and deaths in 1911–14 relative to 1906–09 (percent). Calculated from Movimento da População.

9

See, for example, Movimento da População. Resumo. Anos de 1908 a 1912 (Lisbon: Imprensa Nacional, 1914), p. 15.

10

The difficulty of obtaining adequate financial means to collect and publish vital statistics is mentioned by Ricardo Jorge, in the preface mentioned above (see footnote 1).

11

Relative to 1908–9 the number of registered marriages increased by 19.3 percent in 1911–12.

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The male ratio at birth shows a corresponding adjustment. Table 4 shows that, starting from values significantly above 105 male live births to every 100 female live births before 1911, the ratio goes down to slightly below 105.12 This is a statistical correction corresponding to a social evolution from a traditional situation where females received less attention and consequently were more subject to underregistration, to a modern situation where they were – at least statistically – fully taken into account. Table 4: Male ratio at birth, 1908–12

1908

106.9

1909

105.9

1910

107.5

1911

104.7

1912

104.5

Male live births per hundred female live births Calculated from Movimento da População.

Another interesting aspect concerns the registration of stillbirths. The problems of definition in this area are not easy to solve, but they would be even more difficult from the point of view of a peasant or a parish priest, who would tend to give little importance to a stillborn child or to the death of a child before baptism.13 The registration of the stillborn involved a change from a religious to a secular perspective: the stillborn might be ignored from a religious point of view, but they counted as a statistical fact of the health condition of the population. Insignificant as it might seem, this was a good indicator of modernization.

12

The improvement could also be observed in terms of regional distribution. Considering the male ratios at birth in the 21 distritos of the mainland and islands, the average for 1908-9 was 105.8 (minimum 99.2; maximum 114.5; standard deviation 3.109), while in 1911–12 it went down to 104.8 (minimum 101.2; maximum 108.5; standard deviation 1.958).

13

See Louis Henry, Manuel de Démographie Historique (Geneva-Paris: Librairie Droz, 1970), pp. 12–13.

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Table 5: Stillbirths per thousand live births, 1908–12 Males

Females

Total

1908

17.4

12.3

15.0

1909

18.2

12.6

15.5

1910

16.8

12.3

14.6

1911

25.1

19.8

22.6

1912

40.4

31.6

36.1

Calculated from Movimento da População.

Table 5 shows that the registration of stillbirths relative to live births increased significantly in 1911, increasing further in the following year. Even before 1911, the registration of stillbirths can probably be interpreted as a positive sign of the involvement of the health authorities in the compilation of vital data, an involvement that became more straightforward and politically supported after the creation of civil registration. Thus, in practical terms and from the point of view of the reliability of the data, it is reasonable to conclude that if the civilian authorities – as opposed to religious authorities – at the various levels of the state administration were able to understand and compile the statistics of the stillborn, they must have been capable of compiling accurate data on live births and infant deaths. The other aspects discussed above on increased birth registration generally, and male ratios at birth, confirm this interpretation. The preceding analysis makes clear that it is necessary to be cautious about vital data prior to 1911, but it does not mean that we cannot use them. For example, despite underregistration in 1902, it is possible to gain from the available figures some idea about differences in regional mortality levels. In the specific case of infant mortality, underestimation was almost certainly not evenly distributed across the territory, but it does not necessarily eliminate the picture of overall distribution.14 There is a reasonable consistency in the data: in a simple test, taking infant mortality rates in 1902 as an independent variable, a linear regression explains sixty percent of the regional variation of infant mortality in 1920–21.15 In other words, if we account for different mortality

14 15

Concerning regional differences in underregistration, see footnotes 4 and 18. Including the 21 distritos, the regression coefficient is R2=0.613.

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levels in the two periods concerned, and while admitting some regional distortion caused by deficient registration in the earlier date, infant mortality in 1902 could still be considered a good predictor of infant mortality in 1920–21. Starting from this assumption, I have tried to explain regional variations in observed infant mortality across the seventeen distritos of the mainland.16 Using different socioeconomic indicators, I found two basic types of significant factors, one concerning the predominant agrarian system, the other accounting for the urban component. The agrarian system was represented by the major grain crop as a proportion of the total production of maize, rye and wheat harvested in the distrito. This should not be interpreted as a simple indicator of food availability or diet system, but rather as a complex indicator of the associated agrarian system. Maize, for example, was the major grain crop in the northwest, a region of small landholdings, diversified agriculture and diffusion of property.17 As far as the urban component is concerned, the influence of Lisbon and Porto – the only cities with more than 100,000 inhabitants in 1911 – was tested as a dummy variable, assigning the value of one to the respective distritos and zero to the others. Table 6 shows that the agrarian system on the one hand, and the city environment of Lisbon and Porto on the other, account for much of the observed variation in infant mortality rates. In the maize regions, the apparently less unequal distribution of property and crop diversification contributed to lower the rates of infant mortality. At the other extreme, the urban environment of Lisbon and Porto was simultaneously more unequal and favourable to the spread of infectious diseases, causing higher mortality. The rural areas, including the region of rye in the northeast, were generally more benign, but in this respect it is possible to notice a change during the early decades of the century.

16

The four island distritos were initially included in the tests, but some of the variables were available only for the mainland; still, insofar as the issues in question are probably not independent of territorial continuity and the availability of land communications, the exclusion of the islands finds some justification.

17

Such indicators were found to be significant in explaining, for example, the regional variations of emigration rates in the late nineteenth and early twentieth centuries; see J. Costa Leite, “Portugal and Emigration, 1855–1914” (Columbia University: Ph. D. Dissertation, 1994), esp. pp. 512–15; id., “Portugal and the International Economy: Emigration and Protectionism, 1890-1910" in Jaime Reis et al., ed. “Actas do XIX Encontro da Associação Portuguesa de História Económica e Social” (Funchal: Universidade da Madeira, 1999) (mimeo).

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Table 6: Regional factors in infant mortality rates IMR 1902

IMR 1920–21

Constant

189.719

142.501

Maize

-99.730

-19.071

(-5.560)

(-1.863)

-59.605

30.168

(-1.790)

(1.588)

74.351

27.180

(4.104)

(2.628)

0.781

0.513

Rye LisPort R2

Notes: Results of linear regressions (t-values in parentheses). Maize and rye are variables representing the percentage of the respective grain in the production (tons) of maize, rye and wheat harvested in 1903. LisPort is a dummy variable for Lisbon and Oporto. Sources: For infant mortality rates see Mário Leston Bandeira, Demografia e Modernidade: Família e Transição Demográfica em Portugal (Lisbon: Imprensa Nacional Casa da Moeda, 1996), table I.4, p. 440. For grain production in 1903 see Annuario Estatístico de Portugal. 1903.

Comparing the situation in 1902 and 1920–21 the equations show that in the rye region the differentiating factor evolved from favourable to unfavourable – there is a change of sign – which can be interpreted in connection with a crisis of the agrarian system, also revealed in high emigration rates and an actual loss of population. Maize maintained a negative sign – infant mortality was lower in the northwest – but reduced its impact. Since the distritos in the maize and rye regions were probably more affected by underregistration in 1902, the reduction in one case and change of sign in the other might be attributed to a statistical correction, not to a real change in the regional situation.18 This is possibly a contributing factor, but the comparison of the two equations points to something more substantial: on the whole, the agrarian and city factors become less relevant, and taken together they lose explaining power, the regression coefficient decreasing from 0.781 to 0.513. There is a moment in demographic transition when urban centres – even large cities – become more organized and generally healthier than the rural areas, reversing the

18

The northern distritos, with the notable exception of Oporto, constitute the group characterized by the likeliest underestimation of deaths in 1902; see M. Leston Bandeira, op. cit, table IV.1, p. 143.

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traditional situation. If we notice that in Spain this seems to have happened around the 1920s, it suggests a relevant factor for Portugal as well.19 Table 7: Regional factors in life expectancy at birth Exp life 1902

Exp life 1920–21

Exp life 1920–21

Constant

41.787

42.658

43.699

Maize

12.571

1.691

---

Rye LisPort R2

(6.483)

(0.756)

---

-4.707

-19.182

-20.315

(-1.308)

(-4.622)

(-5.332)

-15.935

-7.113

-7.045

(-8.136)

(-3.150)

(-3.171)

0.894

0.713

0.700

Notes: See Table 6. Sources: For expectation of life see Mário Leston Bandeira, Demografia e Modernidade: Família e Transição Demográfica em Portugal (Lisbon: Imprensa Nacional Casa da Moeda, 1996), table I.2, p. 438. For grain production in 1903 see Annuario Estatístico de Portugal. 1903.

Table 7 shows the results of a similar exercise to explain the expectation of life at birth. In this case we notice a positive contribution of the maize area that becomes almost irrelevant, while the negative impact of the rye area is noticeable from 1902, increasing to 1920–21. Here again the effects of underregistration might possibly play a part, but the overall change is similar to the case of infant mortality discussed above. As in Spain, the change in the urban environment had an earlier impact on the reduction of infant mortality, and later on older age groups. In Portugal the situation was evolving in the same direction, but the equations in Tables 6 and 7 show that in 1920 the influence of Lisbon and Porto on health standards was still negative and statistically significant. In order to obtain a first indication of the chronology of the change in the urban environment, I have tried to assess its impact on the evolution of mortality. Instead of regressing infant mortality or expectation of life at birth on a specific date with other possible causal factors at the same date, I tried to observe whether the share of

19

For Spain see Reher, op. cit., pp. 547–8.

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population living in centres with more than five thousand inhabitants could explain the change in mortality conditions between different time periods. Thus, I am not simply testing the possible impact of the larger cities of Lisbon and Porto, but rather the wider influence of the urban environment. Table 8 shows the results. Table 8: The urban environment and mortality Dependent variable Constant 1

2

3

4

IMR 1910

IMR 1921

ExpLife 1921

ExpLife 1941

78.762

54.199

60.471

71.414

Independent variables 0.217 IMR 1902

1.186 Urb 1911

(1.825)

(3.082)

0.643 IMR 1915

-0.777 Urb 1920

(5.696)

(-2.817)

-0.159 IMR 1915

0.233 Urb 1920

(-3.464)

(2.081)

-0.166 IMR 1931

0.085 Urb 1940

(-5.383)

(1.875)

R

2

0.728

0.751

0.493

0.702

Notes: Results of linear regressions (t-values in parentheses). The variables are Infant Mortality Rates (IMR), Expectation of Life at birth (ExpLife), and Urban Rates (Urb) for the respective dates. Urban rates are calculated as the percentage of people living in centres with five thousand or more inhabitants in each distrito. Sources: For expectation of life at birth and infant mortality rates see Mário Leston Bandeira, Demografia e Modernidade: Família e Transição Demográfica em Portugal (Lisbon: Imprensa Nacional Casa da Moeda, 1996), table I.2 (p. 438), and table I.4 (p. 440). For urban rates see Ana Bela Nunes, “Portuguese Urban System, 1890–1991” in Pedro Telhado Pereira and Maria Eugénia Mata, eds., Urban Dominance and Labour Market Differentiation of a European Capital City: Lisbon 1890–1990 (London: Kluwer Academic Publishers, 1996), table A.1, pp. 32–44 (adapted).

The four equations present different degrees of consistency and explanatory power, but on the whole they lead to the same conclusion: the urban environment was unhealthier than the rural areas in 1910, becoming healthier in the following early decades of the century.20 While in the cases of Lisbon and Porto the negative influence

20

Each equation comprises variables either before or after the introduction of civil registration, so that in this case underregistration should not be a factor.

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could still be felt in 1920, small and medium-sized towns seemed by then to be already better than the surrounding countryside.21 It should be emphasized that, in the circumstances of the time, the change must not be interpreted strictly in terms of relative improvements in hygiene or sanitary conditions in the urban centres. Food supply could play an important role, and this was not just a question of agricultural production, but depended on the transportation and commercial network, and was subject to government policy.22 Infant mortality is a key demographic indicator, reflecting the interaction of socioeconomic variables from the economy to the environment, from the family level to public policy. And as we have seen, its importance starts even before we have any estimates, for the registration of stillbirths and infant deaths provides a good indication not just of the bureaucratic efficiency in the collection of vital statistics, but also of conceptual knowledge, the practice of medicine and sanitation, and social awareness. The observed male ratios at birth in the beginning of the twentieth century, for example, constitute the statistical evidence of less attention being paid to the birth and death of baby girls relative to boys. We have seen that after the republican revolution the introduction of civil registration resulted in a noticeable improvement in the collection of vital data. Thus, estimates of infant mortality and life expectancy, which seem benign before 1911, must be interpreted as a consequence of innacurate registration. The available figures after 1911 seem credible, and are generally in line with contemporary figures for Spain. This, however, raises the problem of the relationship of demographic conditions, the standard of living and economic development. Table 9 compiles different indicators from selected European countries in the early twentieth century. Although different kinds of indicators tend to advance in the same direction – agricultural productivity, income per capita, height and expectation of life all tend to increase with economic development – each indicator has its own characteristics and some degree of autonomy. For example, the Scandinavian countries (here

21

The change of sign, from (+) to (-) in the case of infant mortality and from (-) to (+) concerning life expectancy, occurred just before 1920.

22

Although outside the scope of this study, it would be interesting to test whether the republican regime was capable of enforcing an adequate supply for the urban centres, where it counted its supporters.

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represented by Sweden) enjoyed a clear lead in stature and longevity, far earlier and ahead of what might be expected of their income per capita. In another example, the Irish were tall but poor relative to the English. There are also problems of comparison and accuracy of the estimates.23 Table 9: Demographic and other indicators compared

Sweden

Exp

Life

Height

AgriProd GDPcap

1910

1920

1910

ca. 1906

1913

56

–

171.7

227

3096

UK *

54

–

–

360

4921

France

50

–

166.4

254

3485

Italy

45

–

163.9

98

2564

Spain

42

41

163.7

125

2255

Portugal

–

39

163.5

100

1244

* England and Wales in the case of expectation of life at birth. Notes: The indicators are expectation of life at birth; height of adult males in centimetres; agricultural productivity in equivalent caloric content by male agricultural worker as a percentage of Portuguese productivity; and gross domestic product per capita in 1990 international dollars. Sources: For expectation of life at birth see Graziella Caselli, France Meslé and Jacques Vallin, “Le triomphe de la médecine”, in Jean-Pierre Bardet and Jacques Dupâquier, eds., Histoire des Populations de l'Europe. III. Les temps incertains, 1914–1998 (ed. Fayard, 1999), table 23, p. 134 (adapted). For height data see Roderick Floud, “The Heights of Europeans since 1750: A New Source for European Economic History”, in John Komlos, ed., Stature, Living Standards, and Economic Development: Essays in Anthropometric History (Chicago: The University of Chicago Press, 1994), table 1.1 pp. 16–19; for Spain see A. Gómez-Mendoza and V. Pérez-Moreda, “Heights and Welfare in Spain, 1900–1930” in John Komlos (ed.) The Biological Standard of Living on Three Continents (Boulder, Col., 1995), table 4.2 p. 87. On agricultural productivity see Pedro Lains, A Economia Portuguesa no Século XIX: Crescimento Económico e Comércio Externo, 1851–1913 (Lisbon: Imprensa Nacional Casa da Moeda, 1995), table 2.6 p. 55. GDP figures in Angus Maddison, The World Economy: A Millennial Perspective (OECD, 2001), table A1–c, p. 185.

23

Concerning the use of Portuguese height data, see Joaquim da Costa Leite, “Male Height in Northwest Portugal in the 1890s: Old Data Revisited” in John Komlos and Joerg Baten (eds.) The Biological Standard of Living in Comparative Perspective (Stuttgart, 1998), pp. 459–66; id., “Height and Welfare in the Portuguese Northwest in the 1890s: Sources and Issues”, in “Actas do XX Encontro da Associação Portuguesa de História Económica e Social” (Porto: Universidade do Porto, 2000) (mimeo).

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All estimates deserve further consideration, but in general it can be said that the southern European countries were clearly behind the others in every respect. Within the southern European context, Portugal was poorer than Spain and much poor than Italy, and yet in terms of physical well-being and expectation of life it was fairly close to the other two. This observation deserves comment, even though brief. There are perhaps three major relevant factors. The first is that, differences in monetary product per capita notwithstanding, in Portugal the agricultural productivity in terms of caloric content was of the same order of magnitude as in Spain and Italy: apparently worse than in Spain, just about the same as in Italy.24 The second factor is that, in comparison with other regions of the continent, the three southern European countries shared basic geographical and climatic characteristics, which had some common implications for other factors, namely agriculture and the disease environment.25 And the third factor is that, in spite of the different degrees of economic development, their urban rates were similar, which probably created similar conditions both in terms of the problems raised and the solutions adopted.26 Another factor might still be considered in this context: the so-called early economic growth puzzle. It has been observed that in the nineteenth century initial progress in

24

The method of estimating agricultural productivity in terms of calories rather than cash was used by Paul Bairoch for several countries; Espinha da Silveira made an equivalent estimate for Portugal, subsequently revised by Pedro Lains. See references and estimates in Pedro Lains, A Economia Portuguesa no Século XIX: Crescimento Económico e Comércio Externo, 1851–1913 (Lisbon: Imprensa Nacional Casa da Moeda, 1995), table 2.6 p. 55.

25

Not by accident, latitude is generally found to be a relevant variable in regressions accounting for variations in income per capita; see Xavier Sala-i-Martin, “I Just Ran Two Million Regressions”, The American Economic Association Papers and Proceedings, vol. 86 (Maio de 1997), pp. 178–83; also David S. Landes, The Wealth and Poverty of Nations: Why Some are So Rich and Some So Poor (Nova Iorque: W. W. Norton, 1998); John Luke Gallup and Jeffrey D. Sachs (com Andrew D. Mellinger), “Geography and Economic Development” CAER (Consulting Assistance on Economic Reform II, Harvard Institute for International Development) Discussion paper no. 39, March 1999.

26

The share of the urban population in the total population was 8 percent in Spain in 1900; in 1910 it was 10 percent in Portugal and 11 percent in Italy; see Maria Eugénia Mata and Pedro Telhado Pereira, “A Century of Urbanization in Portugal and Europe: Some International Comparisons” in Pedro Telhado Pereira and Maria Eugénia Mata, eds., Urban Dominance and Labour Market Differentiation of a European Capital City: Lisbon 1890–1990 (London: Kluwer Academic Publishers, 1996), table 4, p. 183.

197


industrialization and economic growth, evident in terms of income per capita, did not translate into an improvement in physical well-being measured in adult height of the population. Either because of more intensive work efforts, limitations in food supply, distortions of purchasing power or an increasing concentration in large urban centres propitious to the spread of infectious diseases, early economic improvements may coincide with a worsening health condition of the population.27 Taken together, the three southern European countries may present in the early twentieth century an interesting example of the puzzle, where the Italian economic lead was only modestly translated into better life expectancy but not average stature. It is possible that economic, medical and administrative improvements were by then reducing the impact of the early economic growth puzzle. This would result in a clear advantage for Italy and Spain, with their higher incomes per capita. But in the early decades of the century, the monetary poverty of the Portuguese population was not as strongly felt in terms of their health standards.

As a relatively backward society with an anchor on modernity, Portugal in the early twentieth century reveals itself as an interesting case study. Essentially rural and traditional, the country’s old routines were being changed by emigration and the influence of an urban-industrial component, small but important enough to establish patterns of cultural and political leadership. Predominantly Catholic, it was being challenged by a radically secular republican regime, one of the first on the Continent. This specific transitional character of Portuguese society raises particular issues and methodological problems that, although not entirely original, require a wider framework of analysis, going back to classical references which tend to be forgotten in the study of more developed societies. To start with, this reminds us that statistics are a social product. Not only in the obvious sense that the collection and publication of data are carried out by a statistical office or institute organized and funded by the political system, and thus ultimately

27

For an introduction to the issue and a discussion in contemporary context, see Henk-Jan Brinkman and J. W. Drukker, “Does the Early-Economic-Growth-Puzzle Apply to Contemporary Developing Countries?” in John Komlos and Joerg Baten (eds.) The Biological Standard of Living in Comparative Perspective (Stuttgart: Franz Steiner, 1998), pp. 55–89.

198


dependent on the importance attached to it by society, but also because the efficiency of the statistical system itself depends on the prevailing habits, methods and concepts of ordinary people and the agents reporting the primary data. They can only report what they can see and recognize. Geography must be brought back into the equation. It affects the disease environment and the agrarian system in multiple ways. Economic and cultural modernization may influence and gradually change the relevance of the geographical factor, but it provides a basic reference. Climate is an essential element of the disease environment, and the model life tables by Coale and Demeny can be seen as the stylized evidence of its impact: a given level of expectation of life at birth is reached in different parts of Europe through different combinations of age-specific mortality. The agrarian system, with its attendant property structure, work patterns and cultural habits, constitutes the basic reference to the relative abundance, composition and distribution of foodstuffs. It also determines the prevailing workload and interacts with the disease environment. For example, different agrarian systems require and feed different animals, with different densities and different degrees of proximity with human beings. There are regions where people occupy the first floor of houses, with cows lodged in the ground floor, whereas in other regions cows are kept in stables across the courtyard from human dwellings. Such concrete arrangements have implications for hygiene and sanitation. Finally, a reference to the urban factor. Whereas in the traditional urban centres the concentration of people made them especially vulnerable to the spread of infectious diseases, in modern towns and cities it became possible for local and central governments to implement measures with a rapid and significant impact on the lives of a large number of people. Concentration was turned into an advantage. While climate and the agrarian system are differentiating factors, dividing the European continent into different areas and regions, the urban component provides a measure of convergence. The international circulation of ideas and the communication of experiences and best practices among political leaders, administrative cadres, experts and professionals such as doctors and urban planners established across the Continent a network of modernization. Firmly established in national capitals and large urban centres, political and professional elites promoted themselves as they learned, fought for and carried out reforms improving the health standards and living conditions of the population.

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The Health of the Population and Health Policy in 19th-century Bohemia: The Case of Asiatic Cholera (1830s−1900s) Petr Svobodný (Charles University, Prague, Czech Republic)

Asiatic cholera in Europe At the beginning of the nineteenth century a new infectious disease appeared in Europe. Known as Asiatic cholera, its dramatic course, mass scale and lethal consequences made it one of the greatest global threats to mankind for many decades. The main symptoms of this disease of the digestive tract were violent diarrhoea and vomiting, usually appearing 2−5 days (but sometimes only a few hours) after infection, muscular spasms, insatiable thirst as a result of dehydration, a fall in the heart rate and finally overall lethargy. Mortality was very high (50−60 percent, and as much as 90 percent among children and elderly people). Until Robert Koch discovered the bacillus Vibrio cholerae in 1883, doctors could only guess at its cause, and there was no effective means of prevention, let alone treatment.1 Outbreaks of cholera had occurred on the Indian sub-continent for centuries, and from there the disease spread first to the Arabian Peninsula as a result of Muslim pilgrimages and later to other continents with the great expansion in overseas trade.2 The first pandemic of 1817−1823 only spread as far as the outlying areas of the Russian Empire, but the next were to advance mercilessly into Europe. The second pandemic of 1826−1837 spread from India through Central Asia into European Russia (1830 was the

1

For comprehensive information on the disease see Dhiman Barua and William B. Greenough (eds.), Cholera, New York 1992.

2

Authors have sometimes differed in the periodization of pandemics. Here the periodization is stabilized following Stefan Winkle, Kulturgechichte der Seuchen, Düsseldorf - Zürich 1997, p. 153 ff.

200

The Health of the Population and Health Policy in 19th-century Bohemia: The Case of Asiatic Cholera (1830s−1900s)

“Russian cholera year”).3 Military campaigns, in this case the Russian suppression of the Polish Uprising, created favourable conditions for the spread of the disease, as they did on many subsequent occasions. The first countries to be hit were Prussia4 and Austria (including the Czech lands), and then other German states, in 1832 England5 and France, and in later years the rest of Europe and North America. Military activities (the Opium War of 1840−41, the European revolutions of 1848/49 and the Crimean War of 1853−56)6 also played a major role in spreading the third pandemic of 1841−1862. Traditional measures from the time of the plague such as the imposition of cordons sanitaires at the frontiers of empires, countries, provinces and towns proved ineffective in the face of the new threat. It was during this wave that doctors, scientists and civil servants in various parts of Europe first noticed the connection between the catastrophic living and hygiene conditions brought by industrialization and urbanization and the spread of infectious diseases (E. Chadwick, J. Snow and M. Faraday in London, M. Pettenkofer in Munich). The fourth pandemic of 1864−1875 struck particularly hard in Central Europe, where the Austro-Prussian War of 1866 (with the major battles on Bohemian territory) assisted its catastrophic spread. During this wave, doctors, including Central European doctors, moved from theorizing to action. The dispute about the precise origin of the disease had not yet been entirely resolved, but the solution – the sanitation of towns (above all by building modern water mains and sewers) – was one on which experts of all schools agreed. The fifth pandemic of 1882−1896 brought a denouement in both respects. Koch discovered and experimentally proved the origin of the disease during outbreaks in Egypt (1883) and India (1884). At the same time the dramatic course of the disease in Hamburg (1892) demonstrated the effectiveness of modern hygiene and public health

3

Roderick E. McGrew, Russia and the Cholera 1823−1832, Milwaukee 1965.

4

Barbara Dettke, Die asiatische Hydra: die Cholera von 1830/31 in Berlin und den preussischen Provinzen Posen, Preussen und Schlesien (Veröffentlichungen der Historischen Kommission zu Berlin, Bd. 89), Berlin−New York 1995.

5

Robert J. Morris, Cholera 1832: the Social Response to an Epidemic, London 1976.

6

On the role of political events see Richard J. Evans, “Epidemics and Revolutions: Cholera in Nineteenth -century Europe”, in Terence Rynger and Paul Slack (eds.), Epidemics and Ideas: Essays on the Historical Perception of Pestilence, Cambridge 1992, p. 149−173.

201

Petr Svobodný

measures and the tragic results of neglecting them. The sixth pandemic after 1899 did not affect Central and Western Europe.7

Epidemics of Asiatic cholera in the Czech lands The mortality curve in the Czech lands for the years 1830–1900 shows nine distinct peaks (1831/32, 1836/37, 1843, 1847, 1850, 1855, 1866, 1872/73, 1877/78) when overall mortality rose higher than 30 per mille. In most (six) cases, the cause of the unusually high mortality rate was an epidemic of Asiatic cholera. The first of these hit the Czech lands at the turn of the years 1831/32 (overall mortality 37.8 per mille), the second in 1836−37 (34.1 and 33.6 per mille), the third at the turn of the years 1849/1850 (34.9), and the fourth in 1855 (34.4 per mille). The fifth wave of cholera in the Czech lands was coincident with the Austro-Prussian War, and so the extreme mortality (44.7 per mille, the second highest since the Napoleonic Wars and accompanying epidemics) arose from a combination of the two causes. The last – sixth – cholera epidemic struck the Czech lands in 1872−73, when it was accompanied by a smallpox epidemic that caused drastic mortality especially among infants. (A smallpox epidemic had also caused a rise in mortality in 1847. The last great epidemic of infectious diseases in the nineteenth century was the epidemic of smallpox and measles in 1877−78.)8 In Prague, the capital of the Lands of the Bohemian Crown (at that time part of the Austrian Empire), Asiatic cholera first appeared at the end of November 1831, and by the end of December was rife in all its districts. In 1831 every twenty-fourth Praguer died of the disease, and in 1832 every twentieth (a total of more than 4,500). Outside Prague, it was Brno in Moravia that was worst hit by cholera, which raged there from

7

From the rich literature on the history of nineteenth -century cholera epidemics in Europe see at least the most relevant titles: Richard J. Evans, Death in Hamburg: Society and Politics in the Cholera Years 1830-1910, London 1990; Francois Delaporte, Disease and Civilization: the Cholera in Paris 1832, Cambridge (Mass.) 1986; Catherine J. Kudlick, Cholera in Post-revolutionary Paris: a Cultural History, Berkeley 1996; Brigitta Schader, Die Cholera in der deutschen Literatur (Schriftenreihe der Münchener Vereinigung für Geschichte der Medizin e. V., Bd. 16), München 1985; compare footnotes 5 and 6 as well.

8

Jan K. Stříteský, Zdravotní a populační vývoj československého obyvatelstva [Health and Demographic Development of the Czechoslovak Population], Praha 1971, pp. 26, 50; Vladimír Srb and Milan Kučera, “Vývoj obyvatelstva českých zemí v 19. století” [“The Population in the Czech Lands in the Nineteenth Century”], in: František Egermayer (ed.), Statistika a Demografie, Praha 1959, pp. 124−125.

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September to January. In the second pandemic it was Brno that suffered most (August – November 1836), in the third pandemic Prague (May 1849–March 1850) and Brno (June–October 1849), and the pattern was the same in 1855. In 1866 the Prussian army brought cholera into Bohemia. The disease spread from eastern Bohemia along the main routes (roads and railways) to Prague and Brno (where it broke out at the end of July, and was at its height in September). In Bohemia alone (excluding Moravia) almost 68,000 people caught cholera and more than 31,000 of them died. In 1872−73 cholera was brought into Bohemia again, this time by military conscripts from Galicia.9 The fifth cholera pandemic did not, however, affect Bohemia and Moravia and thereafter only isolated cases of the disease were recorded in the area, usually under the euphemistic title of cholera nostras, domestic cholera, or cholerine.10

Anti-cholera measures and their results for public health The old health policing system designed to control epidemic diseases (in Austria based on the work of J. P. Frank), and especially cordon sanitaires and quarantine measures, proved unable to prevent the spread of cholera epidemics. Especially at the beginning of the 1830s the disease spread like wildfire in what was virgin territory. Ignorance of its origin, the resulting helplessness of doctors as far as any treatment was concerned and, in any case, a shortage of doctors only made matters worse, but as in the more advanced countries of Western Europe, in Central Europe too (including the Czech lands), this new “scourge of humanity” became a stimulus to the development of public health, community hygiene and medical science.11

9

Antonín Wiesner, “Z dějin epidemií nakažlivých nemocí v Československu” [“From the History of epidemics of infectious diseases in Czechoslovakia”], Časopis lékařů českých 66, 1927, pp. 1916−19, 1955. Detailed data on rates of disease and mortality, especially in the epidemics of 1831/32, 1849 and 1866 in: Wiesner, “Z dějin”, pp. 1916-17; data for 1831/32 and 1866 taken from Emerich Maixner, “O choleře po klinické stránce” [“On Cholera from the Clinical Point of View”], Časopis lékařů českých 50, 1911, p. 872; data for 1866 Srb and Kučera, “Vývoj obyvatelstva”, p. 124, 128.

10

Winkle, Kulturgeschichte, p. 225; Maixner, “O choleře”, pp. 874, 950.

11

The impact of cholera epidemics on physicians' corporate consciousness, on public health policy and organization and on medical professionalization and modernization can be observed as an advance in the direction opposite to the spread of the disease itself – from Western Europe through Central Europe to Eastern Europe. See Morris, Cholera 1832; Delaporte, Disease and Civilization; Evans, Death in Hamburg; Nancy M. Frieden, “The Russian Cholera Epidemic, 1892−1893, and Medical Professionalization”, Journal of Social History, Vol. 10, 1976−77, pp. 538−559. On the professionalization of medical and public health experts in the Czech lands see: Petr Svobodný, “The Professionalization of Czech Physicians, 1848-1939”, in: Charles McClelland, Stephan Merl and Hannes Siegrist (eds.),

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In Prague the anti-cholera measures in 1831/32 were directed by the Bohemian Provincial Proto-Medicus and Director of Medical Studies Ignác Nádherný (1789−1867), an unusually talented, enterprising and industrious organizer. At the beginning of the year he had already been sent by the central Vienna authorities to Galicia, the first place in the empire to be hit by cholera. He was unable to prevent its spread, and so returned to Prague where he organized practical help for the sick. The first cholera hospital was opened at the end of November and several days later every district had at least one such hospital of its own (a total of seven plus other beds in previously established hospitals). At this period Prague had 95 physicians and 46 surgeons (Wundärzte), with four official city physicians, six surgeons and unpaid volunteers entrusted with the care of the indigent sick. Official physicians (the four city and sixteen regional doctors) were supposed to care for the indigent sick in rural areas as well. In practice, however, the care of the Prague and rural doctors was an entirely formal arrangement, and for this reason the Bohemian regions were provisionally divided into cholera districts, to which more doctors, surgeons and medical students were officially assigned. The disastrous experience with the new epidemic disease exposed the formalism and deficiency of the existing public health service founded on the Imperial Health Regulations of the Austrian Monarchy (Generale normativum in re sanitatis) of 1770 and the Provincial Health Regulations for Bohemia of 1773. Nádherný succeeded in exploiting the experience of failure to pressurize the authorities in the direction of improving the health system, although his proposals were significantly ahead of his time and were only implemented to a very limited extent or – naturally in changed form – some time later. By the end of 1833 he had managed to achieve an increase in the number of paid city physicians in Prague to seven, but his project of 1832−1835 for the setting up of 55 health districts with state-salaried physicians was not implemented.12 The establishment of official physicians for each existing legal administrative district had to wait until the overall reform of the Austrian health system on the basis of the law

Professionen im modernen Osteuropa/Professions in Modern Eastern Europe (Giessener Abhandlungen zur Agrar- und Wirtschaftsforschung des europäischen Ostens, Bd. 207), Berlin 1995, p. 145−167. 12

Ludmila Hlaváčková and Petr Svobodný, “Generální raport o asijské choleře v Praze, Vídni a Mnichově” [“General Report on the Asiatic Cholera in Prague, Vienna and Munich”], Documenta Pragensia 16, 1998, pp. 258−9, literature listed there; on the project see especially Ludmila Hlaváčková, “Pokus o ustanovení okresních lékařů v Čechách v letech 1832−35” [“An Attempt at Establishing Official District Physicians in Bohemia in 1832/35”], Archivní časopis 1968, pp. 87−99.

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on public health administration (no. 68/1870 Coll. of Laws), and the establishment of paid community or specially designated health district physicians came even later, with the appropriate provincial laws (for Moravia 1884, for Bohemia 1888 and for Austrian Silesia 1893).13 It was precisely the official physicians – at the district, community and health district levels – who at the end of the nineteenth century played the crucial role in the fight against epidemics (statistics, prevention, hygiene, curative and social aspects). The work of the community of district physicians in this field was undoubtedly one of the reasons for the striking decline in mortality in the Czech lands from the early 1890s onwards. This effect was most conspicuous in the dramatic fall in disease and mortality rates from smallpox (the result of state funded and inspected immunization).14 Here it is interesting to note the conclusions of some historians of medicine who claim that the obstructionism of Czech national politicians (and doctors) towards their German liberal counterparts held up reform of the health system in the Czech lands and therefore delayed its positive effects on the health of the population for nearly two decades (from the issue of the imperial norms of 1870 and issue of the provincial norms at the end of the 1880s and beginning of the 1890s).15 I shall comment only briefly on the other epidemics and their connection with the system of health care. The embarrassment of doctors in the face of their inability to halt the spread of the disease is evident in the specialist literature of the time. In addition to statistical data on the spread of the cholera and thoughts on its possible origin (see below), publications by doctors from Bohemia (mainly associated with the Prague Medical Faculty) contained a range of suggestions on how to treat cholera. From the time of the first serious monograph, written by the Professor of Special Pathology, V. J. Krombholz, director of the Prague cholera hospitals during the epidemic, to publications prompted by the epidemics of 1849/50 and 1866, right up to the last

13

Ludmila Sinkulová, “Z historie základních zdravotních zákonů rakousko-uherských” [“From the History of Health Laws in Austria-Hungary”], I-II, Československé zdravotnictví 18, 1970, pp. 425−432, pp. 579−585; Ludmila Sinkulová, Stát, lékaři a zdraví lidu [The State, Physicians and the Health of the Population], Praha 1959.

14

Smallpox will therefore be part of this study in the second phase.

15

Stříteský, Zdravotní a populační vývoj, pp. 61−63; Sinkulová, Stát, p. 113 ff.

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Bohemian epidemic in 1872/73, symptomatic treatment was the prevailing approach.16 It was not until the bacteriological era and its discoveries that new diagnostics were developed with some new methods of treatment other than the hygiene and prophylactic measures summarized in the Czech literature in 1911.17

Opinions on cholera and the development of scientific medicine Prague medicine between Vienna, Munich and Berlin As in London, where regardless of their theory of the origin of cholera experts saw intolerably unhygienic social conditions as the key factor in the spread of the new disease,18 Central European doctors achieved more success in the practical sphere of public hygiene and health than in a theoretical understanding of the disease or development of treatment.19 In provincial Prague as in imperial Vienna and other cities and towns of Central Europe (publishing in German), a struggle proceeded on the pages of learned journals and monographs between the opinions of the “autochthonists”, who

16

Vincenc J. Krombholz, General-Rapport über die Asiatische Cholera zu Prag im Jahre 1831 und 1832..., Leitmeritz s. d.; Joseph Finger, Die Cholera epidemica nach Beobachtungen... im Prager allgemeinen Krankenhause..., Leipzig 1851; Alfred Přibram and J. Robitschek, “Die Prager CholeraEpidemie des Jahres 1866. Eine epidemiologische und klinische Studie“, Vierteljahrschrift für die praktische Heilkunde von der medicinischen Facultät in Prag 97−100, 1868, pp. 103−168. For more details on therapy see Ellen Jahn, Die Cholera in Medizin und Pharmazie im Zeitalter des Hygienikers Max von Pettenkofer, Stuttgart 1994, pp. 104−134; Wiesner, “ Z dějin“, pp. 1992−1994.

17

A series of presentations published in the Časopis lékařů českých 50, 1911: Emerich Maixner, “O choleře po klinické stránce” [“On Cholera from the Clinical Point of View”], pp. 871−875, 909−913, 948−950, 974−976, 1013−1015, 1036−1037; Gustav Kabrhel, “Epidemiologie a potírání cholery” [“Epidemiology and Combatting Cholera”], pp. 1091−1095; František Kulhavý, “Cholera”, pp. 1145−1150; Ivan Honl, “O choleře” [“On Cholera”], pp. 1173−1179.

18

The lawyer Edwin Chadwick, author of the monumental Report on the Sanitary Condition of the Labouring Population of Great Britain (1842), promoter of health and social reform, was a supporter of miasmatic etiology, while the doctor John Snow, the author of On the Mode of Communication of Cholera (1849), a convinced contagionist, won ever more supporters for his view that cholera was primarily transmitted by contaminated water. See: W. F. Bynum and R. Potter (eds.), Companion Encyclopedia of the History of Medicine, Vol. 2, London and New York 2001, p. 1242 ff. and 1272 ff.; Winkle, Kulturgeschichte, pp. 194−198; the social dimensions of cholera epidemics for instance in: Evans, Death in Hamburg, p. 403 ff.; Morris, Cholera 1832, p. 79 ff.

19

A summary of theories and healing concepts for instance in: Michael Stolberg, “Die Cholera im 19. Jahrhundert: zum Umgang mit einer neuen Krankheit“, in: Heinz Schott (ed..), Medizin, Romantik und Naturforschung, Bonn 1993, pp. 87−109; Morris, Cholera 1832, p. 159 ff.; Delaporte, Disease and Civilization, p. 114 ff.

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did not believe cholera to be an infectious disease, and the “ephodists”, who considered the disease to be communicable. Among the latter the so-called “contagionists” saw the origin of the disease (even if this was still obscure) as the decisive factor (condition) for the development of cholera, while the so-called “localists” considered that it was only in combination with local conditions that the origin of the disease could actually produce the illness.20 Two other Central European cities, the Munich of Max Pettenkofer and the Berlin of Robert Koch, became bastions in the dispute between these two schools of thought and were of course of key importance for Prague. Interesting evidence of the unclear boundaries between the various views on the origin of cholera can be found in a comment of the Brno Augustinian and father of genetics, J. G. Mendel (1822−1884). Although he was a great admirer of Pettenkofer‘s “Boden-Grundwasser” theory, his sentence in a letter to his brother-in-law, “Auch die Cholera haben uns die Preussen mitgebracht...” is in a wholly contagionist spirit.21 The second cholera pandemic hit Vienna rather earlier than Prague (in the autumn of 1831), but loss of life in the Austrian capital was relatively low (roughly one in one hundred and fifty inhabitants died of the disease). The basic official policies implemented to halt the epidemic, whether local, provincial or imperial in scale, organized from Vienna, had no effect. Specific measures – as in Prague – had only limited effect, but discussion and dispute on the origins, nature and possible treatment of the disease led to progress in medical science. As elsewhere in Europe, at the Vienna Medical Faculty the dispute among the professors of internal medicine was between the autochthonists (F. X. von Hildebrand and J. A. von Stift) and the contagionists, who at this point had not yet gained the upper hand.22 In addition to publications by local experts, other “cholera” titles circulated in Vienna (and in Prague), and clearly reflected the dispute.23 In Vienna cholera became the object of interest not only of traditional internists but also of the then fashionable homeopaths, at that time officially banned in Austria. Certain successes in the homeopathic treatment of cholera achieved by J. E. Veith contributed to the official recognition of homeopathy as a university discipline

20

Ellen Jahn, Die Cholera, pp. 34−34.

21

Winkle, Kulturgechichte, pp. 211−212.

22

Erna Lesky, Die Wiener medizinische Schule im 19. Jahrhundert, Wien 1965, p. 47.

23

Jahn, Die Cholera, chapter on “Ausgewählte Bibliographie des Jahres 1831”, pp. 175–186. For accessibility of these volumes in Prague see: Hlaváčková and Svobodný, “Generální raport”, p. 261, footnote 15.

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(1841, first two docents).24 At the Vienna faculty (as in Prague) the practical fight against epidemics was the concern of a special department known as state medicine (Staatsarzneikunde) and of the health police (medizinische Polizei) that came under the department. Like the typhus epidemics of the Napoleonic period, the cholera epidemics of the 1830s provided a stimulus for the further development of state medicine.25 In the 1860s, however, interest in cholera at the Vienna faculty shifted mainly to specialists in pathological anatomy (J. Klob).26 In the fight with cholera the connection between theory and practice on the one hand and between Bohemia and Vienna on the other was embodied by the Pilsen-born professor of internal medicine at Vienna Josef Škoda.27 He first got to know the disease as a cholera doctor in 1831–32 in Bohemia. Later, as a professor in Vienna, he put all the weight of his scientific authority behind the effort to build a modern drainage and water mains system for the Austrian metropolis, just like Pettenkofer in Munich and Soyka and Kabrhel in Prague.28 Unlike Munich, Vienna had to wait until 1875 for the establishment of an independent department of experimental hygiene, and until that date the area came under the antiquated Department of State Medicine. Nonetheless, C. L. Sigmund in the chair of state medicine still contributed significantly to the fight against cholera, on the one hand by promoting a range of sanitation measures in the city, and on the other through cooperation at the international level (for example, he coorganized international health committees and conferences in Vienna with Pettenkofer).29 After the establishment of the hygiene institute, its successive directors such as the Moravian-born E. Kusý joined the fight against infectious diseases including cholera.30 Munich was spared the first wave of the second cholera pandemic but was hit by its second wave in 1836 (approximately 900 fatalities per 100,000 inhabitants).31 The great

24

Lesky, Die Wiener medizinische Schule, p. 50.

25

Details in: Lesky, Die Wiener medizinische Schule, p. 116, 283.

26

Ibid., p. 141.

27

Zdeněk Hornof, “Josef Škoda als Choleraarzt in Böhmen 1831-1832”, Clio medica 1967, vol. 2, pp. 55−62.

28

Ibid., p. 148, 280.

29

Ibid., pp. 290−292.

30

Ibid., p. 27.

31

R. Bauer (ed..), Geschichte der Stadt München, München 1992, p. 300.

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Munich epidemics of 1854 and 1873, however, made the Bavarian capital the capital of the anti-cholera campaign.32 The sanitation measures taken by the municipal council were based on the work of the “high priest of hygiene”, Max Pettenkofer (1818−1901). His works, the most important of which in this context were Untersuchungen und Beobachtungen über die Verbreitung der Cholera (1855) and Über den gegenwärtigen Stand der Cholera-Frage (1873), were not only milestones for the new practical municipal hygiene policies (especially drainage system) adopted in the 1870s specifically in Munich,33 but also the beginning of a new university subject – theoretical and experimental hygiene. Pettenkofer’s career as an architect of the new subject at Central European universities (including Prague) started in 1853 when he gave his first lecture on experimental hygiene, continued with his appointment as a full professor of the subject (1865) and culminated with the opening of his new institute (1879). Pettenkofer’s line in the emergent field of experimental hygiene and epidemiology was distinctive for his conviction that the environment had a more fundamental influence on the spread of infectious diseases than the actual origin of a disease. He argued that in the case of cholera (and typhus) three conditions had to be fulfilled for the disease to spread: a specific germ (originally he talked of miasmata, but later accepted that it was the bacillus discovered by Koch), a porous and damp terrain (hence his “BodenGrundwasser Theorie”) and finally individual disposition to infection. He considered the second factor decisive34 and did not hesitate to try to prove his theory in drastic fashion, when in 1892 he drank a suspended solution of freshly cultivated cholera bacilli. He regarded the fact that he did not fall ill as a proof of the validity of his theory.35 The crucial turning point in disputes over the origin of cholera was, of course, the discovery made by Robert Koch (1843–1910). In 1883, during the fifth cholera pandemic, he was sent to Egypt, where he managed to isolate the cholera bacillus (Vibrio cholerae), and several months later he demonstrated it in India as well. In February 1884 he reported his findings to the Berlin government, and after his return in

32

H. Breyer, Max von Pettenkofer, Leipzig 1985, pp. 66−73.

33

Bauer, Geschichte, pp. 316−317.

34

35

F. Oesterlen, Choleragift und Pettenkofer, Tübingen 1868; H. Breyer, Max von Pettenkofer; Jahn, Die Cholera, chapter 4: “Pettenkofers Choleralehre neu betrachtet”, pp. 37−46; Winkle, Kulturgeschichte, pp. 203−215. Winkle, Kulturgeschichte, pp. 248−251.

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April 1884 he informed the professional public at the first cholera conference at the Imperial Health Institute in Berlin. Koch’s classic description of the cholera bacillus and its effects finally resolved the decades-long dispute on the origin of cholera, even though discussion continued. Koch’s pupils and successors were appointed to most of the newly established chairs of public health at the German medical faculties. Pettenkofer did not himself abandon his own theory, and even his opponents recognised his contributions to the theory and practice of hygiene. Many of his supporters, however, began to have doubts.36 From internal medicine and medical statistics to bacteriology, from state medicine to hygiene During the first Prague cholera epidemic Profesor V. J. Kromholz (1782−1843) not only became one of the main fighters against the disease in Prague in practice, but also tried to understand the problem at a theoretical level. As a versatile clinician, who had experience of several fields as both teacher and researcher (anatomy, surgery, state and forensic medicine), he was extremely well equipped for the task. His study GeneralRapport über die Asiatische Cholera zu Prag im Jahre 1831 und 1832... (Leitmeritz, s. d.) in 133 pages offers a description of aetiology, prognosis, therapy, autopsy finds and statistical overviews. The work is based exclusively on his own observations and does not cite other literature. The 1830s saw publication of a range of other writings on cholera in the Czech lands as elsewhere, some from the pens of renowned Prague professors and others from experienced rural practitioners.37 It was only later, however, with the publication of the famous Prague internist Josef Hamerník’s (1810−1887) Die Cholera Epidemica, mit besonderer Berücksichtungen der allgemeinen pathologischen und allgemeinen therapeutischen Beziehungen (Prag 1850) that we find the first attempt to compare and contrast personal experience with the extensive European “cholera” literature. Like the majority of other writers of the prebacteriological era, Hamerník could do no more than give detailed descriptions of cases and autopsies and produce statistical material. Representatives of clinical internal medicine were still very much concerned with cholera at the beginning of the twentieth century.38

36

Ibid., pp. 215−222.

37

See Hlaváčková and Svobodný, “Generální raport”, p. 259, footnote 9.

38

Maixner, “O choleře” (see footnote 17).

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In Prague as elsewhere, Koch’s discovery shifted the study of cholera to the newly emerging field of bacteriology. In the same year in which Koch discovered and described the cholera bacillus (1883), the top institution of scientific medicine in Prague – the Medical Faculty (like the whole of Prague University a year before) – was divided into two entirely independent institutions, one Czech and one German. The first generation of professors of the Czech Medical Faculty were in many cases faced with the task of building up new departments and fields “from scratch”, while their colleagues at the German faculty enjoyed more institutional continuity and maintained their traditional relations with the other faculties in Germany and Austria. The chair of pathological anatomy was crucial for the institutionalization of bacteriology (and also hygiene and epidemiology) at both the Prague medical faculties. The Czech Institute of Pathological Anatomy was built up from its foundation in 1884 by Professor Jaroslav Hlava (1855−1924), one of the most forceful figures at the faculty and the pioneer of Czech bacteriology. His pupil Ivan Honl (1866−1936) gained his habilitation in bacteriology in 1898, and was to head the Czech Bacteriological Institute when it later became independent from the Pathological Anatomy Institute in 1919. At the German Medical Faculty pathological anatomists built on the work of E. T. A. Klebs (1834−1913), who is regarded as in some respects the precursor of the “father of bacteriology” R. Koch. At the turn of the century the main representative of bacteriology at the German faculty was Professor Ferdinand Hueppe (1852−1938), who was head of its Hygiene Institute in 1889−1912.39 In both the Czech and German cases the question of cholera and other infectious diseases of the digestive tract played a major role in the development of Prague bacteriology. It is no accident that the names of both the Czech professors, Hlava and Honl, can be found among the lectors and authors of a summary of information on cholera of 1911.40 As an internationally respected expert (bacteriologist and hygienist),

39

For more on these figures see Biografický slovník pražské lékařské fakulty 1348−1939 [Biographical Dictionary of the Faculty of Medicine in Prague 1348−1939], I−II, Praha 1988, 1993; Ludmila Hlaváčková and Petr Svobodný, Biographisches Lexikon der deutschen medizinischen Fakultät in Prag 1883−1945, Praha 1998. On the faculties see Jan Havránek and Zdeněk Pousta (eds.), A History of Charles University, II, Prague 2001, pp. 141−143, 215−222, 245−256.

40

See footnote 17.

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Hueppe contributed to measures to end the Hamburg epidemic in 1892, about which he wrote a book, Die Cholera in Hamburg (Prag 1894).41 The part played by the fight against cholera and other epidemic diseases of the digestive tract in the development of hygiene as a university discipline is even more evident. Even before the division of the Prague faculty, its professorial body had sent the young docent in pathological anatomy and hygiene (Klebs’s pupil) Isidor Soyka (1850−1889) to M. Pettenkofer’s institute of hygiene in Munich to gain experience. In Munich, Soyka became a strong supporter of Pettenkofer’s “Boden-Grundwasser” theory, and as Pettenkofer’s assistant took the final decision to devote himself to hygiene. At the time when Soyka was working in Munich (1879−1884), Pettenkofer’s institute was engaged in study of the epidemiology of cholera, the hygiene of soil and water and practical questions of the drainage and sanitation of towns. His stay in Munich also coincided with Koch’s revolutionary discoveries (including the origin of cholera), which Soyka immediately took up and later combined in an eclectic spirit with Pettenkofer’s teaching. In Munich Soyka wrote and published several articles on drainage of the supply of drinking water and familiarized himself with practical issues of Munich city hygiene. He returned to Prague in 1884 as a professor at the German Medical Faculty (after the division of the university), where he was entrusted with the building up and leadership of the Institute of Hygiene. He started lecturing (including on the aetiology and prophylaxis of infectious diseases and on bacteriology), but only some years later (1887) did he manage to obtain suitable premises for the institute. Especially after a visit to Koch’s Berlin institute, Soyka continued to try to combine the approaches of Pettenkofer’s hygiene school and Koch’s bacteriological school, and his successors at the institute took much the same line.42 At the Czech Medical Faculty the task of building up a hygiene institute fell to Gustav Kabrhel (1857−1939). In 1889 he added a habilitation in hygiene to his existing

41

Winkle, Kulturgeshichte, p. 239, 242 f.

42

Petr Svobodný, “Isidor Soyka − Pettenkoferův žák” [“I. Soyka − Pettenkofer's Disciple”], Dějiny věd a techniky 28, 1995, pp. 1−14; Petr Svobodný, “Isidor Soyka − zakladatel hygienického ústavu německé lékařské fakulty v Praze” [“I. Soyka − Founder of the Institute of Hygiene at the German Faculty of Medicine in Prague”], ibid., pp. 145−166; Petr Svobodný, “Isidor Soyka − Gründer des HygieneInstitutes an der deutschen Medizinischen Fakultät in Prag”, Hygiene und Judentum (Historische Blätter, Sonderheft) 1995, pp. 27−30; Otakar Klein and Petr Svobodný, “Die Prager Hygiene Schule: Edmund Weil und andere im Dienste der Wissenschaft Verstorbene”, ibid., pp. 23−26.

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habilitation in experiemental pathology. Like Soyka he familiarized himself with the theories and methods of Pettenkofer’s hygiene and Koch’s bacteriological school directly in Munich (1887) and Berlin (1890). Already a professor (1891), he became head of the new Hygiene Institute in 1897. His most important works are focused on the area that played a major role in the fight against infectious diseases of the digestive tract – water hygiene.43 As the leading Czech hygiene expert he was naturally involved in measures to prevent further cholera epidemics.44

Public hygiene Both founders of scientific hygiene at the Prague medical faculties, just like their teacher Pettenkofer, made major contributions to the radical sanitation of their city. In Prague the sanitation campaign was implemented later than in Munich and Vienna, at the very end of the nineteenth century. At this time Prague’s greatest hygiene problems included the intolerable health conditions in some of its districts, especially in Josefov (the Jewish Town) and the Old Town, which at the turn of the century prompted the socalled “slum clearance” (Assanierung). Isidor Soyka and a number of other Prague (Czech and German) doctors of the 1880s contributed medical expertise to the expert arguments in favour of slum clearance (others being economic, town planning, legal and aesthetic). Soyka gave the most comprehensive summary of his arguments in this area in his book Zur Assanirung Prags (Prag 1886). Clearance of whole districts was then carried out at the turn of the century on the basis of a law passed in 1893. The second area of modernization to which Soyka and especially his younger Czech colleague Kabrhel made major contributions was that of the water mains of the Prague agglomeration. Soyka had already confronted the problem of how to secure good quality sources of drinking water (alongside other questions of practical municipal hygiene) as a member of the municipal health board in the 1880s. Gustav Kabrhel drew up a highly progressive plan for a new Prague water mains system, which was constructed in 1908−1913 on the basis of an agreement made between the Prague City Council and surrounding communities in 1899. At roughly the same time a modern

43

44

Basic data in Biografický slovník pražské lékařské fakulty 1348−1939, I, pp. 256−257, other literature ibid.. .

Kabrhel, “Epidemiologie a potírání cholery” (see footnote 17).

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sewerage system was constructed for the Prague agglomeration.45 Kabrhel’s “cholera” arguments in favour of a modern water mains system can still be found, for example, in his paper entitled “Epidemiologie a potírání cholery” [“Epidemiology and Combatting Cholera”] of 1911. Here he points out, for example, the dramatic differences between the spread of the disease during the Hamburg epidemic of 1892 in Hamburg itself (new water mains, but with unfiltered Elbe water) and Altona (water mains with sandstone filtration).46 After scientists had established the origin of cholera and created a professional framework for the struggle against the disease in the field of prevention (epidemiology and hygiene), diagnostics (bacteriology) and therapy (internal medicine), public health institutions took up the organization of anti-cholera measures. Their powers, based on domestic regulations (the basic health laws of 1870, 1884 and 1888; special cholera instructions of 1886) and international agreements (especially the Dresden Convention of 1893), were lucidly recapitulated in the Czech medical press by a health inspector, Kulhavý, in 1911. He noted that fortunately the Czech lands were now only subject to measures intended for periods in which there was no cholera threat, or sometimes for situations in which cholera had broken out in neighbouring countries, but no longer to measures intended for times of domestic epidemic.47

Epilogue The fact that the threat of cholera epidemics did not vanish either after the last domestic wave of the disease (1872/73), the discovery of the origin of the disease (1883/84) or the completion of sanitation measures in Prague and other towns is evident from the sustained interest of health and administrative bodies in cholera as late as the turn of the century. In the year of the great Hamburg epidemic (1892) the periodically published Report on Health Conditions in the Kingdom of Bohemia included a

45

Svobodný, “Isidor Soyka – zakladatel”, pp. 158−161 and literature listed there. For details on water mains see Statistické zprávy města Prahy z let 1881−1914 [Statistic Reports of the City of Prague, 1881−1914].

46

Kabrhel, “Epidemiologie a potírání cholery” (see footnote 17), p. 1094.

47

Kulhavý, “Cholera” (see footnote 17), p. 1145 ff.

214


description of “Measures against Cholera and Clearance Work” as a special chapter,48 although in subsequent years these data were divided into different sections (infectious diseases, health care system, hygiene, etc.). “The danger that cholera and plague might be spread into this country is not small, and certainly greater in the case of cholera than of plague…”49 As late as 1911 fears that cholera might penetrate into Bohemia from countries neighbouring the AustroHungarian monarchy (from Russia, Turkey, Italy, the Balkan countries or even from Hungary) led health councillor of the Kingdom of Bohemia Hynek Pelc to organize a cycle of lectures for field doctors. The articles by professors of bacteriology (Honl), pathological anatomy (Hlava), internal medicine (Maixner) and hygiene (Kabrhel) and the Provincial Health Inspector (Kulhavý) which were published on the basis of the lecture cycle remain to this day a monument to the victory of modern medicine and public health over one dangerous disease.50

48

Hynek Pelc, Zpráva o poměrech zdravotních v Království českém, chapter on “Opatření proti choleře a práce assanační” [Report on Health Conditions in the Kingdom of Bohemia, chapter on “Measures against Cholera and Clearance Work”], Praha 1894, pp. 101−111.

49

Maixner, “O choleře”, p. 871.

50

See footnote 17.

215

A Persistent Regional Mortality Pattern in Sweden during the Industrial Age Sam Willner (Linköping University, Sweden)

Introduction Several studies have presented evidence for significant socio-economic differences in health in postwar societies. Lower socio-economic groups usually exhibit higher rates of premature death and lower expectancy of life than more affluent groups (Kunst et al. 1998; Marang-van de Mheen et al. 1998; Sorlie et al. 1995; Vågerö and Lundberg 1995). Those who are more permanently excluded from regular working life such as long-term unemployed, individuals dependent on sickness pensions or long-term sickleave allowances or those otherwise living in adverse socio-economic circumstances tend to show particularly unfavourable health characteristics (Socialforskningsrådet 1998; Stefansson 1991). Many questions remain unsolved regarding the pathways linking socio-economic conditions to mortality, for example the importance of material factors per se – individual as well as public resources – versus psychosocial mechanisms such as psycho-neuroendocrine effects and stress-related unhealthy behaviours on the individual level linked to social capital and cohesion within the society (Lynch et al. 2000; Marmot and Wilkinson 2001). What is the role of selection mechanisms such as the “healthy worker effect” in producing differences in health? What are the actual pathways linking socio-economic circumstances to mortality in different temporal or spatial contexts? Analyses of spatial variation of mortality over time may help to uncover the background mechanisms of the relations between socio-economic factors and differentials in the health outcome (Haines and Kintner 2000; Wolleswinkel-van den Bosch et al. 2001). Generally areas characterized by adverse socio-economic conditions experience higher rates of premature death than more affluent areas (Benachi and Yasui

216

A Persistent Regional Mortality Pattern in Sweden during the Industrial Age

1999; Huff et al 1999; Kalediene and Petrauskeiene 2000; Law and Morris 1998; Reijneveld, Verhej, de Bakker 1999). Whether this primarily is attributable to compositional effects (the characteristics of the individuals living in the area) or contextual effects (genuine area-level characteristics) is often unclear, although there are techniques for distinguishing the effects of the group-level and individual-level variables (Diez Roux 2002; Wiggins et al 2002). In spite of impressive improvements in the standard of living and advanced social security systems, in late twentieth-century Sweden area (as well as individual) variations in socio-economic deprivation, measured by indicators such as unemployment, early retirement, dependence on public assistance, etc, are still significantly associated with premature mortality (Kolegard Stjarne et al 2002; Malmström et al 1999; Molarius and Janson 2001; Starrin, Larsson and Brenner 1988; Stefansson 1991; Sundquist, Bajekal and Johansson 1997). Regarding the first half of the century analyses presenting evidence of socio-economic differences in mortality are scarce. According to a few local studies, however, there is evidence of differentials in infant and child mortality in late nineteenth- and early twentieth- century urban Sweden. The lower socio-economic groups exhibited higher death rates than more affluent families (Edvinsson 1992, Rietz 1930, Burström and Bernhardt 2001). But we still lack knowledge on more general socio-economic mortality differentials in Sweden in the early nineteenth century and during the interwar period, regarding individuals as well as area-levels.

Objective The objective of this study is to analyse continuity and change in the regional patterns of adult mortality and the association with spatial and temporal variations of socio-economic conditions from late nineteenth- through twentieth-century Sweden. The primary target of the study is the potential impact of socio-economic deprivation on regional mortality patterns, also considering the impact of underlying socio-economic processes such as industrialization, urbanization and interregional migration. Possible mechanisms linking socio-economic conditions to mortality levels will be discussed tentatively. A greater part of the analyses will be devoted to the earlier periods. The lack of more systematic analyses concerning the long-term development of the regional mortality pattern of twentieth-century Sweden and the potential impact of regional variations of socio-economic conditions from early industrialization to the post-industrial society further motivates this approach.

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Sam Willner

The Swedish mortality decline Sweden, like many other Western populations, has experienced a dramatic decline in mortality since the mid-nineteenth century, when life expectancy at birth was about 40 years for men and 45 for women. Around 1900 it had reached over 50 years for men and 55 for women. At the turn of the millennium it was 77 years for men and 82 for women. Rapid industrialization and urbanization accompanied the accelerated reduction in death rates in the late nineteenth century, primarily explained by the decline of infectious diseases. The improvements in health during the industrial breakthrough could be attributed to factors such as public health measures (for example regarding water supply and sewage disposal in urban areas) and improved nutrition and housing conditions, made possible by increasing real wages and economic gains generated from industrialization (Sandberg and Steckel 1997). The introduction of bacteriology and antiseptic methods in medicine as well as health related cultural changes connected to the modernization and industrialization processes also contributed to the shift. The fertility decline reduced deaths of maternal mortality but also contributed to a rising standard of living for working class families. It has also been argued that industrialization brought about the growth of a “culture of conscientiousness”, generating, among other things, a more negative attitude towards alcohol, which certainly had positive effects on the health of Swedish men in the late nineteenth century (Willner 2001). The introduction of sulphonamides and antibiotics in the 1930s and 1940s further reduced infectious deaths, although medical therapy probably played a rather small role for the earlier periods of the health transition (McKeown 1979). The postwar period and with it the realization of the modern welfare society has been accompanied by further reductions of premature death rates and increasing longevity. However, middle-aged men, particularly bachelors, experienced stagnating or rising death rates during the 1960s and 1970s, while female mortality continued to fall. Subsequently the male excess mortality grew. Increased cigarette smoking and alcohol consumption appear to be important background factors for this development (Hemström 1999). In the 1980s and 1990s mortality declined more rapidly among men, thus diminishing the gender gap in death rates and longevity. More healthy life styles, for example regarding diet and smoking habits, and improvements in medical therapy, particularly regarding cardiovascular diseases, are suspected to be important for this development. Differences in health between socio-economic groups, however, have remained relatively constant (Folkhälsorappport 2001).

218


Data and methods Bivariate correlation and multiple regression analyses are used to examine the associations between the potential explanatory variables and mortality on the regional (county) level. The major sources of data are official statistical series and censuses (see Table 3). Contemporary socio-economic reports and medical literature are examined, particularly regarding information on more proximate factors (or mediators) such as diet and overcrowding, not usually found in the official statistics. The dependent variables or potential health determinants are regional death rates for ages 20−69 (standardized for age according to the Swedish population structure of 1970) and specified for sex. The regional mortality pattern and the impact of different socio-economic or demographic conditions is analysed for four different sub-periods: 1901−10, the 1930s (not specified for sex), the 1960s and the 1990s, representing respectively the industrial breakthrough, the interwar period, the industrial welfare society and the present “post-industrial” society. A shorter background analysis for the pre-industrial (or early industrial) period is also presented.

Overview of explanatory variables and their potential health effects Indicators of socio-economic deprivation are unemployment rates and the proportion of the population dependent on poor relief or social assistance. Potential factors linking socio-economic deprivation to increased health risks are for example direct material effects such as poor nutrition and housing conditions, but also harmful physiological or behavioural effects of psychosocial stress (Brunner and Marmot 1999). Regarding the more general socio-economic background factors or processes such as industrialization and urbanization, the effects are more complex (and indirect). It is likely that industrialization paved the way for improvements in the standard of living and public health (housing conditions, diet, sanitary measures regarding water supply and sewage in urban environments, etc) that were of vital importance for the acceleration of mortality decline in late nineteenth century. But in the initial phase, overcrowding and unsanitary housing conditions characterized many industrial communities, for example in the sawmill districts during the boom of the forest and sawmill industry in northern Sweden in the decades succeeding the mid-nineteenth century (Edvinsson 1992; Norberg 1980).

219

Sam Willner

Urbanization was partly related to industrialization, but to a large extent early industrialization in Sweden took part outside administrative towns. Factors such as overcrowding and unsanitary living conditions but certainly also the urban life style (for example excessive alcohol consumption) contributed to a significant urban excess mortality, particularly among men, in pre-industrial and early industrial Sweden (Edvinsson and Nilsson 1999; Willner 1999). In fact the urban penalty was more marked in the pre-industrial society than during the decades of rapid urbanization in late nineteenth century (Fridlizius 1988). At the turn of the century females of reproductive ages experienced lower death rates in urban than in rural areas. Although there was still an urban excess mortality among men, the difference had declined substantially. The introduction of water supply and sewage facilities in urban Sweden was important for this development, although the evidence is not completely straightforward (Edvinsson and Nilsson 2000). On the other hand the urban population usually had better access to medical care than the rural population, a factor of increasing importance after the breakthrough of bacteriology and the introduction of antiseptic methods in the late nineteenth century. New ideas on hygiene and health care were probably accepted more easily there than in more remote rural areas (Wolleswinkel-van den Bosch et al. 2001). We will, however, focus on potential socio-economic background effects of the south(west)-northern mortality differentials, while the urban-rural differences and the excess mortality of the metropolitan areas will be further examined in the future. In this context the urban penalty effect is primarily considered as a confounding variable. Migration is largely related to the urbanization and industrialization processes (and working opportunities). High in-migration could aggravate problems of overcrowding and transmission of infections, particularly during early industrialization. High outmigration may have negative health effects on the ecological level, if those moving out are healthier than those remaining in the area. It has been suggested that the unfavourable death rates of the northern forest counties in the late twentieth century might be an effect of such selection effects. Those healthy and fit for work are moving out to get a job in other parts of the country to a larger extent than those less healthy or with a reduced capacity for work (Sveriges National Atlas 2000). It is expected that fertility should be positively related to levels of maternal (and child) mortality, but also to adverse socio-economic conditions. Furthermore, risks of contracting infections probably increased with the size of the household. No significant effect on mortality levels is expected for the postwar periods.

220


It has been suggested that due to differences in death rates between single and cohabiting or married persons, variations in the proportion of marital status groups might be of importance for the regional mortality pattern in late twentieth century, the former group exhibiting the most unfavourable mortality levels, particularly among middle-aged men (SCB 1992). Among males single living is strongly associated with lifestyle factors such as unhealthy dietary practices, smoking and excessive use of alcohol. According to national data from 1969–78, deaths due to circulatory diseases and alcohol-related causes were much more frequent among divorced and never married men compared to married men (SCB 1981). There are, however, difficulties to distinguish between effects of the family situation and socio-economic conditions. Single living is more common among men, though not among women, of lower socioeconomic groups (Johansson and Qvist 1997). There are certainly several other factors potentially affecting the regional mortality pattern. In studies and reports of the late twentieth century, it is suggested that lifestylerelated factors such as diet (particularly consumption of saturated fat) and smoking habits are important (EpC-rapport 1997:1; SCB 1984, 1992, 2002; Rosén 1987; Rosengren et al. 1999). These health determinants are certainly associated with underlying socio-economic conditions. Smoking prevalence and diet-related risk factors such as obesity and hypertension are more common in lower socio-economic groups, thus contributing to social mortality differentials of today (EpC-rapport 1997:1). The impact of those more approximate health determinants is difficult to operationalize because we have few data. There is, however, some information in contemporary literature or reports that allows a tentative discussion regarding the importance of lifestyle factors for the regional mortality differentials. Variations in climate and access to medical care may also contribute to the regional mortality differentials (Gyllerup 2000). Because of changes in the data presentation of official statistics and censuses and the wish to use as reliable and valid data as possible in the period analyses, the opportunity to make temporal comparisons of some of the explanatory variables, for example regarding levels of income or unemployment, is limited.

221

Sam Willner

Fig 1. Map of Swedish counties

BD

AC

Z

Y

X W C S

U T

R O

AB D

E

P F N

H

I

G L

K

M

222

AB

Stockholm

C

Uppsala

D

Södermanland

E

Östergötland

F

Jönköping

G

Kronoberg

H

Kalmar

I

Gotland

K

Blekinge

L

Kristianstad

M

Malmöhus

N

Halland

O

Göteborgs och Bohus län

P

Älvsborg

R

Skaraborg

S

Värmland

T

Örebro

U

Västmanland

W

Kopparberg

X

Gävleborg

Y

Västernorrland

Z

Jämtland

AC

Västerbotten

BD

Norrbotten


Results Regional patterns of mortality in Sweden The highest levels of premature mortality in recent times are found in the sparsely populated forest counties of northern and central Sweden and in the urban areas around the big cities (Stockholm, Gothenburg and Malmö). The lowest mortality levels are found in the south-western part of Sweden (the metropolitan areas excluded) and in the county of Uppsala in central Sweden. According to official statistical reports, this regional pattern has been recognized at least since the 1960s (SCB 1964, 1974, 2002). Regarding the period preceding the 1960s, systematic analyses of regional mortality differences are sparse. But also in the late nineteenth and early twentieth century the health situation was more unfavourable in the metropolitan areas and in northern Sweden compared to the rural parts of the south, while in the pre-industrial period crude death rates were very low in the north (Sundbärg 1910; Norberg, Norman and Åkerman 1979; Lindberg and Rosén 2000). During the pre-industrial period, at least from the early nineteenth up to the midnineteenth century, there was a pattern of high mortality (CDR) in the more urbanized and densely populated regions in the south. Low death rates were observed for the relatively isolated and sparsely populated areas of northern Sweden, particularly in Jämtland, but also for some highly rural counties of southern Sweden, reflecting the marked urban penalty of mortality in pre-industrial Sweden (Sundbärg 1910). This description is roughly correct also regarding the regional mortality pattern for the ageinterval 20–69 years in the late 1850s (Figure 2). From the industrial breakthrough a new and different pattern gradually develops. The pace of the general mortality decline accelerates and the regional differences in death rates diminish (Table 1), but there are still significant differences. The mortality levels of the forest region of central and northern Sweden deteriorate in relation to other parts of the country. The position of the southern counties generally improves towards moderate levels in the east and low levels in the west (except for the counties including the metropolitan areas of Stockholm,Gothenburg and Malmö). Blekinge in the southeast, next to the lowmortality counties of Kronoberg and Kristianstad, departs from this main pattern, exhibiting relatively unfavourable death rates until the 1930s. Since the interwar period this general mortality has become established along its the main lines. In the following article, these regions will be referred to as the forest region (including the counties of

223

Sam Willner

Värmland, Kopparberg, Gävleborg, Västernorrland, Jämtland, Västerbotten and Norrbotten) and the southwest region (including the counties of Jönköping, Kronoberg, Kristianstad, Halland, Älvsborg and Skaraborg). Table 1: Mean and coefficient of variation (standard deviation divided by the mean) for age-standardized mortality rates (per 1,000) in ages 20–69, during different periods for Swedish counties (24). Pre-industrial or Industrial early industrial breakthrough c. 1880−1910 (1856−60)

The interwar period c. 1920−40

Industrial welfare society c. 1950−70

Post-industrial society c. 1980−95

Mean

17.03

12.54

9.51

5.79

4.32

CV

0.22

0.12

0.10

0.07

0.07

Sources: See Figure 2 Fig 2. Regional mortality in ages from 20–69. Sweden 1856−1995 Pre-industrial or early industrial

Industrial breakthrough

period (1856−60)

(c. 1880−1910)

Death rates ages 20-69 1. Highest 2. 3. 4. Lowest

(6) (6) (6) (6)

224


Fig 2. Cont. Interwar period (c. 1920−40)

Industrial welfare society (c. 1950−70)

Post-industrial (c. 1980−95)

Sources: BiSOS A. Befolkningsstatistik (1856–60). E. Hofsten and H. Lundström, Swedish Population History. Main Trends from 1750 to 1970. Stockholm 1976 (periods 2−4). SCB. Livslängden i Sverige. Livslängdstabeller för riket och länen (1981−95). Commentaries: Pre-industrial or early industrial society (1856−60), industrial breakthrough (1881, 1889−92, 1899−02, 1909−12), the interwar period (1919−22, 1929−32, 1939−42), industrial welfare society (1949−52, 1959−62, 1969−72), post-industrial society (1981−85, 1991−95). Mortality rates are standardized to age, according to the age structure of the Swedish population in 1970. .

Major causes of death for the regional mortality pattern Cardiovascular diseases are the most important causes of death for producing the regional variations in mortality of the late twentieth century (SCB 1978, 2002). The forest region shows high death rates in ischaemic heart disease and strokes, while alcohol-related diseases, suicide and tumours play a major role for the excess mortality of the metropolitan areas (Molarius and Janson 2001). It is believed that regional variations in the household composition (the proportion of those living alone) and the

225

Sam Willner

socio-economic structure of the population contribute to differences in health-related lifestyle factors and living conditions, for example regarding smoking and dietary habits, and thus influence the spatial patterns of mortality (Lindberg and Rosén 2000). A high consumption of saturated fat is suggested as a major factor in the excess mortality in cardiovascular diseases in northern Sweden (Rosén 1987), while smoking habits or alcohol abuse do not appear to be a major factor for the north-south mortality differential mortality in circulatory diseases (Nyström, Rosén and Wall 1986).

Table 2: Causes of death ages 20−69. Percentage of total mortality 1921−30. Standardized for age according to the total population 1921–30. Tubercu- Tumours Circula- Respira- External Maternal Unspec. Other losis

tory

tory dis. causes

mortality or

dis. Males

Deaths

causes Per

vague

1,000

19.3

15.3

21.5

9.5

10.2

0.0

2.4

21.9

8.95

Females 21.7

17.6

23.1

8.6

2.2

2.0

2.8

22.1

8.05

Sources: SCB. SOS. Befolkningsrörelsen. Översikt för åren 1921−1930. Commentaries: Circulatory diseases also include the diagnosis cerebral haemorrhage. Unspecified or vague includes diseases of old age and of unknown or insufficiently defined causes. Standardized for age (ten year age intervals) according to the age structure of the whole population in 1921−30.

According to the official statistics, in 1921−30 tuberculosis contributed with about 20 percent of all causes of death in ages from 20−69. Among younger adults almost half of the deaths were caused by tuberculosis. Other major categories were circulatory diseases, tumours, respiratory diseases and external causes (among men). Only a small proportion of the female mortality in the age interval was caused by deaths directly connected to pregnancies and deliveries. It is obvious that tuberculosis was a major factor for regional differences in mortality during the early twentieth century (Figure 3). Death rates were highest in the northern forest region, but the counties of Gotland, Blekinge, Stockholm and Göteborgs och Bohuslän in the south also exhibited relatively high levels. Several studies have shown that tuberculosis is clearly related to adverse socio-economic conditions (Gandy

226


and Zumla 2002; Elender, Bentham and Langford 1998). It has been suggested that the high TB mortality level of northern Sweden was to a large extent an effect of the low acquired immunity of the original population, which was thus highly vulnerable to infection during the breakthrough of industrialization and the inflow of migrants from other parts of the country (Henschen 1962). This view has, however, been questioned in more recent studies, which support the importance of living standard factors for changes in the frequency of tuberculosis rather than immunological processes (Puranen 1984, p. 224).

Fig 3. Major causes of death for Swedish counties 1921−30 (SMR for all population). All Sweden=100. Tuberculosis 172-208 (1) 137-172 (2) 102-137 (8) 67-102 (13)

Circulatory dis. 112-125 (1) 99-112 (8) 87-99 (11) 74-87 (4)

Tumours 113-124 (3) 101-113 (3) 90-101 (10) 79-90 (8)

Commentary: The official statistics only give data on total cases of different causes of death (not specified for age) at the county level. Indirectly standardized for sex and age according to the structure of the national population in 1921−30. Source: SCB. SOS. Befolkningsrörelsen. Översikt för åren 1921−1930.

227

Sam Willner

The impact of other major causes such as circulatory diseases and tumours is more difficult to estimate. These cases dominated in older ages with a relatively large proportion of unknown or diffuse diagnoses; such as “old age”, which were more common in rural areas with few doctors, for example in the sparsely populated northernmost counties. The regional variation was substantially lower than for tuberculosis according to the standardized mortality indices. According to the data given by the official statistics, mortality levels of circulatory diseases were (when standardized for age) relatively high in northern Sweden (except for the county of Jämtland), although contemporary studies, based on autopsies, indicate clearly lower levels of arteriosclerosis in the northern than in the southern parts of the country (Lundquist and Björnwall 1936). A reasonably large proportion of deaths in heart diseases in those times, such as rheumatic fever (Benedek 1993; Dahlberg 1937; Howell 1993), were however induced by infections, and that might be an important underlying factor for the relatively high levels of northern Sweden.

Socio-economic and demographic factors and regional mortality patterns Table 3: Variables in the analyses: Means and standard deviations for Swedish counties (City of Stockholm excluded), parameterization and data sources. Mean

Stand.

Parameterization

Sources

dev. Industrialization 1901−10

29.44

7.40

% of total population 1910

Census 1910

1931−40

36.32

7.59

% of total population 1940

Census 1930

1961−70

33.82

8.24

% of working population, 1965 Census 1965

1991−95

22.46

4.86

% of working population, 1990 Census 1990:V

1901−10

17.77

10.93

% in towns (admin.) 1910

Census 1910

Urbanization 1931−40

24.68

13.82

% in towns (admin.) 1935

Census 1935

1961−70

70.65

11.17

% in urban areas (“tätorter”)

Census 1965:VII

1991−95

77.75

7.53

% in urban areas (“tätorter”)

1965 1990

228

Census 1990


Table 3: Cont. Mean

Stand.

Parameterization

Sources

Net in-migr.1891–1910/pop

SOS

1891 %

Befolkningsrörelsen

Net in-migr.1921–40/pop 1921

SOS

%


Net in-migr. 1951–70/pop 1951

SOS

%

Befolkningsförändring

dev. Net migration 1901−10 1931−40 1961−70

-9.02 -4.55 0.68

9.60 5.30 11.14

ar 1991−95

2.37

3.83

Net in-migr. 1981–96/pop 1981

SOS.

%

Befolkningsstatistik:I.

Single living 1901−10 males females 1931−40 all

19.28

2.33

% unmarried in ages 50–59

SOS

32.22

2.93

1901–10


28.15

2.34


Census 1935

1935 1961−70 males

20.52

2.65


23.15

1.69

1965

16.21

1.60

% single living in ages 30–64

11.92

1.45

1990

1901−10

111.50

15.31

Births/1,000 females aged 15–

SOS

49, 1901–1910


1931−40

58.54

10.77


SOS

49, 1931–1940


1961−70

69.03

4.05


SOS

49, 1965

Befolkningsförändring

females 1991−95 males females

Census 1965 Census 1990

Fertility

ar 1991−95

64.26

2.14


Database “Hur mår

44, 1994

Sverige?” EpC, National Board of Health and Welfare

229

Sam Willner

Table 3: Cont. Mean

Stand.

Parameterization

Sources

Dev. Soc. assistance 1901−10

4.07

0.82

% receiving poor relief 1905−06

BiSOS U 1905−06

1931−40

8.60

2.99

% receiving poor relief 1935

SOS Fattigvården 1935

1961−70

3.56

0.83

% receiving social assistance

SOS Socialvården 1965

1965 1991−95

34.63

3.10

% receiving social assistance,

Database “Hur mår

unemployment benefits, early

Sverige?” EpC,

retirement pensions or sickness

National Board of

allowances (>21.8% of wage

Health and Welfare

earnings) in ages 20−64, 1994. Unemployment 1901−10

0.89

0.38

% of all population in

Arbetsstatistik H:1.

participating local communities 1909−01−12* 1931−40

0.98

0.94

% males aged 15−65,

SOU 1938:21 (Official

1937−08−31*

report)

1961−70

4.00

0.95

% males aged 40−49 1965

Census 1965:VII

1991−95

12.59

1.42

% in ages 18−64 1994

Database “Hur mår Sverige?” EpC, National Board of Health and Welfare

Infant mortality 1901−10

81.65

13.66

deaths/1,000 live births

1931−40

45.97

8.07


1961−70

13.35

1.40


1991−95

4.36

0.61


230


Table 3: Cont. Male mort. (20−69) 1901−10

12.11

1.24

deaths/1,000, 1901–10

SOS Befolkningsrörelsen

1931−40

-

-

-

No data

Mean

Stand.

Parameterization

Sources

deaths/1,000, 1964−67

SOS Dödlighets- och

dev. 1961−70 6.68

0.43

dödsorsaker med regional fördelning 1964−1967 1991−95

5.08

0.37

deaths/1,000, 1991−95

SOS. Demografiska rapporter 1997:1 Livslängden i Sverige.

Fem. mort. (20−69) 1901−10

10.72

0.95

deaths/1,000, 1901−10


1931−40

-

-

-

No data

1961−70

4.11

0.29

deaths/1,000, 1964−67

SOS Dödlighets- och dödsorsaker med regional fördelning 1964−1967

1991−95

2.82

0.18

deaths/1,000, 1991−95

SOS. Demografiska rapporter 1997:1. Livslängden i Sverige.

All mort. (20−69) 1931−40

9.01

0.79

deaths/1,000, 1931−40


*Official investigation of the number of unemployed on 12 January 1909 and 31 August 1937, based on counts organized by the local communities. The figures are certainly not complete, but they appear to give a crude or approximate picture of the regional variations in unemployment levels. The reported national unemployment rate of union members for the year of 1937 was circa 11 percent.

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Sam Willner

Table 4: Bivariate correlations with mortality, 20−69 years of age, for Swedish counties, city of Stockholm excluded (n=24). 1991−95 entire county of Stockholm excluded (n=23). 1901−10

1931−40

1961−70

male

female

0.34

0.05

-0.35

Urbanization

0.33

-0.01

-0.29

0.27

-0.04

0.12

0.10

Net migration

0.58

0.30

-0.11

-0.23

-0.32

-0.28

-0.31

Fertility

0.59

0.85

0.67

-0.15

0.02

-0.50

-0.46

Single living

0.35

0.03

-0.33

-0.25

-0.32

0.74

0.58

Industrial.

all

male

1991−95

-0.10

female male -0.02

female

-0.42

-0.37

Soc. assistance

0.39

0.31

0.64

0.72

0.62

0.76

0.62

Unemployment

0.54

0.44

0.71

0.48

0.32

0.58

0.58

Infant mortality

0.79

0.59

0.84

-0.10

0.13

0.08

-0.07

Male-fem mort

0.73

-

0.57

0.72

Sources: see Table 3.Commentaries: in bold type: p < 0.05.

Table 5: Multiple regressions with mortality in ages 20−69 years as the dependent variable for counties of Sweden, city of Stockholm excluded (n=24). 1991−95 entire county of Stockholm excluded. (n=23). Males Reg.coeff. SE

Females Sign.

Reg.coeff. SE

Both sexes Sign.

Reg.coeff. SE

Sign.

Constant 1901−10

5.620

4.543

-

1931−40

-

-

5.703

1961−70

4.201

3.482

-

1991−95

1.715

1.586

-

1991−95 incl.

2.109

1.720

-

single living Urbanization 1901−10

0.050

0.016

**

0.009

0.013

---

-

-

-

1931−40

-

-

-

-

-

-

-0.008

0.009

---

1961−70

0.023

0.010

*

-0.002

0.008

---

-

-

-

1991−95

0.003

0.007

---

-0.001

0.004

---

-

-

-

1991−95 incl.

0.013

0.006

---

-0.007

0.003

*

-

-

-

single living

232


Table 5: Cont. Males Reg.coeff. SE

Females Sign

Both sexes

Reg.coeff. SE

Sign.

Reg.coeff. SE

Sign.

Net migration 1901−10

0.053

0.015

**

0.011

0.012

---

-

-

-

1931−40

-

-

-

-

-

-

0.034

0.021

---

1961−70

-

0.010

---

-0.001

0.009

---

-

-

-

0.019 1991−95

0.015

0.018

---

0.000

0.011

---

-

-

-

1991−95 incl.

0.005

0.015

---

-0.014

0.008

---

-

-

-

0.014

0.004

**

0.009

0.002

***

-

-

-

1901−10

0.049

0.011

***

0.052

0.009

***

-

-

-

1931−40

-

-

-

-

-

-

0.043

0.011

**

1901−10

0.145

0.207

---

0.081

0.164

-

-

-

1931−40

-

-

-

-

-

-

0.135

0.034

***

1961−70

0.248

0.093

*

0.207

0.079

*

-

-

-

1991−95

0.103

0.023

***

0.037

0.014

*

-

-

-

1991−95 incl.

0.048

0.022

*

0.018

0.010

---

-

-

-

single living Single living 1991−95 incl. single living Fertility

Social assistance

single living Adj R² 1901−10

0.73

0.70

-

1931−40

-

-

0.67

1961−70

0.57

0.30

-

1991−95

0.53

0.29

-

1991−95 incl.

0.73

0.65

-

single living Sources: see Table 3. Commentaries: Two-tailed t-test for significance: *** : p0.10 Axe 1:12,3% Axe 2:8,6%

370

French Cities and the Origins of Medical and Social Policy: Late 19th–20th Century France

More surprisingly, our investigation revealed the duration of the effects of an early and voluntarily created Board of Hygiene and thus, before the law of 1902, the orientation of the current medical policy of the municipalities. Undoubtedly this is an indication of how a basis in local know-how, developed by a specific administrative organization, publications, facilities for carrying out investigations, the recognition of expertise within the municipal institution, has endured. This local tradition, pre-dating the 1902 legislation, which still directs local medical policies today, gives pause for thought with regard to the extent and variety of the conditions – regional, intellectual and professional – which, by organizing the field of study of public health, lead to the transformation of the city. *** The extent of municipal achievements at the institutional level is confirmed by empirical investigations showing the positive impact of public investment on the decline in mortality rates (Szreter 1988; Sheard, Power, 2000; Cain, Rotella, 2001). The theses of McKeown, though currently rejected, may at least be beneficial for the purposes of further research in a field where the answers appeared dubious or a priori (McKeown 1976). During the last twenty years, it has become clear that an increasingly broad part of the population demanded a higher quality of medical care, that the medicalization of society was not achieved without the involvement of the whole population (Léonard 1981, Faure, 1993, Vigarello, 1993, Bourdelais, 2001). Many recent works lead one to conclude, in accordance with the assertion of Max Weber, that cities often carried out experiments that were subsequently adapted at the national level for the preparation of new laws; they also underline the perception that the diffusion of the rules of hygiene in society were due less to state initiatives in the form of grand directives than to local initiatives and interaction between a variety of public health officials and voluntary groups, where various municipalities offered examples (Bourdelais, 2001; Guyot and Herault, 2001; Marec 2001). Moreover, the beginning of the twentieth century saw the results of a process of rationalization of local public action in housing (Fijalkow 2001) which resulted in the emergence of a true “municipal science” (Topalov, 1999). The passing of the 1902 law came finally when the majority of large French cities had already created Boards of Hygiene. How then do we explain some cities’ resistance to the application of the provisions of the 1902 law in the form of the retrograde and egoistic character of elected municipal representatives? The decision to institute Boards of Hygiene in all cities with more than 20,000 inhabitants simply amounted to unifying

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approaches found in cities that had already established Boards of Hygiene – whose practices were moreover very different – with those that did not take any initiative in this field. Certain local actors, in particular those who had already set up a Board of Hygiene in the 1880s and had been able to refine its procedures for action, considered it regrettable that the 1902 law restricted the capacities of the Boards of Hygiene by transforming them into “simple executive bodies of the municipalities, deprived of all initiative” and, even worse, devolving on the départements certain aspects of public health policy whose integration had appeared to constitute the element essential to success. Moreover, it should be stressed that these medical achievements entered into competition with other, equally legitimate, outlays of capital such as the construction of schools for girls and for boys in every commune. The situation of Grenoble and of its Board of Hygiene, studied very closely by Lucie Paquy, has made it possible for us to come to a better understanding of the conditions of the resistance of cities already very proud of the achievements of their board, in particular the integration under the same authority of medical inspections in schools and in unhealthy places of residence, of vaccination and of laboratory analyses, all of which, after the law of 1902, were allotted to different authorities (Paquy 2001). The resistance of cities that already had a Board of Hygiene was above all related to the conviction of municipal officials that a system developed locally over several decades was better adapted to meeting local conditions than that envisaged by the law. One tends to reach the conclusion that the technocrats who issue ministerial directives do not always propose the most relevant solutions at the local level!

References Bourdelais, P. and Fijalkow, Y. (1997), “The Success of Jacques Bertillon’s International Classification of Causes of Death: Why”, communication to the conference on “Health in the City: A History of Public Health, Liverpool 1997, Annual conference SSHM. Bourdelais, P. (2001), “Les logiques du développement de l’hygiène publique”, in Les Hygiénistes - Enjeux, modèles et pratiques, P. Bourdelais (ed.), Belin, 2001, 5–22. Bourdelais, P. (2003), Les épidémies terrassées. Une histoire de pays riches, Ed de la Martinière, 156 ff. Cain, Louis P. and Elyce J. Rotella (2001), “Death and Spending: Urban Mortality and Municipal Expenditure on Sanitation”, in Annales de démographie historique, 2001,1, 139–154. Cheysson, E. (1906), “Le casier sanitaire des maisons de Paris”, L’Architecte, 65–69. Du Mesnil, O. (1886), “Les bureaux municipaux d'hygiène institués en France et à l'étranger, mode d'organisation et fonctionnement”, Séance du Conseil Supérieur d’Hygiène Publique du 29 mars 1886, tome 16, 182–247. Durkheim, É. (1893). De la division du travail social, Presses Universitaires de France.

372

French Cities and the Origins of Medical and Social Policy: Late 19th–20th Century France

Faure, O. (1993), Les Français et leur médecine au XIXe siècle, Belin, 1993. Fijalkow, Y. (2001), “La notion d'insalubrité Un processus de rationalisation 1850–1902”, in Dix neuvième siècle, 1/ 2001. Filassier, A (1902), La détermination des pouvoirs publics en matière d’hygiène, Ed Rousset, 188. Gibert, Dr., (1878, a), Une visite au Bureau d’hygiène de Bruxelles, Imprimerie F. Santallier, Le Havre. Dr. Gibert, Fauvel, Lafaurie (1878, b), Création d’un Bureau d’hygiène municipal, proposition faite dans la séance du 11 février 1878, Imprimerie Alphée Brindeau et Cie, Havre. Guyot J.L and B. Herault, eds. (2001), La santé publique un enjeu de politique municipale, Bordeaux, MSH. Juillerat, P. (1916), “Le rôle des administrations municipales dans la protection de la Santé Publique”, Exposition du congrès La cité reconstituée, Paris. Lee, Robert W and Jörg P. Vögele (2001), “The Benefits of Federalism ? The Development of Public Health Policy and Health Care Systems in Nineteenth-Century Germany and their Impact on Mortality Reduction”, Annales de démographie historique, 2001, 1, 65–96. Léonard, J. (1981), La médecine entre les savoirs et les pouvoirs, Aubier. Marec, Y (2002), Bienfaisance communale et protection sociale à Rouen 1796–1927, La Documentation Française. McKeown, T. (1976), The Modern Rise of Population, London: Edward Arnold. Murard, L and P. Zylberman (1996), L’hygiène dans la République. La santé publique en France, ou l’utopie contrariée, 1870–1918, Fayard. Nonnis, S. (2001), “Idéologie sanitaire et projet politique. Les congrès internationaux d’hygiène de Bruxelles, Paris et Turin (1876-1880)”, in P. Bourdelais, Les hygiénistes, enjeux, modèles et pratiques, Belin, 241–265. Paquy, L. (2001), Santé publique et pouvoirs locaux. Le département de l’Isère et la loi du 15 février 1902, Doctoral thesis in History, Université Lyon 2, 2001. Rasmussen, A. (2001), “L’hygiène en congrès (1852–1912): circulation et configurations internationales”, in P. Bourdelais, Les hygiénistes, enjeux, modèles et pratiques, Belin, 213–240. Sheard, Sally and Helen Power (2000), Body and City. Histories of Urban Public Health, Ashgate. Strauss, P (1903), La croisade sanitaire, Bibliothèque Charpentier. Strauss, P. and A. Fillassier (1905), Loi sur la protection de la santé publique. Travaux législatifs, guide pratique et commentaire, Jules Rousset, 60. Szreter, Simon (1988), “The Importance of Social Intervention in Britain’s Mortality Decline 1850–1914”, in Social History of Medicine, 1 (1988), 1–38. Topalov, C. (1999), Laboratoire du nouveau siècle, la nébuleuse réformatrice et ses réseaux, ed. EHESS. Vigarello, G. (1993), Le sain et le malsain. Santé et mieux-être depuis le Moyen Age, Seuil.

373

Public Hygiene as a General Concern in an Industrial 19th-century Town: Seraing Suzy Pasleau (University of Liège – Laboresi, Belgium)

“This densely populated town’s authorities are […] the district’s most careful local authorities when implementing the Superior Council for Hygiene’s regulations; they are actively supported by the Public Health Committee.”1 As cholera hit Seraing for the fourth time since the beginning of the nineteenth century in 1858–1859, provincial authorities welcomed the initiatives of Seraing’s elected representatives.2 These actors did not fight alone for the improvement of public, industrial and private hygiene, but in cooperation with public health “professional” bodies. Where did health committees or commissions originate? What were their missions? What was the local administration’s competence? It “freely decided […] on all matters regarding public health provided its decisions contradicted neither the state and the provinces’ powers nor the special public health and hygiene laws.”3 Why did public hygiene concern not only medical professionals, but also political leaders and industrial manufacturers during the nineteenth century? Such numerous questions – and others still to be asked – demand that we first briefly describe our paper’s geographical framework and reconsider the notion of public hygiene. Rural Seraing was located on the right bank of the river Meuse about ten kilometres upstream from the city of Liège, and was inhabited by small farmers, small metalworkers and coal miners. From the first quarter of the nineteenth century onwards,

1

Exposé de la situation administrative de la province de Liège. Session de 1858, Liège, 1859, p. 189.

2

They repeated their congratulations on several other occasions. Ibid., Session de 1854, 1855, p. 447; Session de 1894, 1895, p. 251.

3

Devaux, A., Organisation de l’hygiène, in Kuborn, H., Aperçu historique sur l’hygiène publique en Belgique depuis 1830, Brussels, 1897, p. 27.

374

Public Hygiene as a General Concern in an Industrial 19th-century Town: Seraing

Seraing evolved into a major centre for heavy industry. Its two main enterprises, Cockerill – a steel company founded in 1817 – and the Val-Saint-Lambert crystal glassmaking company – founded in 1825 – became internationally renowned, while four – then three from 1877 onwards – collieries were in operation. Along with such extraordinary economic growth, Seraing’s population increased dramatically: from 2,000 inhabitants around 1800 to almost 40,000 around 1900.4 It benefited not only from the progressively positive balance of natural demographic movements (births/deaths) but also from the settlement of millions of migrants and their families,5 who were attracted by the high wages offered in heavy industry. Such massive arrivals destabilized the town in many respects. Anarchic housing development, an excessive population density, a lack of appropriate sanitary equipment, an inadequate education system, powerless welfare, deficient distribution circuits, etc. resulted in abnormally high death rates. But “the most obvious way to explain this phenomenon was to blame contagious conditions and epidemics, which proved to be more deadly in disrupted ecological environments like industrial towns” – which grew too rapidly.6 Like many other industrial centres, Seraing provided a fertile breeding ground for the development and spread of infectious diseases (cholera, typhoid fever as well as smallpox, scarlet fever, whooping cough, measles, mumps, tuberculosis, etc.), which made the population particularly vulnerable. Throughout most of the nineteenth century, the main concern, especially for medical practitioners, was the spectre of cholera.7 The debate on cholera’s causes was long, open and lively. Many specialists at the time put the disease down to miasma (lethal fumes and animal, vegetable and earth transpiration), carried by the air and inhaled by organisms. Houses must be aired, streets

4

See the detailed description of economic and population growth by Pasleau, S., Industries et populations: l’enchaînement des deux croissances à Seraing au XIXe siècle, Geneva, 1998.

5

See P. Bourdelais’s outline of industrial cities’ demographic systems during their paroxysmal growth phase in: Contribution à une histoire comparée des villes de l’industrie en Europe in Annales de démographie historique, 1999–92, p. 7.

6

Oris, M., “Mortalité, industrialisation et urbanisation au XIXe siècle. Quelques résultats des recherches liégeoises”, in Desama, C. and Oris, M. (eds.), Dix essais sur la démographie urbaine de la Wallonie au XIX e siècle, Brussels, 1998, p. 300.

7

“Hygiene and cholera: these two words were inseparable and the joint thinking they sparked off resulted in one of the nineteenth century’s most typical, important medical debates.” Havelange, C., Les figures de la guérison (XVIIIe-XIXe siècles). Une histoire sociale et culturelle des professions médicales au Pays de Liège, Paris, 1990, p. 325.

375

Suzy Pasleau

must be widened, refuse must be collected and construction sites ventilated; the air must be agitated.8 According to some others, the “cholera agent” was carried by water. On a principle similar to ventilation, water must circulate so as to carry rot away, to clean grounds and floors9 and to wash people and things. Having a clean skin is the best means to ensure protection against contagion: baths – and later, showers – came to symbolize personal hygiene. Other specialists claimed cholera resulted from poisoning. Before the revolution that followed Pasteur’s discoveries, medical knowledge was essentially limited to appearances.10 This marked the development of environmentoriented medicine, a view of hygiene according to which physical and moral aspects could not be dissociated and which allowed [specialists] to overcome conflicting stances on the “ultimate principle” and to agree on numerous “predisposing factors”: poverty, insalubrity, lack of food, unripe fruit, the weakening resulting from previous diseases, old age, cramming people together, the lack of air and light – referring to “aoristic” ideas […]. Such positions did not really make therapeutics easier, since it could only rely on experimentation.11

As a sub-discipline of medicine, hygiene affected all health-related fields, including environment preservation and life quality improvement;12 it aims at protecting the

8

We shall quote, among our sources, the writings of a medical practitioner from Liège: Davreux, Quelques considérations sur la thérapeutique générale du choléra, Liège, 1869; among studies: Corbin, A., Le miasme et la jonquille. L’odorat et l’imaginaire social, XVIIIe-XIXe siècles, Paris, 1982, p. 19 notably.

9

“All that tends to impregnate the soil with organic substances must be considered a direct or indirect cause of insalubrity; such matter’s accumulation and unstable character do not only lead to ground infection (…). Buried animal remains, excremental matter leaking from lavatories, urine spouting out on the public highway, organic matter leaking from houses into the soil, condensed matter in the liquid state leaking through gas pipes – these are the causes of the infection of inhabited grounds.” Levy, M., Traité d’hygiène publique et privée, t. II, Paris, 1845, p. 418, quoted by Libart, V., Côté cour, Côté jardin. La ville et la campagne au XIXe siècle dans le discours hygiénique, unpublished final dissertation (History), University of Liège, 2001, p. 127.

10

Salomon-Bayet, C., Pasteur et la révolution pastorienne, Paris, 1986, p. 434.

11

Poncelet-Renard, P., “L’épidémie de choléra de 1866 à Liège”, in Desama, C. and Oris, M. (eds.), op. cit., pp. 275–276.

12

Vigarello, Le propre et le sale. L’hygiène des corps depuis le Moyen Age, Paris, 1985; Idem, Le sain et le malsain: santé et mieux-être depuis le Moyen Age, Paris, 1993.

376


population.13 It can be divided up into several sections: (controlled) public hygiene, industrial or work hygiene (described in numerous studies) and (recommended and moralized about) private hygiene. More specifically, the first section came into existence “following the diseases that affected densely populated centres and turned them into real focuses; it did not govern their emergence, nor did it oversee the construction of such numerous hives of intense activity with bees and workers bustling about […] – as a late science, its practical task consisted in mending rather than building, correcting rather than preventing.”14 An “unhealthy”, contagious environment thus demands that local elected representatives take tough measures.15 During the 1854 epidemic, Dr Hyacinthe Kuborn drew up a (perhaps too) ambitious programme intended for local authorities, which were expected to enact regulations aimed at stopping any repairs to horrible hovels – real graves for the living – if they do not comply with public health rules; to allow construction on condition that new accommodation should be provided with cellars and that ground floors should be tiled or equipped with flooring; that all houses should be fitted out with pipes so as to drain refuse water down to the street […] and the sewage system […]; that houses should be equipped with lavatories put in at a reasonable distance from living spaces […]. It is the authorities’ right and duty to impose conditions concerning the number of inhabitants, to ensure that this number is proportional to the dormitory space […], to control the gutters that criss-cross the town […] and to cut new rivulets so as to divert sewage away from accommodations and prevent it from emitting effluvium just in front of houses. As far as drinking water is concerned, the introduction of public fountains is an excellent measure, which will bring positive changes; it will make it possible to have well-aired, healthy and digest water.16

The town’s economic, political and social stability depended on all its inhabitants’ (physical and moral) health condition! In addition, medical practitioners and local

13

The authorities’ rising awareness is notably illustrated by the first censuses and births and deaths calculations (see Adolphe Quetelet’s publications), then by the drawing up of medical topographies.

14

Levy, M., op. cit., pp. 413–414, quoted by Libart, V., op. cit., p. 46.

15

“Not all diseases are inevitable; all towns that are ready to act forcefully can clean up and lower death rates.” Arnould, J., Nouveaux éléments d’hygiène, Paris, 1881, p. 1215.

16

Kuborn, H., Rapport présenté au Conseil communal et au bureau de bienfaisance d’Ougrée sur l’épidémie cholérique qui a sévi dans cette localité de septembre-décembre 1854, s. l., s.d., pp. 14–16.

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Suzy Pasleau

representatives were convinced that “the destitute were the most vulnerable to cholera attacks”.17 After this first part devoted to a general description of local competence in public hygiene matters, we will focus on three specific aspects of such competence within the framework of nineteenth-century Seraing:18 the cleaning up of working-class accommodation, the construction of a full sewage system and the distribution of healthy drinking water, for the sake of which local representatives made endless efforts (through local regulations and police control) and investments that threatened Seraing’s finances.19 Besides salubrious housing, water – as the most important transmission vehicle20 – was the main concern in the fight against cholera in Seraing and elsewhere.21 In the third part, we will examine some of the physical, moral and medical “hygiene precautions” taken by Seraing’s major enterprises. “Some industrial companies implement what the state (and local authorities) cannot do […]. They [have] workmen’s housing built, [set up] grocery stores, schools, hospitals or infirmaries, [organize] medical services that provide free medicines and [set up] relief and pension funds.”22

17

Havelange, C., Les figures de la guérison, p. 328; Eggerickx, T. and Poulain, M., Le choléra, cet autre fléau social du XIXe siècle. L’épidémie de 1866 en Belgique et l’exacerbation des inégalités face à la mort in Historiens et populations. Liber Amicorum Etienne Hélin, Louvain-la-Neuve, 1991, p. 211–212.

18

As far as public hygiene was concerned, local elected representatives also cared about foodstuffs, slaughterhouses, graveyards, public urinals, public baths, prostitution, the transmission of syphilis, etc.

19

“In addition to the shortage and the bad quality of accommodation, all industrial towns were characterized by a lack of equipment. The first urbanization’s spontaneous and anarchic development turned out to be a handicap when authorities had to build sewage and drinking water systems. Seraing’s first administrators came from traditional farmers’ backgrounds and were fascinated – but powerless – witnesses of their village’s radical transformation. Their powerlessness was commensurate not only with their incomprehension, but also with the modesty of their fiscal resources, since taxpayers were poor workers with little money.” Alter, G., Bourdelais, P., Demonet, M. and Oris, M., Mortalité et migration dans les villes industrielles au XIXe siècle: exemples belges et français in Annales de démographie historique, 1999-2, p. 35.

20

“Scientific research has shown that water is the main vehicle for epidemics – some types of water are poisonous, while others are healthy.” François, J., Rapport sur un projet destiné à procurer de l’eau potable à toutes les parties de la commune in Rapport sur l’administration et la situation des affaires de la Ville de Seraing ( R.A.S.A.), 1893, p. 47.

21

For example, for the textile city of Verviers, see Lafosse, A., Epidémies de choléra à Verviers (1833–34, 1849, 1866), unpublished final dissertation (History), University of Liège, 1977, pp. 211–212 notably; Delforge, P., Le problème de l’eau à Verviers au XIXe siècle, unpublished final dissertation (History), University of Liège, 1985, pp. 194–195.

22

Kuborn, H., Aperçu historique sur l’hygiène publique, p. 157.

378


As they were concerned about their workmen and their families’ health conditions, Seraing’s major owners and managers took more targeted and concrete measures than local authorities.

Local prerogatives in public hygiene matters The following paragraphs will not and cannot aim at giving a comprehensive list of Belgian laws, orders, ministerial circulars, etc. on public hygiene during the nineteenth century. Some of them will nevertheless be selected and outlined so as to make out local authorities’ roles.23 National measures obliged them notably to see to the maintenance of sanitation, to declare all cases of epidemic or contagious diseases, to organize local vaccination and disinfection services, etc. The Belgian state got involved as well: on the one hand, it set up local hygiene commissions and committees in charge of centralizing, controlling and monitoring the respect of national norms and assisting local authorities;24 on the other hand, it granted “subsidies so as to help them carry out cleaning up work or coping with epidemic-related expenses.” 25 Under the French regime, Belgian local districts were already acknowledged to be competent in hygiene matters (government decrees of 14 December 1789 and of 16–24 August 1790). Under the Dutch regime, central authorities sought to regain some control (law of 12 March 1818) and established Provincial Medical Committees in charge of controlling all health and healing-related matters.26 Such committees were allowed to delegate their competence to Local Medical Committees (made up of four medical practitioners or surgeons at least), settled in other cities and districts and duly authorized by the Ministry of the Interior. They were in charge of observing citizens’ health, checking water and foodstuff quality, controlling the appearance of epidemic diseases and proposing appropriate measures to curb them, etc. Under the Belgian

23

For all norms mentioned above, we will avoid quoting endless bibliographical references and refer readers to the extensive collection Pasinomie ou Collection complète des lois, décrets, arrêtés et règlements généraux qui peuvent être invoqués en Belgique, Brussels, 1788–1900.

24

Jacob, R., Les interventions de l’Etat dans les travaux de voirie, d’hygiène et de salubrité publique, depuis 1830 in Bulletin trimestriel du Crédit Communal de Belgique, nr. 37, July 1956, pp. 1–8.

25

Devaux, A., op. cit., pp. 25–26.

26

Velle, K., De rol van de gemeente in het ontstaan en de evolutie van de Belgische preventieve gezondheidssector. Een inleiding in L’initiative publique des communes en Belgique, 1795–1940. Actes du 12e Colloque international d’Histoire de Spa (4-7 septembre 1984), Brussels, 1986, p. 420.

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Suzy Pasleau

regime, the health law of 18 July 1831 stipulated that the king should be granted special prerogatives as far as fighting against epidemic diseases was concerned. As cholera threatened to appear at the Belgian border, Special Health Committees were created to investigate each town’s situation.27 Since they encroached upon the 1818 medical committees’ activities, they were abolished in pursuance of the royal decree of 17 April 1833. The local law of 30 March 1836 confirms local authorities’ autonomy (art. 31) and prerogatives (art. 108) and allows them to enact regulations and rulings in health matters (art. 90, 131).28 As cholera affected Belgium again in 1848 – just after the publication of the painful Enquête sur la condition des classes ouvrières (see below) – Charles Rogier, the new Minister of the Interior, decided to tackle the public hygiene problem: in meeting onefifth to one-third of expenses, the state began to help local districts to undertake major collective cleaning up work. “One of the first forms of liberal state interventionism emerged and the government in place then yielded to the hygiene obsession in the hope of eliminating popular filth’s danger and disorders.”29 In December 1848 Rogier suggested that local authorities should set up Public Health Committees.30 Such committees were made up of medical practitioners, pharmacists, engineers, architects, etc. and were in charge of carrying out research on elements likely to affect public health and on the improvements to be made “concerning not only the cleaning up of streets and housing, but also concerning the absence of a sewage system – or its

27

A Health Subcommission was already given the responsibility to visit houses, to identify all elements likely to affect public health and to make inhabitants aware of possible dangers in 1832. A.C.S., Délibérations du Conseil Communal, t. II, fo25-26, meeting of January 14, 1832. It should be noted that Dr Nicolas Peetermans and the pharmacist Jean-Henri Kuborn (Hyacinthe’s father) were among this subcommission’s members.

28

Throughout the nineteenth century, “hygiene-related measures [merged] with road networks’ repairs and simple public health maintenance”. Van Audenhove, M., Histoire des finances communales depuis l’indépendance nationale jusqu’à la fin de la première guerre mondiale, 1830-1918, Brussels, 1992, pp. 103–104.

29

Csergo, J., Liberté, égalité, propreté: la morale de l’hygiène au XIXe siècle, Paris, 1988, p. 35.

30

Oris, M., L’hygiène publique à Amay. Première partie: le temps du choléra (1832-1880) in Annales du Cercle hutois des Sciences et des Beaux-Arts, t. XLI, 1987, p. 165 and following; Orianne, P., Les structures administratives de la commune de 1836 à 1940 in L’initiative publique des communes, p. 58.

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inadequacy – and the shortage of water for the inhabitants’ private needs and the maintenance of the public highway.”31 In 1849 different ministerial circulars listed public benefit measures local authorities should take: building workmen’s housing following a given plan, laying new streets with cobblestones in densely populated districts, demolishing houses known as unfit for habitation, etc. Local authorities’ investments were justified in many respects, since “the working population can draw more energy for work from better health conditions: numerous workers, now laid up with diseases, will be able to resume salutary occupations; poverty will decrease, which will cut public charity expenses” (circular of 5 April 1849). As early as 1851–1852, national subsidies began to be granted to local authorities dependent on certain conditions.32 After Charles Rogier’s resignation in 1852, hygiene-related concerns were pushed into the background of Belgian government policy. Nevertheless, Public Health Committees and other provincial and national health bodies continued to operate, driven by the wish to eliminate physical and moral dangers threatening the population. They gave endless descriptions of pervading insalubrity, brought up work to be carried out and emphasized the urgent need to spread hygienic behaviour. Public bodies then definitely aimed at “processing society’s waste so as to better control resulting dangers, [among them] physical waste (refuse, sewage, slaughtering sites).” 33 Former Provincial Medical Committees were re-established by the law of 31 May 1880; they were given the responsibility of controlling the observance of public hygiene laws and regulations, reporting violations to competent authorities and providing all the

31

As a centralizing body, the Conseil Supérieur d’Hygiène Publique (the Superior Council for Public Hygiene, founded in May, 1849) was given the responsibility to study local committees’ reports, to draw up various programmes and special instructions aimed at local authorities (hygiene-related precautions after floods, programme for the building of workmen’s housing, instructions to follow in case of cholera epidemic, etc.). See notably Oris, M., “Choléra et hygiène publique en Belgique. Les réactions d’un système social face à une maladie sociale”, in Bardet, J.-P. et al., Peurs et terreurs face à la Contagion, Paris, 1988, p. 97 and following.

32

Subsidized towns, such as Seraing, were notably required to award an annual cleanliness prize to “the families that most took care over their accommodation’s interior cleanliness throughout the year”. A.C.S., Délibérations du Conseil Communal, t. IV, fo7, meeting of 4 April 1850; fo78, meeting of 7 June 1851.

33

“Moral waste (dockers, sewage workers, rag-and-bone people, prostitutes)” should be added to this list. Vigarello, G., Le sain et le malsain, p. 201.

381

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information and recommendations required by the Minister of the Interior and provincial authorities (for the construction of sewage systems, water supply networks, hospitals, etc.). If transmissible or potentially epidemic diseases appeared, such committees had to take required measures in consultation with local authorities, which ineffectively supported [the Provincial Medical Committees’] efforts: such administrative bodies were frequently careless in implementing imposed prophylactic measures and sometimes showed total negligence or obvious ill-will. Even though there were major advances in hygiene matters, there still remained a lot to be done […] the efforts made by Superior Authorities had to be enhanced; they had to be allowed to take the place of local administrations when required and necessary.34

Taking up an 1818 principle, the 31 May 1885 Royal Decree stipulates that the general practitioner35 must notify the Provincial Medical Committee’s chairman of the appearance of a contagious disease in a town; it does not make provision for any penalty in case of dereliction of duty. According to the Royal Decree of 1 May 1888, mayors are in charge of taking the necessary steps to face up to threatening, urgent situations. Although mayors have to notify the governor and the Medical Committee (of a case of epidemic or contagious disease) without delay, they refrain from doing so, out of ignorance or laziness and more frequently out of self-interest. They fear that they will be required to take prophylactic measures, which will lead to heavy sacrifices for local resources; they immediately think that their popularity rate will decrease and that their re-election will be endangered.36

Though the French regime legislation granted the competence of enacting regulations on houses’ internal and external salubrity to local authorities, few concrete measures were taken during the first half of the nineteenth century. Yet “housing insalubrity affects individuals and causes constitution deterioration, increases the

34

Devaux, A., op. cit., p. 41. The Superior Council for Public Hygiene was also restructured in 1884. Other informal associations existed besides such official institutions. The Société Royale de Médecine Publique et de Topographie Médicale (Royal Society for Public Medicine and Medical Topography) was founded in 1876 and was in charge of identifying circumstances affecting general health and studying the population’s static and dynamic situation.

35

Besides general practitioners, Welfare Offices’ doctors, death controllers, clinical, hospital and prison directors, hotelkeepers and collective accommodation owners were required to notify local authorities of cases of contagious diseases.

36

Kuborn, H., De l’hygiène en Belgique, Paris, s.d., p. 1 [from Revue d’hygiène, December 1879].

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number and seriousness of diseases and leads to epidemic explosions and abnormal mortality rates.37 As the study (ordered by the Royal Decree of 7 September 1843) on the working classes’ living conditions emphasized, it was absolutely necessary for authorities to tackle the problem of population concentration and the directly related insalubrity. Aside from a few exceptions, local authorities did not yet undertake to build workmen’s housing; but they were at least required to take radical steps – supported with local regulations if need be. The laws of 1 July 1858 and 15 November 1867 on expropriation for public benefit provided them with appropriate legislative means to fight against unfit housing.38 As the Work Commission – set up by the Royal Decree of 15 April 1886 – was carrying out its own study, Provincial Medical Committees were given the responsibility of collecting information on the state of workmen’s housing. “Housing conditions [are] less poor than before. Nevertheless, workers’ accommodations do not [meet] hygiene, public health and moral requirements in most towns of the country.”39 The law of 9 August 1889 instituted Patronage Committees for Workmen’s Housing in all districts; they were to visit houses so as to note upkeep, control the appropriateness of space and airing to the number of inhabitants, check that drinking water was sufficiently available and healthy, that refuse was regularly collected and that sewage systems were correctly put in, notify owners, tenants and the local administration of possible defects and inform them on adapted remedies, and promote savings, retirement and mutual insurance institutions allowing working people to purchase their own accommodation.40 It should be pointed out that the Patronage Committee’s missions – except for the very last one – were very close to those entrusted to the Public Health Committee, which was still in existence. The new committee was completely independent from local authorities but was not allowed to encroach upon the old body’s

37

“The housing problem not only relates to private and collective hygiene but also to social hygiene since it is intimately connected with the working class’s moral standards”. Idem, Aperçu historique sur l’hygiène publique, p. 59.

38

Godding, P., L’évolution de la législation en matière d’urbanisme en Belgique au XIXe siècle in Villes en mutation XIXe-XXe siècles. Actes du 10e Colloque international d’Histoire de Spa (2–5 septembre 1980), Brussels, 1982, pp. 27–28.

39

Kuborn, Aperçu historique sur l’hygiène publique, p. 69.

40

“The two aims of this law are the stimulating of the cheap construction and the stoppage of local authorities’ apathy.” Potelle, B., L’initiative publique des communes en Belgique, 1795–1940. Les logements sociaux à Verviers in L’initiative publique des communes, pp. 225–231, 251.

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prerogatives. In addition, it carried out its mission of controlling and stimulating on the provincial rather than the local level. On the eve of the twentieth century, local authorities were supported by Public Health Committees and the newly established Patronage Committees for Workmen’s Housing and continued to care about public hygiene. Did they do so with all required vigilance? Did they have the necessary regulatory and financial means? The following pages will outline the initiatives taken by Seraing’s elected representatives during the second half of the nineteenth century.

Public hygiene first concerned local representatives The Rapports sur l’Administration et la Situation des affaires de la Ville de Seraing (Reports on the Administration and the State of Seraing’s Affairs – R.A.S.A.) and the Délibérations du Conseil communal and du Collège échevinal (Town Council’s Deliberations and Council of Deputy Burgomasters’ Deliberations) enable us to draw up annual lists of all measures aiming at the improvement of Seraing’s public hygiene (and funds released to that end). We have also been able to consult the reports of the Public Health Committee and of other health committees. This paper would not be complete without examining the numerous writings of one of the most illustrious observers of Seraing’s industrial centre, the hygienist Dr Hyacinthe Kuborn (18281910). Simply outlining his biography and bibliography would require much more than a paragraph. We will content ourselves with citing some of the key dates in his professional career and with quoting numerous extracts from his reports, books and articles. As a medical practitioner in several companies, Kuborn became a member of Seraing’s Public Health Committee in 1856.41 He was elected town councillor in 1866 and was appointed Deputy Burgomaster for Public Education four years later. He became a correspondent of the Royal Society of Medicine in 1863, a member in 1869 and the Chairman in 1885. He was appointed Chairman of the Royal Society for Public Medicine and Medical Topography in 1877.

41

R.A.S.A., 1856, p. 21.

384


Table 1: Cholera Deaths in Seraing in the nineteenth century42 Year

Population

Deaths

Rate

1832

3362

30

8,92

1848–49 (1)

11490

248

21,58

1854–55

15555

378

24,30

1859 (2)

17208

16

0,93

1866

19451

656

33,73

1894

35097

63

1,80

Source: Pasleau, S., Une population dans le développement économique. La formation d’un prolétariat industriel. Seraing 1846-1914, Unpublished thesis (History), University of Liège, 1990, p. 1442. N.B.: (1) Putzeys, J., Rapport sur l’épidémie de 1866 only reports 145 deaths. (Manuscript from the University of Liège General Library). (2) See R.A.S.A., 1860, p. 22: except for a few cases, deaths were concentrated in one street.

While Kuborn drew up his first recommendations intended for local authorities in 1854 (see above), Seraing’s elected representatives regretted that their “town seems to have the singular misfortune of being badly affected […] each time [cholera] appears in the country”43 (see Table 1). Why? Because Seraing was overpopulated, sanitary conditions were appalling, the water, the air and the ground were “soiled” with refuse, secretions, fumes, etc. Let us note that such elements could not account separately for the spread of epidemic diseases and the intervention of local authorities was required in several other respects. “In addition to healthy housing, two other requirements must be met for the town to be cleaned up: the draining away of wastewater and an adequate supply of drinking water.”44

42

A department in charge of controlling causes of death (made up of remunerated practitioners) was created in 1885. Only infectious contagious diseases were subject to compulsory notification. R.A.S.A., 1885, pp. 43–44.

43

R.A.S.A., 1854, p. 16.

44

Kuborn, H., Topographie médicale du Royaume de Belgique. Zone VII. Bassins houillers. 47e Monographie. Sections 10 et 11, Liège, 1908, p. 41.

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Suzy Pasleau

1. “Decent” workmen’s housing Dr Nicolas Peetermans (who was Seraing’s Mayor from 1857 to 1861) gave a description of housing near Seraing’s major factories in 1848.45 “We have a kind of ‘caserne’46 that is even poorer than our individual accommodation; these are underground buildings, with no air and almost no sunlight, where families are crammed together and – as if that was not enough – general cleanliness is shamefully and fatefully neglected.”47 The inhabitants of such “casernes” were often “logés” and had to face up to hard housing conditions48 owing to their status as “weekly migrants”.49 But they were not alone in that situation. Seraing’s inhabitants also suffered from the poor state of their accommodation. The flood of newcomers induced not only a lack of housing but also deterioration in housing quality.50 In other words, high demand brought about numerous rapidly built, cheap houses, which soon developed into hovels. As another consequence of speculation in land, housing was frequently built before collective facilities (sewage and drinking water systems) were put in. This made their subsequent installation more complex and expensive, since mains trenches had to be cut without threatening to shake weak foundations.51 As soon as it was set up, the Public Health Committee (founded in 1850 by Charles Rogier’s ministerial circular after the second cholera epidemic) denounced the appalling

45

“The workmen’s condition as depicted in Dr Peetermans’s report to the Province’s Salubrity Council turns out to be particularly grim.” Idem, Aperçu historique sur l’hygiène publique, p. 62.

46

The term refers to a large, cheaply contructed building providing inexpensive housing for many workers.

47

Peetermans, N., Mémoire relatif à l’enquête sur la condition des ouvriers et sur le travail des enfants adressé au Conseil de Salubrité Publique de la Province de Liège, in Ministère de l’intérieur, Enquête sur la condition des classes ouvrières et sur le travail des enfants, t. III, Brussels, 1846, pp. 141–142.

48

“Bedrooms are very small, low-ceilinged and dirty; they have as many beds as can be packed inside and remain continually closed, since beds that are left by day-shift workers are immediately occupied again by night-shift workers, and so on each day. Keepers hardly have enough time to toss the warm mattresses”. Ibid., p. 142.

49

Pasleau, S., “Un aspect de l’immigration ouvrière au plus fort de la croissance. La population flottante à Seraing, 1861–1866”, in Desama, C.. and Oris, M. (eds.), op. cit., pp. 243–271.

50

See the meticulous research carried out by De Saint-Moulin, L., La construction et la propriété des maisons. Expressions des structures sociales. Seraing depuis le début du XIXe siècle, Brussels, 1969, pp. 46–60 (in particular table on pp. 52–54 for the quantity of available housing in Seraing), 61–73 (in particular graph p. 69 for its quality).

51

Ois, M., “L’hygiène publique à Amay. Deuxième partie: la commune au centre des débats (1881–1914)”. in Annales du Cercle hutois des Sciences et des Beaux-Arts, t. XLII, 1988, pp. 144–145.

386


state of workmen’s housing in Seraing, where the “main causes of insalubrity”52 were humidity, lack of air and light, absence of latrines, poor wastewater discharge and overcrowding. All the necessary conditions were fulfilled to rapidly harbour and spread most contagious diseases.53 Relying on prevailing air-based sanitation principles, the Public Health Committee also cared about the town’s general cleanliness and saw to street cleaning, refuse collection and the draining away of stagnant water. Although the committee enacted the first local regulations in January 1851, the Council of Deputy Burgomasters accused its members of inertia and incompetence and dismissed them.54 But that was not where the real causes of insalubrity lay. After a general review of workmen’s accommodation, the new Public Health Committee urged owners to remedy the poor quality of the housing; otherwise no worker would ever be allowed to live there anymore. The Police Commissioner was in charge of implementing such measures and seeing to it that “most identified causes of insalubrity [disappear], that houses [are] cleaner and that workers have started taking care of their health.”55 Cholera reappeared briefly in Seraing in 1853, killing about twenty people in twenty-seven days.56 Local officials reacted promptly at Dr Peetermans’s urging. After a further review of workmen’s housing and another criticism by the Public Health Committee of the poor state of upkeep, the police observed that “manure, cowsheds and refuse were removed from courtyards and houses were cleaned up and whitewashed in less than fifteen days. Statements of offence were drawn up against late and recalcitrant landlords.”57 Some owners’ carelessness nevertheless caused the closing down of unfit housing, to the detriment of helpless tenants who ended up on the street. Thanks to the financial support of Seraing’s major factories (S.A. Cockerill, Hauts-Fourneaux and Charbonnages de l’Espérance, Fabrique de fer d’Ougrée and Charbonnage des Six-Bonniers), local representatives were able to hastily start building a wooden

52

R.A.S.A., 1851, p. 30.

53

“Like birds of prey, epidemic diseases swoop down on such insalubrious areas, such horrible dens’ (…) inhabitants. Cholera showed it, influenza made us remember and typhus will maybe some day provide us with a third example”. Peetermans, N., op. cit., p. 142.

54

A.C.S., Délibérations du Collège échevinal, 26 April 1851; R.A.S.A., 1851, pp. 29–31.

55

Ibid., p. 30.

56

R.A.S.A., 1853, pp. 17, 19 (daily information on number of cases and deaths).

57

Ibid.

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Suzy Pasleau

hospital.58 In addition to the fear it inspired in the population, however,59 it was soon badly affected owing to the poor quality of its facilities and in 1959 was torn down because of insalubrity!60 Cholera reappeared in very localized areas in August 1854.61 According to Seraing’s elected representatives, a great number of houses that were meant to be workmen’s accommodation leave much to be desired. […] Not infrequently we discover houses with 20 to 25 inhabitants, while 10 people could hardly live there. […] In a word, the administration could legally ban workers from occupying a third of these houses pursuant to the regulations of 25 January 1851, but this remedy would make things worse since housing is already saturated – in addition to such insalubrity causes. […] The causes of the situation are deeply worrying for the administration; we have long thought that private speculation should be allowed to remedy it.62

While local authorities had to face up to financial difficulties and to ask for state subsidies,63 identical salubrity measures were implemented as far as the road network, refuse collection and workmen’s housing were concerned. They were repeated the following year and in 1859.64

58

A.C.S., Délibérations du Conseil communal, t. IV, f°143, meeting of 18 November 1853; Kuborn, H., Topographie médicale, p. 119.

59

R.A.S.A., 1856, p. 20. Such manifestations of hospital rejection also occurred under other circumstances. Poncelet, P., Le choléra à Liège en 1866, unpublished final dissertation (History), University of Liège, 1985, p. 14; Potelle, J.-F., La population de Dison au milieu du XIXe siècle, unpublished final dissertation (History), University of Liège, 1987, p. 117.

60

“According to the College of Deputy Burgomasters’ report on the administrative situation in 1856, they wished the temporary rooms would become an adequate building. They indirectly called upon our industrial companies’ charity to definitively ensure the hospital’s future activity”, in vain. R.A.S.A., 1859, pp. 14–15.

61

While France experienced the worst epidemic ever, Belgium was relatively spared. In the Province of Liège, only 42 towns were affected – 19 of them reported less than three deaths. After February 1855, the relapse only hit 13 towns, among which was Seraing. Exposé de la situation administrative de la province de Liège. Session de 1855, 1856, p. 198; Ibidem. Session de 1856, 1857, p. 187; Schwann, T., Rapport sur la situation exceptionnelle dans laquelle s’est trouvée la province de Liège, à l’époque de l’épidémie cholérique de 1854 et 1855, Liège, 1857.

62

R.A.S.A., 1854, pp. 16–17.

63

R.A.S.A., 1855, p. 14.

64

Ibidem, p. 15; 1859, p. 20.

388


During the fourth cholera epidemic, Seraing’s authorities decided for the first time to take preventive steps (building lavatories, digging water-draining rivulets, opening windows) as well as curative steps (closing down acknowledged unfit housing).65 Such steps “were effective; there is no doubt that they contributed to decreasing the effects and duration of the disease; the epidemic, which had begun on 1 November 1859, was completely gone on 23 November.”66 The steps were renewed during the 1864 smallpox epidemic.67 It was good form to be concerned and to get involved during epidemics, but in spite of the recommendations of the higher authorities, Seraing’s representatives sank back into indifference as soon as danger was momentarily dispelled. Local officials’ observations were identical at the height of the cholera epidemic, in July 1866: “Certain working-class areas do not yet meet all basic hygiene requirements.”68 They were not necessarily more affected by cholera than others. Whereas both observers and popular commonsense postulated, in all sincerity, that overcrowding was the principal vehicle for spreading the disease, statistical data now enable us to moderate this view.69 Cholera rates and the average number of inhabitants in a house were not automatically connected. Like the turnover of labour, individual selection (genetic predisposition, gender and age), neighbourhood connections, the lack of sanitary drains and sufficient refuse collection, housing density must be considered a risk factor for the spread of cholera.70 Seraing’s authorities simply stuck to classic health recommendations:71 street cleaning, the whitewashing of houses72 and the closing

65

A.C.S., Délibérations du Conseil communal, t. IV, f° 281, meeting of 19 December 1859.

66

R.A.S.A., 1860, p. 22. The book by Kuborn, H., Considérations sur l’état sanitaire de la population de Seraing en 1860, Brussels, 1862, is actually the Public Health Committee’s report on the 1859 epidemic.

67

R.A.S.A., 1864, pp. 34–35.

68

The “College repeatedly urged owners to improve housing, put in lavatories, clean out rivulets and remove stagnant water causing infection in accommodations; the police drew up statements of offence (…): owners were fined, they paid and left their barracks in the same dilapidated state”. A.C.S., Délibérations du Conseil communal, t. V, fo 199-200, meeting of 20 July 1866.

69

See notably Oirs, M., “De la démographie à l’épidémiologie. Les épidémies de choléra dans une grande ville industrielle (Seraing) au XIXe siècle”. in Bulletin de l’Institut Archéologique Liégeois, t. CVI, 1994, pp. 324–325; Poncelet-Renard, P., op. cit., pp. 285–287.

70

Kuborn, H., Topographie médicale, p. 90, notes that numerous streets that reported the highest numbers of deaths due to the 1866 epidemic were “among the healthiest”.

71

“Public measures and regulations did not change much for about thirty years […]. The same treatments and preventive measures were maintained for want of more precise data on the disease’s etiology. Though the fight did not alter, it was intensified.” Havelange, C., op. cit., p. 324.

389

Suzy Pasleau

down of unfit accommodation.73 The authorities relied on the recent legislation (see above) to be firmer; they would not “tolerate speculators’ detrimental indifference towards workmen’s housing – which jeopardizes the health and raises the mortality rate of the most interesting part of our constituents.”74 Yet implementing such measures was very expensive. Since the town did not have any financial reserves, the administration was forced to institute new taxes. So in 1863 a tax on industrial companies was introduced, based on the number of employees and workers.75 In the absence of other taxpayers, local industry had to pay its share. During the serious 1870–1871 smallpox epidemic, the Public Health Committee met several times; after visiting numerous dwellings, committee members once again deplored their poor state. A great amount of housing is basically unfit for habitation through bad construction, equipment faults, […]; pigsties and stables back on to houses. Hens and rabbits are kept inside some of them. Back streets that lead to some of them and adjacent backyards are horrible. When there are latrines, their number and quality are inadequate and such facilities frequently seem to work as miasmatic focuses rather than as devices designed to dispel danger. […] The buildings’ poor state – maintained by the owners’ ill-will and lack of interest – are the major causes of insalubrity, identified in all districts and houses. And the number of inhabitants? It is out of proportion to the capacity of the housing.76

Nothing seemed to have progressed since the time Dr Peetermans made his observations twenty-two years earlier!

72

R.A.S.A., 1866, p. 38.

73

The explicit aim was to make an example, “to notify owners on authorities’ rights in salubrity matters [but] banning orders were far from reaching all unfit houses and accommodations; the College had to restrict measures because of the lack of salubrious housing. In today’s situation, the College would not get better results or would simply shift the problem without solving it if it had to do its duty completely.” See notably A.C.S., Délibérations du Conseil communal, t. V, fo 206, meeting of 26 October 1866.

74

Ibid., fo 199-200, meeting of 20 July 1866.

75

Notably R.A.S.A., 1863, p. 16. It was revised upwards – from 0.75 franc – in 1874, 1879, 1892, 1893, etc., so as to finance large-scale work and to tackle the economic crisis.

76

Godin and Kuborn, H.., Rapport fait au nom du Conseil de Salubrité publique au Collège des Bourgmestre et Échevins, Seraing, 1870, p. 2.

390


Instead of contenting itself with basic remarks, Seraing’s Public Health Committee “feels that local regulations on housing, ‘bataillons carrés’77 and ‘casernes’ should be essentially modified, that lodgers’ houses should be subjected to special provisions and that no sacrifice should prevent the authorities from improving the current situation.”78 In addition to the building of new workmen’s housing, it recommended that refuse should be collected promptly and regularly. Such improvements were within local authorities’ reach but were implemented without haste or vigilance. Financial resources were lacking.79 In fact the Public Health Committee continued to review housing from 1870 to 1885 without being able to notice any major changes. “Many lavatories are badly situated and defective. Liquid matter pours out on the ground – through which it seeps. Building permits should only be granted provided builders put in latrines that correspond to the model stipulated in a decent place. Dunghills, slurry pits and pig rows are located near accommodation.”80 When he was giving testimony before the 1886 Work Commission, Hyacinthe Kuborn proved to be less scathing than his colleagues.81 “If we managed to get rid of about twenty ‘casernes’ and ‘bataillons carrés’, which lack space, air, sunlight, wastewater drainage and closets, workers would be satisfyingly accommodated here [in Seraing]”. Some workmen also testified before this commission. To the question “Is to easy for you to find hygienic accommodation [in Seraing]?” one answered “Yes, we find accommodation easily. We have nothing to complain about where the muncipal authorities are concerned. The Public Health Committee is doing its duty.”82 Despite

77

A form of inexpensive housing for workers in the shape of a square; the large inner courtyard of the building formed a kind of dead end for street traffic.

78

Ibid., p. 4.

79

“The poor accounted for more than 65 percent of the population. Such an observation helps to understand Seraing’s anarchic, globally wretched development in spite of its prosperity: few people could afford to have enough interest and time to get involved in the local organization; besides, few taxpayers would have been able to pay for such an urban organization, which was desperately lacking.” De Saint-Moulin, L., op. cit., p. 236.

80

Hippolyte Kuborn, reporter of the Public Health Committee, quoted by Kuborn, H., Topographie médicale, p. 30.

81

Commision du Travail (Work Commission), Réponses au questionnaire concernant le travail industriel, t. I, Brussels, 1887, pp. 566-569. To be more precise, Kuborn was answering question no. 50: “how are workmen housed in your town ?”

82

Idem, Procès-verbaux des séances d’enquête concernant le travail industriel, t. II, Brussels, 1887, p. 170.

391

Suzy Pasleau

improvements (among them a sharp decrease in cul-de-sacs83 and hovels), Kuborn complained in 1891 that Seraing’s representatives had not laid down any police regulations imposing the compulsory disinfection of housing.84 The next year’s smallpox and measles epidemics required the same measures as forty years earlier.85 At the Public Health Committee’s instigation, Seraing acquired an effective new prophylactic tool in 1894: an autoclave.86 During preceding cholera epidemics, the Council of Deputy Burgomasters or the Welfare Office had had iron sulphate distributed and required or imposed the whitewashing of houses.87 From now on, the autoclave was used for immediate housing and clothing disinfection.88 As a consequence, Seraing was considered a pioneer in prevention. Thanks to the autoclave, the 1894 cholera epidemic was less virulent (Table 1).89 In 1901, 242 houses were disinfected.90 A permanent service was also set up. From 1903 onwards, between 60 and 80 accommodation disinfections were carried out each year.91 Yet for fear of seeing their belongings or houses damaged, some inhabitants refused to resort to such a device.92 The cleaning up of Seraing’s housing mostly happened after 1890. In addition to some health standards that had to be respected during construction, the law of 9 August 1889 also contributed to improvements in working-class accommodation. Two housing companies (Le Foyer de l’Ouvrier [The Workman’s Home] and La Société Anonyme de garantie pour favoriser la construction de maisons ouvrières dans l’arrondissement de

83

“There were considered to be an investment, regardless of any social restriction: those who built them wanted to have as much housing as possible on the smallest possible plot of land so as to reduce expenses”. Idem, Réponses au questionnaire, p. 226.

84

Tablettes de la Société Royale de Médecine Publique, July, 1891.

85

R.A.S.A., 1892, pp. 43–44; 1893, pp. 40-41; Tablettes de la S.R.M.P., September 1892; September 1893.

86

R.A.S.A., 1894, p. 43.

87

R.A.S.A., 1866, pp. 31–32.

88

A.C.S., Délibérations du Conseil communal, t. IX, f°311, meeting of 18 March 1894; R.A.S.A., 1894, p. 45.

89

The device was also used during smallpox, measles, scarlet fever epidemics, etc. to disinfect private houses as well as school premises.

90

R.A.S.A., 1901, p. 34.

91

R.A.S.A., 1903, p. 57; 1904, p. 71; 1905, p. 77; 1906, p. 81; 1907, p. 87; 1908, p. 98; etc.

92

According to Kuborn, H., Topographie médicale, pp. 114–115, such refusals explained the persistence of scarlet fever, typhoid fever and diphtheria epidemics.

392


Liège [The Guarantee Limited Company for the Construction of Workmen’s Houses in the Liège Area]) enabled some hundreds of workers to afford to build or purchase “sound” accommodation.93 Simultaneously, better-off people left the town’s workingclass, lower part, which was polluted by fumes and increasingly encircled by factories. Wooded hills served as a refuge. In 1900 the Patronage Committee for Workmen’s Housing visited 1502 housing units and observed that “66 still lack latrines; […] in some cul-de-sacs, latrines [are used] by the inhabitants of several houses; […] 51 […] [have] no pit or container and […] faeces are lying around.”94 Compared to the black pictures painted in the decades 1840-1880, such criticism sounds like a hymn to victory! “The number of ‘casernes’, ‘bataillons carrés’, […] has been decreased […] to about thirty, and their hygiene conditions are strictly controlled.”95 2. The sewage system In the middle of the nineteenth century, Seraing’s rain and wastewater could only be drained off through open-air rivulets on roadsides. Local authorities had to start major road and sewage work so as to get rid of such reservoirs of infection. Whereas the main local streets had been laid with cobblestones and gutters had been cut by the beginning of the 1870s, the sewage system was far from satisfactory. Scarcely four or five sewers had been built where the situation appeared to be the most worrying (i.e. in the “Bottom” of Seraing, which was flooded regularly, since it was a damp area level with the river Meuse).96 Local officials doubted their usefulness and effectiveness.97 New districts were built on the surrounding hills and the slopes made wastewater draining faster and easier. The real cleaning up began in 1875, but it was disrupted by numerous

93

De Saint-Moulin, L., op. cit., pp. 132-133. “In total, we can reasonably estimate that 25 houses on average were built in Seraing each year from 1891 to 1914 thanks to advances provided for by the law of 9 August 1889. The financial support amounted […] to more than 50 units from 1891 onward – also considering the support that indirectly resulted from demolitions carried out by factories with a view to expansion.”

94

Kuborn, H., Topographie médicale, p. 79.

95

Ibid., pp. 13–14.

96

R.A.S.A., 1857, p. 29; 1863, p. 40; 1870, pp. 63–64; 1873, p. 57.

97

R.A.S.A., 1867, p. 49; 1868, p. 47; 1869, p. 59. “ Studies on the construction of the sewage system are not included yet but will be closely examined”.

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mining subsidence problems,98 which required endless, costly repair work on the pipes.99 What was more, frequent floods (1874, 1876, 1879, 1880–1881, 1882) damaged the sewage system. The town council examined a project by François-Guillaume Kamp (former Mayor, 1861–1870) in 1883; this programme aimed at protecting Seraing from the damage caused when the Meuse overflowed its banks. Floods were considered more than ordinary “newsflashes” when they affected industrial structures and led to workmen’s redundancies. A special Study Committee was set up. While waiting for its conclusions, the authorities took some steps, among them the purchase of pumps.100 In addition to the damage caused to sewage structures and factories, floods also helped to spread diseases among the inhabitants of riverside houses.101 As a result of several centuries of coalmining, the Bottom in Seraing was lower than the river Meuse in times of flood. Searching for sustainable solutions and, even more important, implementing them, required real political commitment and willingness to overcome both technical and financial obstacles and public reluctance. In 1886 Kuborn denounced the poor state of the existing sewage system as well as the absence of any system at all in several places. “In the lower area, […] most ‘casernes’ and much private housing lack wastewater drainage. Water stagnates in backyards, passages, putrefying or seeping through the ground and contaminating wells. The inhabitants have no option but to dump it in the streets or pour it into holes […] – which do not absorb water or cause other hazards after some time.”102 In addition, household refuse was still being dumped into tubs, which were left outdoors and emptied twice a week; lavatories were often unequipped with watertight pits. Nothing but a harsh measure imposed by the elected representatives could possibly remedy this

98

R.A.S.A., 1875, p. 50; 1876, pp. 61–62; 1877, p. 53; 1879, p. 60; 1880, p. 51; 1885, pp. 51–52; 1886, p. 44; 1887, pp. 43–44.

99

Such repair work should normally have been taken care of by concessionary companies exploiting the subsoil. But local authorities gave up, as time-consuming assessments were required to prove the companies’ responsibility.

100

Two machines were bought from the Cockerill factories for 10,000 francs each; the pumps came from Liège. R.A.S.A., 1883, p. 44.

101

Kuborn, H., De l’influence des inondations sur la santé publique in Bulletin de la Société royale de Médecine Publique, t. II, 1883, nr.4, pp. 584–594.

102

Work Commission, Réponses au questionnaire, p. 567.

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poor situation. Under article 39 of the new local regulations enacted on 24 November 1888, “all housing buildings [must] have latrines. Nevertheless, if the need for it can be proved, local authorities [may] allow the installation of common latrines for several dwellings on conditions they [prescribe].”103 Numerous exceptions proved the rule! A global sewage project was finally designed in 1892. It was closely linked to the drinking water supply system and was meant to be a large prophylactic programme, whose “implementation might not protect Seraing from epidemic diseases, but will at least significantly weaken their effects. [The programme will consist in] constructing a main sewer with a network of secondary sewers aiming at preventing the stagnation of rain and domestic water [and] confining the river Meuse so as to protect the town’s lower areas against frequent floods that cause infection and considerable material losses to riverside inhabitants.”104 From 1895 on, the Bottom of Seraing was equipped with a complete sewage system thanks to a 500,000-franc loan.105 Three years later, the system was extended to other districts.106 From 1903 on, an automatic sewer cleansing system was put in so as to avoid any deposits.107 Only peripheral districts (Chatqueue and Biens Communaux) were still neglected at the beginning of the twentieth century, as new problems emerged in the Bottom of Seraing as a consequence of mining subsidence.108 3. Drinking water In 1856, Seraing’s officials prided themselves on the fact that “the quality of the town’s drinking water is generally good, which greatly influences the inhabitants’ health.”109 Unfortunately, it was not so throughout the town, nor had it always been so.

103

De Saint=Moulin, L., op. cit., pp. 240, 248–249.

104

François J., Rapport sur un projet de construction d’un réseau d’égouts dans les parties basses de Seraing et d’endiguement de la Meuse in R.A.S.A., 1893, p. 70. For a detailed description of improvements, see Kuborn, H., Topographie médicale, pp. 41–54.

105

R.A.S.A., 1895, p. 12.

106

R.A.S.A., 1898, p. 43; 1899, pp. 39–40; 1907, pp. 84–85.

107

R.A.S.A., 1903, pp. 54–55.

108

R.A.S.A., 1904, pp. 68-69; 1907, p. 84; 1908, pp. 95–97.

109

R.A.S.A., 1856, p. 22. Such an empirical assessment was confirmed by Kuborn, H., Considérations sur l’état sanitaire, p. 15.

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Opposite the alluvial plain – where shallow wells were almost always full110 – Seraing’s foothills underwent a fast settlement extension, which led to a clear insufficiency of water. This explains why the Lize district’s inhabitants demanded that improvements should be carried out to remedy the water “shortage” in 1866.111 After the cholera epidemic took a terrible toll in the same district, Seraing’s elected representatives sought a study on the state of the groundwater so as not to undertake major expenditures with poor results.112 They had every right to be proud of their cautious reaction, as was pointed out in 1870: “If our town had decided earlier on which improvements to carry out, it would not have had the pleasure of mentioning what we can almost claim now: we will always have plenty of superior water.”113 At a rate of 200 metres each year – in order to spread out costs – the long-awaited water trench was finally completed in 1880.114 The building of the first side trenches began the year after, but that was not enough. Indeed, Kuborn described a very precarious situation in 1886. “In numerous dwellings, drinking water is soiled by seepage […] in addition to sediments from the river Meuse’s frequent floods […]. We have been able to examine water from at least twenty wells and have concluded that it carries animal organic matter three times out of five”!115 After observing such poor conditions, he suggested that “the trench that supplies the population upstream with superior quality water should be extended and that water should be directed […] to public fountains. Considering the water’s quality, owners should unquestionably have it brought to their dwellings and collected charges will cover the interest on the invested capital – and even more.” Such a programme would require heavy investments, which the town could not yet afford. A project (designed by J. François) meant to be implemented throughout Seraing was submitted to the town council in 1892–1893, which acknowledged that “only a

110

The bad quality of water was acknowledged in the 1860s. R.A.S.A., 1857, p. 29; 1863, p. 40; 1867, p. 49; 1869, p. 59.

111

A.C.S., Délibérations du Conseil communal, t. V, f°185, meeting of 1 February 1866.

112

R.A.S.A., 1867, pp. 46, 48-49; 1868, pp. 46-47; 1869, pp. 57–59.

113

R.A.S.A., 1870, pp. 64-67. The planned work aimed at draining waters from the Vecquée wood (on Seraing’s hills) through a 1,000-metre trench cut in schist and sandstone.

114

R.A.S.A., 1880, pp. 53–54.

115


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third of inhabitants are supplied with drinking water; the Bottom of Seraing is in a delicate situation because fissures due to soil subsidence […] have allowed stagnant water and water from earth closets and slurry pits to reach the groundwater that feeds wells.”116 Contamination hazards were increased when the river Meuse’s overflowed. Global investments to ensure a sufficient supply of drinking water were included in Seraing’s budget for 1893 and later, and required major financial commitments. Steps had to be taken so as not to threaten local finances: carrying out a bacteriological analysis117 and beginning with the main streets. The elected representatives aimed at promoting population settlements in healthy areas while taking budgetary imperatives into account. Hygienists – led by Kuborn – first meant to protect Seraing’s inhabitants against new epidemics. “The situation is such that in the event of cholera or any other epidemic […], the first measure will be to ban all wells.”118 This is clearly exaggerated, since only sixty-three people died as a result of the 1894 cholera epidemic. It seems to be established that these victims drank unsuitably collected, probably soiled rainwater.119 At the end of the nineteenth and the very beginning of the twentieth century, the work was pursued with a view to putting in complete water supply and sewage systems depending on underground, watertight mains throughout Seraing. In addition to the Public Health Committee’s recommendations120 and many instructions given by the Superior Council for Public Hygiene, Seraing’s elected representatives drew on local regulations enacted in 1851, 1888, 1902 and 1908. The latter document listed nearly 200 articles (!) that coordinated all previous measures and aimed at including all major industrial centres’ sanitary requirements.121 So “the College of Burgomaster and Deputy Burgomaster’s prior written authorization is required for the following operations: any building’s […] construction, reconstruction,

116

R.A.S.A., 1893, p. 8.

117

Dr Firket, Analyse bactérioscopique des eaux de distribution de Seraing in R.A.S.A., pp. 55–56; Dr Jorissen, Analyse chimique des eaux de distribution de Seraing in Ibidem, pp. 56–58; R.A.S.A., 1898, pp. 43–44.

118

François J., Rapport sur un projet destiné à donner de l’eau potable, p. 48. On the following page, the report only mentioned one third of all wells.

119

R.A.S.A., 1894, p. 45.

120

According to Kuborn, the committee was consulted and met only during epidemics. As soon as the danger was over, “the control slackens, things get back to their original state and remain so until new epidemics are suspected.” Work Commission, Réponses au questionnaire, p. 566.

121

Kuborn, H., Topographie médicale, p. 32.

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improvement, repair and demolition; any well, tank or manure pit’s […] digging, demolition or removal; the conversion of any building into a dwelling; any sewer or side sewer’s […] construction, reconstruction, improvement and removal” (article 10). “Any building serving or likely to serve as accommodation or as a meeting place should be equipped with an appropriate number of masonry lavatories […] Such lavatories should be located in places that are easily accessible to all inhabitants by day and night” (art. 119). “Accommodation located in back streets, cul-de-sacs, inner courtyards or socalled workers’ housing developments should be connected to the public sewage system. Each housing unit should have a separate sewer linked to the global system directly or via a main sewer” (art. 124). “Any accommodation should be connected up to the town’s drinking water network if the property in which it is located adjoins – in any place – a road equipped with a public-service water pipe” (art. 131). The Val-Saint-Lambert district had lower death rates throughout the second half of the nineteenth century. It was almost “spared” by the cholera epidemics in 1848–1849, 1854–1855 and 1866. The population density was not lower than in other districts (200 households lived in the crystal glassworks’ courtyard), housing quality was not superior, sewage and drinking water supply systems were not better nor had they been put in before other systems in the rest of the town.122 But the workers were the most controlled and the best “hygienically” protected in Seraing. The efforts made by the Val-SaintLambert crystal glassworks’ management were appreciated by local authorities123 but in fact only reflected the management’s fear of losing (highly) skilled labour!124

122

“To what cause should the Val-Saint-Lambert’s immunity be put down […], while [the factory] had been hit so severely in 1832? Could it not rather be that the place was [then] covered with horrible cesspits, appalling hovels, where dirty paupers milled about? Could it not rather be that the streets where they lived were constantly clouded by gas emitted by putrefying animal and vegetal substances? Some might object that such elements are but predisposing factors. But such predisposing factors become efficient or secondary as soon as the epidemic process has affected a place and transmitted its formula. This can be proved by the fact that cholera never hit the Val-Saint-Lambert again after such factors disappeared.” Idem, Rapport présenté au Conseil communal, p. 9.

123

A.C.S., Délibérations du Collège échevinal, t. I, p. 104.

124

As he gave testimony before the Work Commission, Jules Deprez – the General Manager of the ValSaint-Lambert crystal glassworks – insisted on emphasizing that “our working-class population is extremely civilized, very stable and hard-working; it deserves our deepest sympathy.” That was attachment! Work Commission, Procès-verbaux des séances d’enquête, p. 191.

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Public hygiene and management In examining some employers’ initiatives aimed at providing workers with medical and pharmaceutical care,125 we will consider measures meant to fight against occupational diseases and to promote the workforce’s housing conditions – both sectors being largely touched on in the second part of the article from the perspective of public decision-making. Owing to lack of space, we will have to omit a great number of “hygienic precautions” taken by Seraing’s factories.126 As a consequence, we will not dwell on some industries’ specific physical measures (water drainage and ventilation at coal mining sites,127 workshop lighting and airing, etc.); nor will we analyse moral matters, which were discussed at length by legislative authorities, managers and the first workers’ organizations (women’s and children’s work, night work, etc.); nor will we consider material help (provided through mutual help organizations, relief or contingency funds, savings unions and pension funds) offered to workers and workingclass families to assist them in facing up to life’s uncertainties. Finally, we will also leave out any consideration on pay rises, which improve living conditions (diet, housing,128 education). Kuborn’s work and several industrial studies made it possible to define both employers’ and workers’ concerns in hygiene matters. Qualified medical practitioners were crucial. Among necessary hygiene precautions meant to protect ill or injured workers, the most important is unquestionably to require the presence of a qualified and, above all,

125

On the number of medical practitioners in Seraing, see Ois, M., “Hygiène publique et médicalisation dans une cité industrielle. Seraing au XIXe et au début du XXe siècle”, in Revue Belge de Philologie et d’Histoire, t. LXXIII, 1995, p. 998.

126

When he was asked “What hygienic precautions should be taken in the province’s factories, manufactures, mines and plants to protect workers’ health?”, Peetermans, N., op. cit., pp. 143–165, notably mentioned “frequently whitewashing and perfectly cleaning work places; sluicing down floors, which should always be made of wood; spraying courtyards and, above all, urinals; opening doors and windows at mealtimes and even at night; making draughts during work hours; ensuring a temperature as moderate as possible […] inside workshops: such are the means to get pure, cool and frequently renewed air. Requiring a minimum level of personal hygiene from workers; keeping male and female workers apart and visiting workers twice a month will make it possible to prevent most contagious diseases.”

127

“Since [Seraing’s] mines have very high galleries and excellent airing in general, working there is absolutely not unhealthy and workers enjoy much more favourable conditions.” Answer by J. Genaert, engineer in the sixth district of the third mine section (Liège) in Ministère de l’Intérieur, op. cit., t. II, p. 314.

128

Wage increases could not positively influence quality as long as quantity requirements were not fulfilled.

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zealous medical practitioner or surgeon in each industrial establishment. He will be the only person able to define all hygiene measures to implement, to observe a specific type of industry’s impact on workers and particular threat to workers’ health […]; he will be in charge of reducing or eliminating causes of diseases, disabilities, deformities or accidents […] [and] of ensuring that he has everything he is likely to need to treat all cases of injuries, burns, poisoning, suffocation, etc.”129

From 1848 onward, the Établissements Cockerill’s steel complex and collieries had a surgeon and a pharmacy; medical and pharmaceutical expenses were paid for by provident funds.130 Similarly, the Val-Saint-Lambert crystal glassworks opened a health service with free medical care five years later.131 In 1860, Kuborn claimed that medical and pharmaceutical expenses were taken care of “better than anywhere else. Each industrial establishment uses a deduction of 2.5 percent from all wages to pay special medical practitioners and provides ill workers not only with medical care, but also with prescribed medicines under all circumstances.”132 Four years later, the Val-SaintLambert crystal glassworks and the Charbonnage de l’Espérance extended this system to workers’ families – before the Établissements Cockerill.133 The most deadly conditions – at least for miners134 – affected the respiratory tract; logically enough, they were blamed on humidity, bad air and the alternation of warm

129

Peetermans, N., op. cit., p. 146–147.

130

“Expenses caused by the distribution of medicines are taken care of by the contingency fund […] created […] thanks to the 2 percent deduction from workers’ wages; in addition, workers are entitled to half wages in case of unfitness for work.” Ibid., p. 148.

131

Le Centenaire des cristalleries du Val-Saint-Lambert 1826–1926. Compte-rendu des cérémonies et festivités 27-28 juin 1926, s.l., s.d., p. 37. It soon “transformed into a complex organization based on a rather unpretentious infirmary – provided with the best hospital equipment and supported by a male nurse, three nursing sisters and twenty-seven medical doctors, among whom renowned specialist practitioners.”

132

Kuborn, H., Considérations sur l’état sanitaire, p. 36.

133

Rapport de la Commission médicale de la Province de Liège sur ses travaux pendant l’année 1864, p. 205.

134

Kuborn was in charge of the health services of several of Seraing’s collieries and took advantage of his position to draw up statistics on miners’ diseases (for periods 1857–1862 and 1885–1888). Kuborn, H., Etude sur les maladies particulières aux ouvriers mineurs employés aux exploitations houillères en Belgique, Paris, 1863; IDEM, Sur l’état sanitaire – maladie, mortalité, longévité – des ouvriers employés dans les exploitations charbonnières pendant les dernières années, spécialement dans la province de Liège in Congrès d’hygiène et de Démographie de Paris 1889, Paris, 1890, pp. 741–758.

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and cold places when working in pits, galleries135 and workshops. After work, workers walked home with sweat-soaked clothes – at night, come rain or shine. The SixBonniers collieries put in the first miners’ washhouse in the Liège region in 1868 to fight against diseases such as bronchitis, tuberculosis, lung anthracosis and other bronchopulmonary conditions. The washhouse was made up of 40 free baths.136 In addition, working clothing could be distributed and washed for free.137 A year later, the Marihaye coal mine also had baths (see Table 2) for which workers had to pay (0.75 francs per fortnight; this amount also paid for clothes washing). Such an innovation gave rise to reluctance among miners, who were used to (free) washing at home and to having their wives wash their working outfits each evening. The Cockerill steel factories also put rooms at their workers’ disposal to allow them to wash and change clothes before returning home. In “iron factories and in all workshops where dirty, sedentary, badly-paid work is carried out, […] heat, sweat and dust cause skin dirtying, which makes it always difficult to clean.”138

135

“Since mineworkers have to work in high temperatures, they sweat and often take their clothes off. When they stop working, they are stricken by cold draughts […]. Why do workers operate naked? […] Because of sweat. Workers often labour out of draughts and get excessively hot. That is why they keep only their trousers on.” Work Commission, Procès-verbaux des séances d’enquête, p. 174.

136

Gaier, C., Huit siècles de houillerie liégeoise. Histoire des hommes et du charbon à Liège, Liège, 1988, pp. 186–187.

137

“On request, each worker can get two grey cotton working suits consisting of trousers, a shirt and a jacket. All suits are washed and looked after for free by the mining establishment. Workers are charged for such suits only if they quit their occupation before the agreed termination date […] or if they have worn them out before that date.” Article 3 of Règlement d’ordre pour le service des bains et lavoirs de la houillère Saint-Antoine, dépendant du charbonnage des Six-Bonniers, à Seraing in Résultats de l’enquête ouverte par les officiers du corps des mines, p. 461.

138

Peetermans, N., op. cit., pp. 162-163, 165, adds that “glassworks furnace workers are subjected to difficulties that are virtually identical to those imposed on iron factory workers; as a consequence, they should enjoy the same hygiene precautions, in a way.”

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Table 2/1: Medical “Hygienic Precautions” in Seraing’s factories, 1869 Factory name

No

John Cockerill company In some sections only. No

No

-

-

-

How many workers use these facilities? What steps does the company take to help workers in case of injury or disease?

-

-

-

In addition to medical care, injured workers are entitled to a 1.25-franc daily allowance, while ill workers receive a 0.75-franc sick pay. Workers’ families are entitled to the doctor’s care.

In addition to medical care, ill workers are entitled to 40% of their wages, while injured workers are entitled to 30% of their wages as a daily allowance.

In addition to medical care, injured or ill workers are entitled to half wages. In general, sick pay is only granted from the fourth non-working day.

Is there an infirmary?

No

Yes

Yes, for first aid.

Is there a special consultation room where the doctor can see patients at given times, on given days? Does the doctor give home care? Within what distance? Are medicines free?

No

Yes

No

Yes

Yes, within a 2-league radius.

Yes, within a 10-kilometre radius.

Yes, for workers, but not for families.

No

Yes, expenses are taken care of by the relief fund.

Do workers have a room for washing after work? Are there baths and wash houses? What equipment do they have?

L’Espérance Company (blast furnaces) No

402

Ougrée Iron Factory Public Company No


Table 2/2: Medical “Hygienic Precautions” in Seraing’s factories, 1869 Marihaye collieries

L’Espérance collieries No

Cockerill collieries

Six-Bonniers collieries

No

Yes

Yes, on site nr. 1. The two other sites will be fitted out soon. 30 closets, heated room.

No

No

Yes, on the main site.

-

-

1/5 of miners

-

-

A bathroom and wash houses; a laundry room and a clothes airer. 5/6 of workers

Ill and injured workers and their families are entitled to medical care; injured workers are granted a daily allowance equal to half of their wages.

Injured workers are entitled to a 1.25-franc daily allowance, while ill workers receive a 0.75-franc sick pay. Medical care for injured workers. Families are only entitled to the doctor’s care. No

In addition to medical care, ill workers are entitled to 40% of their wages, while injured workers are entitled to 50% of their wages as a daily allowance.

In addition to medical care, injured workers are entitled to 50% of their wages, while ill workers are entitled to 30% of their wages.

Yes

No

No

Yes

No, the doctor only sees patients in his practice.


Yes, throughout the town.

Yes, within a 2-league radius.


Yes

Yes

No

Yes

Yes

Yes, on each working site. Injured workers are treated there until complete recovery. Yes

Source: Résultats de l’enquête ouverte par les officiers du corps des mines sur la situation des ouvriers dans les mines et usines métallurgiques de la Belgique, Brussels, 1869, pp. 336–337, 404–407.

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From 1886 onwards, the Cockerill company (steel workshops and collieries) had an infirmary and a hospital139 where injured and ill workers could be treated free of charge. It also relied on the three medical practitioners, who looked after the health of workers and their families. The pharmacy supplied free medicines.140 An orphanage, the hospital and the pharmacy cost the company between 70,000 and 80,000 francs each year.141 In addition, Cockerill’s directors paid particular attention to “imposing hygiene, order and cleanliness everywhere and were an example for workers, who copied the rules enforced at the factory when they came back home; the management put in […] washrooms where workers could wash rapidly and change clothes before leaving the mine.”142 During examination sessions, the Work Commission’s members questioned those involved on medical care and companies’ efforts in hygiene matters. On the basis of the accounts given by several workers employed in Seraing’s collieries and the Cockerill Company, the commission observed that injured workers were entitled to appropriate care and that housing conditions were satisfactory. Yet they advised owners to put in more washhouses so as to allow “miners’ wives to wash their husbands’ clothes outside houses”.143 There was only a fine line left between industrial hygiene and private or personal hygiene.144 At the end of the nineteenth century and at the beginning of the twentieth century, miners were affected by inflammatory conditions of the digestive tract due to drinking

139

Such an institution turned out to be essential, since “there are frequent injuries in the establishment”. Work Commission, Procès-verbaux des séances d’enquête, p. 176.

140

From 1908 on, five medical practitioners were in charge of medical care in the Cockerill Company. Kuborn, H., Topographie médicale, p. 67.

141


142

Ibid., pp. 375–376.

143

Work Commission, Procès-verbaux des séances d’enquête, p. 183. Company leaders demanded the building of country railways, which they considered very useful for improving housing conditions in Seraing as well as general hygiene. “Workers living in the country [would be able to go back home each day], would enjoy better housing, better food and would be able to take better care of their families.” Ibid., p. 189.

144

In 1848-1849 Charles Rogier, the Minister of the Interior, asked the local authorities to build public baths and washhouses. These were used free or for a modest sum by the population. There is no trace of this service to be found in the documentation for Seraing. Lombaerde, P., Het casino, het thermengebouwd en het openbare zwembad: evolutie and invloed op de stedelijke ontwikkeling in L’initiative publique des communes, pp. 148–149, 153–160.

404


water flowing in galleries – which was contaminated by human and horse excrement. In view of the spread of ancylostomiasis in particular,145 the directors of the Cockerill and Six-Bonniers collieries took major hygiene steps such as putting in latrine buckets in underground mining sites.146 Yet in 1907, when testifying before the Board of Enquiry on Working Hours in Coal Mines, Henri Dubar – a mineworker in charge of pushing coal wagons in the Marihaye collieries – bemoaned the fact that workers did not yet have “tubs” to relieve themselves.147 However, it was forbidden to drink water from the mine; instead, there were flasks of coffee and water supplied in inlets in galleries thanks to a connection with the town’s mains. Such improvements had helped to decrease the number of workers affected by ancylostomiasis, which was confirmed by Louis Eloy, the director of the Marihaye collieries.148 At the same enquiry, Isidore Boeyckens, a miner from the Six-Bonniers collieries, lamented that the washhouse did not suffice and “left much to be desired as far as cleanliness was concerned,”149 Baudouin Souheur, the collieries’ director, acknowledged that the “washroom has become a little cramped. […] I ordered a new shower room about three weeks ago. People complained about the current washroom’s lack of maintenance; a supervisor is specially responsible for it but it has to be admitted that workers do not really take care of the equipment.”150 In addition to lavatories, Marihaye workers also asked for the building of “a shower room like the one in operation at the Cockerill Company, because tub washrooms […] are frequently badly-

145

Hookworms live in intestines and penetrate the human body through the skin or through food ingestion. Hookworms feed on blood, which can lead to a kind of anaemia. Ancylostomiasis appeared in the Liège region around 1880 following the arrival of Italian workers from the Saint-Gothard and Mont-Cenis construction sites coming to work in mines. While the Ministerial Decree of 7 August 1900 set up boards of enquiry in charge of assessing the extent of the disease and suggesting radical prophylactic measures in the main coal mining centres, Kuborn, H., De l’anchylostome duodénal en général et de sa propagation en Belgique, Brussels, 1900, attempted to give the first answers.

146

Idem, Topographie médicale, pp. 112-113; Commission d’enquête sur la durée du travail dans les mines de houille (Board of Enquiry on Working Hours in Coal Mines), Documents annexes, Brussels, 1909, pp. 29-30 (letter written by A. Greiner on behalf of the Cockerill Company).

147

Idem, Enquête orale. Dépositions des ouvriers. Section de Liège, Brussels, 1907, p. 219.

148

Ibid., Dépositions des patrons, p. 165. The figures he cites (“4 to 6 percent of the workers infected at the time of the last census”) were even revised downwards by Charles Dehousse, the collieries’ Chief Engineer: 3 to 4 percent only. Ibid., p. 240.

149

Ibid., Dépositions des ouvriers, p. 143.

150

Ibid., Dépositions des patrons, p. 179.

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kept; workers have to undress before their workmates and to wash successively so that all colliers may be contaminated if one of them is suffering from a contagious disease.”151 Such an explanation was slightly exaggerated but it had to be admitted that showers were decidedly more hygienic than baths! Lastly, miners demanded that a laundry room, a lavoir d’effets,152 should be created. Other fields such as working-class housing were also improved by employers’ initiatives. A. Lecocq observed in 1847 that “many workers have to live at considerable distances from the [Cockerill] factory because housing is very expensive in densely populated centres like Seraing.”153 Long journeys to work tired workers and caused them to perform badly. From 1825 onwards, the Cockerill Company offered accommodation to workers so as to fight against the poor housing conditions mentioned above and to induce labour to settle near factories with a view to increasing productivity. It was soon followed by Seraing’s other major companies.154 As the 1869 study emphasized, workmen’s accommodation could not be purchased, but only rented by occupiers for a monthly rent of 5 to 10 francs (and even 15 francs for Ougrée’s Iron Factory); rents of privately-owned houses in Seraing or neighbouring localities could sometimes be twice as expensive. Whereas Marihaye’s houses only accommodated single workers who returned home – out of town – the “factory houses” sheltered whole families in the Six-Bonniers and the Espérance collieries as well as in the Cockerill Company, in the Espérance Company (blast furnaces) and the Ougrée Iron Factory.155 From 1886 onward, the Val-Saint-Lambert crystal glassworks owned 120 houses with gardens within the

151

Ibid., Dépositions des ouvriers, p. 225. Before other collieries, Marihaye’s site of Flémalle was equipped with 33 shower boxes for 350 workers in 1907. Daily use (shower with soap and towel) and pit clothes washing cost 15 centimes a day or 50 centimes a fortnight. Gaier, C., op. cit., p. 187. A Royal Decree dating back to 1911 stipulated that all collieries were required to put in free baths at the pit workers’ disposal. This measure was extended to surface miners in 1919.

152

Account by Nicolas Brandebourger, miner in the Marihaye collieries. Board of Enquiry on Working Hours in Coal Mines, Enquête orale. Dépositions des ouvriers, p. 227. Working clothes did not have to be washed by collieries until 1974!

153

Lecocq, A., Description de l’établissement John Cockerill à Seraing, Liège, 1847, p. 68.

154

In Verviers, the construction of workmen’s housing begun in 1818, with the “quartier des Grandes Rames”, sustained by six local industrial manufacturers. Potelle, B., L’initiative publique des communes en Belgique, pp. 223-224, note 3.

155

Résultats de l’enquête ouverte par les officiers du corps des mines, pp. 322–323, 392–393.

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factory’s compound and 40 outside it.156 Management considered that such a “workingclass institution” – like the schools, savings union, leisure-time organizations and food organization set up for the Val-Saint-Lambert’s workers – deserved attention. “The authorities always thought that one of the best measures that could be taken in the interest of the working class was to provide them with cheap, salubrious houses with gardens.”157 L. de Saint-Moulin’s wide-ranging study enabled him to calculate that 89 new houses were built by the Cockerill Company from 1830 to 1914. Elsewhere, 55 houses were built by the Ougrée Factory, 54 by the Six-Bonniers collieries, 40 by the Marihaye collieries, 29 by the Espérance collieries and 101 by the Val-Saint-Lambert crystal glassworks.158 Before the First World War, Seraing’s major industrial companies had actually built only a few workmen’s houses – and houses which, according to the same author, were poor quality forms of accommodation. “Therefore, we cannot speak of competition with private initiative; this does not imply that a systematic social control policy should be imposed on workers either, except maybe as far as Val-Saint-Lambert and – to a lesser extent – the collieries are concerned.”159 Seraing’s industrial establishments purchased a small number of houses to the same end.160

Conclusion The history of public hygiene in Seraing fits into the general framework of the reconstruction, redevelopment and quality urbanization of the industrial urban environment that emerged at the beginning of the nineteenth century.161 It was marked by the fight against the spread of diseases and the eradication of cholera, smallpox, measles epidemics, etc., whose virulence decreased as decades went by. Yet such a

156

Work Commission, Procès-verbaux des séances d’enquête, p. 191.

157

The crystal glassworks also had “16 model houses in the country around Ivoz – on a site where 100 such houses were to be built.” Ibid., p. 207.

158

De Saint-Moulin, L., op. cit., pp. XLVIII-XLIX, 167–169.

159

Ibid., p. 169.

160

See table, ibid., p. 199.

161

“Hygiene and education are the only true sources of civilization and well-being. A country’s wealth is a mere façade if it does not improve the working class’s overall well-being. Political economy has to take hygiene and individual organization laws into account.” Kuborn, H., Aperçu historique sur l’hygiène publique, p. 69.

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phenomenon and the resulting lower general mortality rate162 could only appear if the biological, ecological and socio-economic environment was resilient enough to resist pathogenic influences and strains. In addition to wage increases (which improved individuals’ resistance, notably through better, healthier diets163) and medical progress, the population benefited from appreciable improvements in its daily environment: housing, sewage systems, drinking water supply, etc. Local authorities should be given the credit for such developments.164 According to Hyacinthe Kuborn in 1890165 and other hygienists, the system that had been established since the Belgian Revolution was not sufficiently effective and did not work properly.166 This marked the emergence of a new trend concentrated on the development of a health law coordinating local initiatives and achievements under the aegis of the state. As this trend had already resulted in the adoption of specific standards, the setting up of different bodies made up of – theoretically – competent members and the granting of subsidies meant for major improvement work, the state’s role had to be reinforced significantly167 to remedy the inertia shown by local officials (and by mayors in particular168).

162

Pasleau, S., Industries et populations, pp. 423–457.

163

See notably MacKeown, T., “Food, Infection and Population”, in Rotberg, R.-I. and Rabb, T.-K. (eds.), Hunger and History, Cambridge, 1988, pp. 29-49; Floud, R., “Medicine and the Decline of Mortality: Indicators of Nutritional Status”, in Schofield, R., Reher, D. and Bideau, A. (eds.), The Decline of Mortality in Europe, Oxford, 1991, pp. 146–157.

164

Only the private housing companies and the industrial manufacturers took initiatives in connection with the construction of workmen’s housing during the nineteenth century. “Local authorities’ interest concerns the outside general setting.” Potelle, B., L’initiative publique des communes en Belgique, p. 224.

165

In 1886, he already lamented that “the provincial authorities could not directly compel municipalities […]. They should be allowed to list some public health expenses in the municipalities’ budgets as firstrank expenses of general interest. The population’s health is not of local interest.” Work Commission, Réponses au questionnaire, p. 567; Velle, K., op. cit., p. 433–434.

166

Havelange, C., Discours, pratiques et pouvoirs – La santé publique et les médecins au XIXe siècle in L’initiative publique des communes, p. 447.

167

The health bill of 9 November 1912 was only reconsidered in 1938 and led to the Law of 1 September 1945.

168

“ But […], while giving the municipality’s first officer weapons against mortal curses, the legislator was not able to imbue him with […] the necessary science and competence.” Kuborn, H., Discours lors de la discussion du rapport sur les mesures à prendre en cas d’épidémie, p. 65 [excerpt from the Bulletin de l’Académie royale de médecine, 1890].

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Because public health is of general and not of local interest, only superior power levels can decree and ensure the implementation of protection measures that impose duties on local authorities and individuals. Formerly, laws could entrust local bodies with the exercise of public health on their territories; municipalities were isolated, as it were. Nowadays, distances and limits have disappeared due to countless rapid means of communication, multiple, easy possibilities for contact and population development and density. […] There are no specifically municipal rights or duties any more. […] What is the isolated action of a local authority worth – even intelligent, swift, vigorous action – if the measures taken become unrealistic because neighbouring local authorities fail to cooperate?”169

In addition to the state’s administrative supervision of all public hygiene matters, Kuborn put his trust in the Public Health Committee.170 In Seraing, “It always worked with restless zeal and dedication and never stopped its actions. It responded to each epidemic threat by visiting all districts and all houses and by initiating all needed sanitary measures. Most of the measures taken in the interest of public health originate in it, like the establishment of the disinfection service, […] the organization of medical inspection in schools, etc.,”171 which we did not dwell on. Admittedly the Public Health Committee frequently assisted Seraing’s elected representatives during the second half of the nineteenth century, but it would be necessary to examine situations in other municipalities to be able to assess its global effectiveness. Kuborn could not judge impartially since he and his brother Hyppolite had been members of Seraing’s Public Health Committee for years. Before the medical progress of the 1880–1890s (the Koch bacillus), local officials took public hygiene measures that often turned out to be inefficient, since their impacts were limited in time and space. From then on, better insight into the ways in which diseases were transmitted (water and cholera miasmas)172 made it possible to pursue a

169

Ibid.

170

“Committees, on the other hand, had often been and were still often pushed into the background because they are cumbersome. They are called together when danger is imminent, when one is forced to protect one’s responsibilities while pretending to have one’s hand forced, or when the government requires advice before granting some subsidies.” Ibid., p. 57.

171

Idem, Topographie médicale, p. 114. As in 1908, it was made up of four medical practitioners, a veterinary surgeon, a chemist-pharmacist, an engineer and an architect.

172

Besides epizootics and so-called pestilential human diseases such as the plague, cholera and yellow fever, other diseases such as smallpox, croup, diphtheria, scarlet fever, measles, puerperal fever, typhus

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more appropriate, wider, preventive prophylactic policy. Resorting to effective disinfection methods obviously represented a significant step forward in fighting cholera and other contagious diseases.173 “More than ever before, hygiene was the leitmotiv.”174 In cooperation with Dr E. Janssens, Kuborn prepared Instructions pratiques à l’usage des administrations communales pour prévenir et combattre la propagation des principales maladies épidémiques et transmissibles in 1890.175 Besides information (compulsory notification of local authorities in case of contagious diseases), isolation and disinfection, cleaning up had to remain the top priority. The multiple causes for insalubrity that clear the ground for the invasion of diseases […] and contribute to their spread must be rigorously addressed […]. General hygiene and cleaning up rules will thus be most strictly enforced and applied by local authorities, notably concerning soil cleanliness, drinking water purity, well water controls and pollution analysis, regular collection of mud, manure and refuse, […], the hygienic condition of workshops, lodging houses, working-class houses, private or public toilets and urinals, cesspools, public sewage systems and their individual connections, hydraulic equipment, and stink and stench traps connecting sewage tubes with house interiors. (recommendation no. 37)

After all, this official programme – drawn up by local authorities – differs only slightly from the 1854 programme. Seraing’s case enables us to identify the reasons why public hygiene improved so slowly.

and typhoid fever were virulently rife. “Their expansion at a given time shows all features of a public curse […]. Five cholera epidemics in 40 years, from 1833 to 1873, made 85,000 victims. In ten years’ time only – from 1870 to 1880 – the aforementioned diseases killed 230,000 people.” Kuborn, H., Discours lors de la discussion du rapport sur les mesures à prendre en cas d’épidémie, pp. 66–67. 173

“Applied pathology must concentrate its efforts against contagion, the contagious environment – space or object – and the contagious agent.” Idem, Les maladies épidémiques contagieuses et la désinfection, Brussels, 1886, p. 10.

174

“Body cleanliness, soul cleanliness, city cleanliness: this triple ideal towards a unique, irreducible notion of progress gives rise to ‘hygienism’, i.e. ‘an ambitious state of mind that is primarily concerned with the population’s life and health preservation and ventures in all directions while hiding behind public welfare.” Loenard, J., La médecine entre les savoirs et les pouvoirs, Paris, 1981, pp. 149-150, quoted by Havelange, C., Les figures de la guérison, p. 332.

175

Janssens, E. and Kuborn, H., Instructions pratiques à l’usage des administrations communales pour prévenir et combattre la propagation des principales maladies épidémiques et transmissibles [excerpt from the Bulletin de l’Académie royale de médecine, 1890, pp. 3–32].

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Until the end of the 1880s, the authorities in Seraing were unable to control many demographic, biological, economic, geographical and geological factors:176 population growth, endless epidemics, housing shortage and deterioration, space saturation due to the increase in the number of industrial sites, the precariousness or lack of collective facilities, significant mine subsidence, frequent floods, etc. As all needs increased, local financial resources soon appeared to be insufficient, for want of – well-off – taxpayers. Compared with other budget items, ordinary public health expenses did not weigh heavily on Seraing’s finances: 3 percent in 1860, 2 percent in 1870, 3 percent in 1880, 2 percent in 1890, 5 percent in 1900 and 5 percent in 1910.177 In addition to asking the Province of Liège and the state for subsidies and collecting direct taxes on companies,178 local authorities resorted to loans for extraordinary expenses (150,000 francs in 1888, 480,000 francs in 1893, 500,000 francs in 1895, 360,000 in 1897, etc. secured with the Crédit communal)179 and put Seraing into debt.180 Throughout the nineteenth century, Seraing’s elected representatives mainly lived in the Bottom of Seraing and in the Cockerill district.181 Being close to major industrial sites and workmen’s houses, they were also close to “hovels” and “casernes” 182 that

176

The poor standard of social organization was obvious between 1856 and 1876: “Anybody can build anything, anywhere, anyhow.” De Saint-Moulin, L., op. cit., p. 231.

177

Pasleau, S., La gestion d’une commune, pp. 108–109. On average, Liège’s hygiene improvement expenditure accounted for almost a fifth of all expenses from 1867 to 1880. Lovinfosse, P., L’hygiène publique à Liège. Quelques éléments d’interprétation, unpublished final dissertation (History), University of Liège, 1987, pp. 86–94.

178

In intensively exploiting the subsoil, (sometimes excessively) expanding their activities and hiring massive numbers of workers (which, in the event of an economic crisis, led to unemployment for hundreds of workers and accordingly to increased public welfare expenses), such companies brought about the slow deterioration of the industrial landscape and of local finances. As a consequence, they were allowed to contribute to improving the environment and decreasing charges!

179

Kurgan-Van Hentenryk, G., Contribution à l’étude du rôle du Crédit Communal dans le financement des travaux publics (1861–1913) in L’initiative publique des communes, pp. 199–206.

180

R.A.S.A., 1875, pp. 51–53; 1888, pp. 49–50; 1891, p. 50; 1897, pp. 37–38; 1898, p. 44; etc.

181

Pasleau, S., La gestion d’une commune en proie aux mutations économiques et sociales. Seraing, 1836–1993, Brussels, 1998, p. 72.

182

In Seraing, “the housing shortage […] was dramatic […]. Small private owners’ responses could not meet the demand. This marked the development of building contractors’ initiatives, which finally turned out to become standard. The first initiative consisted in building so-called ‘casernes’ […]. Such a ‘caserne’ was notably to be seen in the Val-Saint-Lambert crystal glassworks’ Cour du Val.” Alter, G., Bourdelais, P., Demonet, M. and Oris, M., op. cit., pp. 33–34.

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were explicitly considered by the Public Health Committee to be focuses for cholera epidemics and other contagious diseases. As a consequence, they took special care to adopt cleaning-up measures meant for their own streets! Whereas until 1850 Seraing’s officials had been people of independent means, landowners, farmers or professionals, after then they belonged to sectors such as trade, crafts, transport and industry. Can we then assume that the town’s policies tended to take into account the latter’s interests? Not at all. “The top management of Seraing’s major companies […] seldom intervened at the level of political decision-making: one cannot detect any interference in electoral processes […] or any support from any public representative or any special favour […]. Were the managers of the ‘giant factories’ indifferent to local management? It would seem so. Indeed, not a single measure implemented was likely to impede production.”183 After the Liberals’ domination from 1850 to 1895, the Socialists arrived in force and introduced proletarian demands. As this article emphasizes, public hygiene did not only concern local authorities. Indeed, the top management of Seraing’s major companies wisely realized that the wellbeing, health and safety of workers – and even beyond that, of the population – were far from being prejudicial to their interests. Employers’ representatives of the Cockerill Company answered the 1886 Work Commission’s question (no. 11) on the salubrity of industrial premises very clearly; all investments intended to improve better air, heating, lighting, cleanliness, order, etc. within steel workshops and mining sites aimed at “making workers stronger, […], getting them used to order, so as to have them work more and better”.184 Companies devoted significant amounts of money to putting in baths and setting up washing services for working clothes – in some cases – and then to equipping premises with lavatories and shower boxes, but such investments appeared profitable because of the decrease in sick leave and workmen’s benefits. Besides industrial businesses, workers also contributed financially to improving their own hygiene conditions at work: indeed, deductions from their wages also paid for the medical surgeon and free medicines! While it could be used as an argument for appointments and/or as a means of applying pressure during social conflicts, the employers’ housing policy also derived from economic calculations since it allowed them to decrease expenses related to

183

Pasleau, S., La gestion d’une commune, p. 90.

184

Work Commission, Réponses au questionnaire, pp. 115, 119.

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mining damage caused to buildings owned by third parties. On the other hand, the hopes harboured by Seraing’s elected representatives and mining engineers, who expected industrial establishments to effectively contribute to working out a structural solution by renovating housing through the building of workmen’s houses, were thwarted.185 Hardly more than 300 houses were built by Seraing’s major companies. They could not meet the increasing demand resulting from the collieries, steelworks and crystal glassworks’ permanent calls for labour. In addition to the brief financial support they granted the temporary hospital in 1853, Seraing’s manufacturers also contributed to local authorities’ outlay for public hygiene with donations.186 Notwithstanding numerous difficulties, Kuborn concluded in 1908 that Seraing’s elected representatives had finally managed to meet first-rate public hygiene requirements. “There can be no limit to our congratulations for their efforts and the results brought about after so many sacrifices.” He sometimes moderated his praise and observed that Seraing had not been spared “indifference and traditional inertia, which are common in a great number of municipalities. There is absolutely no excuse for such a misappreciation of the most pressing requirements. Hostility, personal interest and political dissension are often involved, to the detriment of the most obvious public interest.”187 Despite several recommendations,188 the town still did not have its own hospital by the beginning of the twentieth century – even though the establishment of such an institution should have been given precedence over any other improvement!

185

A.C.S., Délibérations du Conseil Communal, t. V, f° 200, meeting of 20 July 1866; Résultats de l’enquête ouverte par les officiers du Corps des Mines, pp. 29–30, 142; De Saint-Moulin, op. cit., pp. 213–214.

186

Notably R.A.S.A., 1848; A.C.S., Délibérations du Conseil communal, t. V, f° 200, meeting of 20 July 1866; Ibid., t. VI, f°343, meeting of 4 September 1884 but also Brassinne, E., Le petit commerce à Seraing, Ghent, 1904, p. 51.

187

Kuborn, H., Topographie médicale, pp. 150–151.

188

In 1869, the Résultats de l’enquête ouverte par les officiers du corps des mines, pp. 143-144, states that “It would be most desirable that the collieries in the southen part of the 5th district should agree on the setting up of a hospital between Flémalle and Jemeppe.” The Royal Society for Public Medicine expressed the same wish. Bulletin de la S.R.M.P., t. XVII, 1899, p. 150; Ibid., t. XXIV, 1906, p. XLVI.

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Science, Institutions and Legislation: Aspects of the History of Public Health and the State in Norway Kari Tove Elvbakken (Stein Rokkan Centre for Social Studies, University of Bergen, Norway)

The history of public health in Norway, the building of institutions and the development of legislation to ensure health have parallels in the history of public health in other European countries. This paper presents some features of the history of public health in Norway. The aim is to discuss the relations between the building of the state and public health in the nineteenth and early twentieth centuries. I argue that public health institutions, like certain legislative and administrative bodies, were established early in Norway in a European context. I link this to the process of nation building. During its early years, when it was all-important to develop legislation and institutions, the Norwegian state was characterized by, among other things, a political environment dominated by relatively liberal and democratically-minded men, a weak to nonexistent aristocracy, and medical doctors who functioned as bureaucrats rather than members of a profession. The relation between public health institutions and public health policy is influenced by available knowledge, as produced within academic institutions. Many historians and political scientists argue that there are important links between public health initiatives and the rise of the modern social sciences (e.g. Desrosières 1990). Population statistics were used, on the one hand, as a means of evaluating the quality and quantity of the population, which was regarded as the ruler’s resource, and on the other, as a means of studying connections between social conditions and health. A second element in the discussion concerns the relationship between the city and the state. In his essay “The City” (1958), Max Weber points out one aspect of the relationship between the city and the state that I consider highly relevant for the history of public health. He argues that systems of national legislation and state administration often took the cities as their

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model. Cities – also in Norway – developed institutions and regulations in the field of public health that later provided patterns for national systems. In this paper I shall look first at the flow of knowledge from the discipline of state medicine and hygiene at the university to the state, focusing in particular on the orientations and work of the professors of hygiene from 1824 to 1975 (Elvbakken 1995). This will also allow me to illustrate changes in focus and means within public health policy in Norway during the period. After a brief account of the Norwegian background from the beginning of the nineteenth century onward, I shall describe the discipline of hygiene. This will be followed by a section on the health administration system in Norway and the relation between local and central government responsibility for public health. I shall conclude with a discussion of the Norwegian situation compared to the history of public health in other countries.

A new nation The first phase of state building in Norway began in 1814 after the end of the union with Denmark, which had lasted nearly 500 years. During the spring of 1814, an assembly of delegates from across the country formulated a Constitution and subsequently elected the Danish Crown Prince as King of Norway (Steen 1951). This happened while the Treaty of Kiel was being negotiated by the major European powers following the fall of Napoleon. The treaty provided that Sweden, which was among the victors of the Napoleonic wars, had earned the right to rule Norway as part of its own kingdom. Norway was allowed to keep its new Constitution and government. In the late autumn of 1814 a second Norwegian constitutional assembly elected the Swedish king as Norway’s monarch, and made some changes to the Constitution. From then on, Norway had a Constitution, a government and a small state administration, although certain areas of responsibility, such as foreign policy, remained in the hands of the king and the Swedish government. The union with Sweden ended in 1905. The Norwegian Constitution was heavily indebted to its American and French counterparts (Steen 1951, Slagstad 1998). In many ways the political situation of the new nation, as partner in a union with Sweden, was characterized by a democratic spirit and a will to build new institutions, despite very difficult economic circumstances. Norway was the first of the Nordic countries to adopt a Constitution committed to democratic principles and restricting the absolute power of the king.

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Academic medicine and public health The first university in Norway was opened in 1813, with faculties for theology and law. These were joined in 1814 by a Faculty of Medicine, with three professorial chairs. As Østerberg (1991) has pointed out, the addition of medicine as the third faculty can be understood as an expression of state priorities. As a discipline interested in the statistics and general condition of the population, medicine was at that time highly relevant to the state, which regarded its population as a form of capital. Building institutions and legislation State medicine was among the subjects taught at the Faculty of Medicine from the beginning, and in 1824 a fourth professor, Frederik Holst, was appointed with responsibility for state medicine, toxicology and pharmacology. In Norway, the discipline of hygiene, or state medicine, can be traced back to Professor Holst and the 1820s (Elvbakken 1995). The university professors played a major part in the development of public health initiatives. Between 1824 and 1975, six professors held the chair of hygiene, although the topics they covered varied to some extent. Toxicology and pharmacology were linked to the discipline from the start. Bacteriology was added later, and social medicine was separated from the discipline in 1952. In 1975 the department changed its name, to the Department for Preventive Medicine, thus avoiding any mention of hygiene. Frederik Holst was a remarkably energetic figure and very influential as a scholar, a civil servant and a builder of institutions. He held his professorship for more than forty years and is characterized as a social reformer (Steen 1958, Benum 1979, Berg 1986). His achievements illustrate the importance of the relationship between the state and the university in the early professionalization of medicine. Holst studied medicine in Copenhagen, as did most of the few Norwegians who became doctors prior to the opening of the university in Oslo (then Christiania). In 1817 he was the first to defend a doctoral thesis at the new university, with a dissertation on radesyke (a variant of syphilis). By the time he was appointed professor of hygiene, he held the post of state physician in the capital. In the cities, medical doctors were employed by the state to coordinate measures against plague and other diseases. This arrangement dated back to 1603.

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After completing his dissertation, Holst traveled abroad and studied medical institutions in Ireland, England, Germany and France. He wrote about many questions. For example he published a treatise on the new prisons in Britain (1823). He was impressed by these institutions, their architecture and the idea of combining punishment with rehabilitation, which gave criminals a chance to change for the better. Holst made an important contribution to the planning of a prison in the capital, built in 1851 on the panopticon principle (Larsen 2001). The new Norwegian state took an interest in the building not only of prisons but also of asylums, and this too lay within Holst’s field of interest (Ludvigsen 1998, Skålevåg 1998). The same architect was employed to design Norway’s first state asylum, which was also based on the panopticon layout. It is a point worth noting that the new state, which had to contend with serious economic problems, gave priority to the building of a prison and an asylum even before its Parliament had a representative home. In 1828, as member of a commission studying questions of mental health, Holst was the first to assess the number of mentally ill people in Norway. His assessments were used in formulating legislation that would provide for the insane. In 1848, Parliament passed an act specifying the responsibilities of the authorities towards the mentally ill. Such patients were to be diagnosed by doctors and their care paid for by the authorities. This legislation led to the building of state and municipal asylums (Ludvigsen 1998). The building of institutions extended beyond the provision of facilities for prisoners and the physically and mentally ill. Within the academic sphere, scientific societies and journals were founded. Once again, it is important to underline that these institutions were new in Norway. The first issue of the first medical journal, called Eyr, appeared in 1826. Among the founders of this periodical was Professor Holst, who had already helped to launch a journal of broader natural science interest in 1823. The publication of journals for the exchange of scientific ideas was important for the development of academic medicine. The Norwegian Medical Society was founded in 1833, and again Professor Holst was part of the initiative. Both the journals and the society promoted academic debates that addressed philosophical and medical issues as well as questions concerning the administration of medicine. The members of the society and the editors of the journal read numerous international publications and printed summaries of foreign articles in their own periodical. Both the society and the journals facilitated the professionalization of medicine, although up until the 1870s the Medical Society showed a clear reluctance to

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support arguments that might be seen as serving doctors’ self-interest. The fact that it encouraged doctors to become members of a college for the administration of medicine might be seen as an attempt to strengthen the position of the profession, but it can also be seen as an effort to improve the ministries, the state and the health administration. Discussions of philosophy and medical theory were among the Medical Society’s regular activities. Its members were well informed on international debates concerning theories of contagious disease. Conflicts between the miasmatic and contagious positions also occurred in the Norwegian setting. The use of quarantine in prevention was discussed, and was in fact the topic of the main exam for medical students in 1848. Holst wrote about the importance of quarantine in the struggle against epidemics (Holst 1847), thus bringing European discussions of this strategy to the Norwegian medical community. Holst’s career progressed from the city health authorities to the university. This pattern was to become typical in the case of the professors of hygiene. With only one exception, all those appointed to the university Chair of Hygiene prior to 1975 had previously headed health authorities in the Norwegian capital. Holst argued against forms of organization that promoted the interests of the medical profession. He was a civil servant and the defender of state interests rather than the representative of his professional colleagues. Holst represented a philosophic orientation that was closely interested in medical institutions and the role of the state in public health. The first professor of hygiene at the Norwegian university thus played an integral part in the building of institutions within the new state. Population statistics and the establishment of indigenous hospitals, prisons and asylums were vital to a nation that was striving to build an identity and to gain recognition as an independent part of the union with Sweden. Ernst Ferdinand Lochmann followed Holst as professor of hygiene and toxicology in 1865. Before being called to the Faculty of Medicine he held a position as military doctor. Like Holst, his interests tended towards questions of medical theory; he was an early advocate of the anti-miasmatic position. During his period as professor – he retired in 1892 – medicine experienced the breakthrough of bacteriology, which has since been identified as an important paradigm shift (Rosen 1958). Lochmann was an energetic author of popular scientific literature. He discussed literary and political questions and was an early promoter of public awareness on health matters, writing pamphlets to enlighten the population on topics such as nutritious foods and the design of schools

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to promote pupil health. From the late 1870s the influence of bacteriology began to be felt in many fields. In Norway, Armauer Hansen described the leprosy bacterium. New insights led to new legislation, which made registration of leprosy sufferers obligatory. Bacteriology provided support for older strategies of internment and isolation. Lochmann argued that hygiene should be based on other disciplines such as physiology, biology, anthropology, geology, architecture, botany and meteorology. In his view hygiene was not just a matter of applied natural science; rather it had to be seen as one of the social sciences (Falkum and Larsen 1981). Unlike other professors of hygiene, Lochmann did not participate in government commissions. Even so, he was directly involved in the public sphere by promoting the spread of information. Bacteriology: science and public health regulations In 1893, Frederik Holst’s grandson, Axel Holst, took over the chair of hygiene and bacteriology. He was a bacteriologist but, like his grandfather, had acquired medical experience in the service of the capital’s health administration. Axel Holst had visited the Pasteur Institute in Paris and the Koch laboratory in Berlin. Thus he was familiar with significant institutions in this new medical era. Prior to taking over the professorship, he served as a sanitary inspector. In this capacity he had undertaken a study of living conditions among the working class in Christiania. Like most European cities in the last quarter of the nineteenth century, Christiania experienced enormous growth, which led to serious problems regarding housing, the supply of water and food and of course waste disposal. Holst combined his interest in the design of public health institutions with his knowledge of recent scientific developments acquired during his travels in Europe. Holst wrote on a wide range of topics, and among his works is a textbook on hygienic aspects of schools. He participated in many commissions, including one that discussed measures to limit the abuse of alcohol. Another of the commissions on which he sat prepared guidelines for the school environment, placing priority on matters of hygiene in the construction of new schools. Starting in the 1890s, several Norwegian cities built schools according to the new hygienic principles, which specified, among many other things, how much fresh air and light they should provide. In some respects, the building of well-designed schools was also part of the effort to develop a universal public school system in Norway. This latter became a priority in the 1860s. The aim was a school system that would function so efficiently as to win the active support of even the wealthier sections of the Norwegian population (Froestad 1995). During Axel

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Holst’s period as professor of hygiene, which lasted until 1930, nutritional science made important progress. Holst was one of three Norwegians who were the first to prove that scurvy resulted from a lack of ascorbic acid (Norum and Gran 2002). Holst was head of the Faculty of Medicine, and Rector of the University of Oslo for a period. He was active as an academic writer and took the initiative to establish various organizations, among them one concerned with the history of medicine and the Nordic Hygienic Society. Once again, it is worth noting the particular combination of experience gained from working on the city of Oslo’s Board of Health and expertise in bacteriology, which was becoming a prestigious field of medicine. Like his grandfather, Holst built institutions and served the state through his participation in commissions that addressed a broad range of issues. The discipline of hygiene combined the insights from health administration with scientific research covering a wide range of issues in relation to biology, statistics and bacteriology. Measuring and implementing welfare actions In Norway, the academic field of hygiene developed a new orientation with its fourth professor, Carl Schiøtz, who took the post in 1931. Like his predecessors, his former position was with the capital’s health administration, where he was responsible for school health services. Healthy conditions for school children – especially with regard to nutrition – formed a central aspect of his interests. From the late nineteenth century school meals were offered to poor children in cities like Oslo and Bergen, Norway’s second largest city. This measure can be seen as part of the effort to legitimize public schools. In order to ensure the quality of education in public schools, it was considered necessary to feed poor and hungry pupils so as to improve their capacity to learn (Seip 1984). Schiøtz was opposed to the practice of providing warm meals for pupils after school. He considered these meals too heavy and fatty. Instead he advocated provision of breakfast before lessons, thus preparing the children for a day of learning. The new system, the so-called Oslo Breakfast, was introduced for all school children in Oslo, free of charge, in 1935. Thus a measure that was originally meant to help a vulnerable group was extended to all children. As such, it was part of a welfare policy that aimed to overcome the stigma associated with the older school meal system. During the First World War the provision of school meals had become common in many European countries, several of which retained the system into the interwar period. Most commonly, school meals were offered for lunch. Another

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policy of the school health service was to send underweight children to the countryside during the summer to gain weight. During the interwar years, the discipline of hygiene grew steadily in extent until it related to almost every sphere of activity: food hygiene, mental hygiene, occupational hygiene and sexual hygiene were among the topics that experts had on their programmes. From a situation where the discipline was primarily concerned with ways of regulating housing and the supply of food and water – an orientation characteristically interested in problems of infrastructure – the focus shifted towards ways of changing people’s lifestyles. This shift is clearly visible in the first Norwegian and Nordic publication of recommended standards for women’s body weight in relation to height, prepared by Schiøtz in 1934 (Elvbakken 2002). In a booklet he argues for the benefits of maintaining a young figure – a youthful type of body – also beyond the thirties, claiming that stable body weight is beneficial to beauty. This can be seen as an effort to promote the refinements of upper-class culture and self-discipline: voluntary control of the body and the intake of food. Methodology also changed. Population statistics were important before bacteriology and laboratory work took over. In the interwar period the discipline of hygiene in Norway began to focus increasingly on biological methods, including the use of anthropometric measurements such as body height and weight and body typologies. Whereas Axel Holst had conducted research on vitamin C and other nutritional factors, Carl Schiøtz concentrated on broad studies of growth among children. Carl Schiøtz was an active health campaigner, writing pamphlets for ordinary people and giving engaging radio talks, aimed particularly at women and housewives, to promote hygienic conditions (Schiøtz 1932). He established a journal called Sundhedsbladet (Health Journal) to spread information among the general public; it carried articles on a variety of topics and offered examples of how to lead a healthy life. In this respect he was similar to Professor Lochmann in his orientation. During the depression of the 1930s, a considerable part of the population was dependent on support from local authorities. This was a difficult period for many municipalities (Strøm 1980). As in other countries, the Norwegian central authorities engaged academics to calculate a so-called minimum diet, in an effort to save local government money and ensure that no person would benefit unfairly from receiving support. Within the Medical Society this situation triggered a serious conflict between the hygienists and Socialist doctors on the one side and physiologists on the other.

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The hygienists protested against the physiologists’ political orientation and their willingness to calculate how small food rations could be, arguing instead that poor people should be given money to buy food rather than ration cards for the types and amounts of food determined by a minimal survival diet. The connections between Oslo’s health administration and the hygienists at the university were strong and enduring. Surveys of actual food consumption were made by the city in cooperation with the university and the Socialist doctors’ organization (Evang and Galtung Hansen 1937). Carl Schiøtz died young, after less than ten years as professor of hygiene. In 1940 he was followed by Axel Strøm. Strøm was, like his predecessors, formerly employed by Oslo’s health administration. In his capacity as an inspector of housing, he had worked with several aspects of social hygiene, and this field now grew in importance within the department of hygiene. In 1952 the field of social medicine was separated from the department of hygiene and Axel Strøm became the first Norwegian professor of the subject, a position he held until 1971. With this change the discipline of hygiene became more technical. Haakon Natvig took over as the new professor of hygiene. Topics such as food hygiene and occupational hygiene acquired more attention. Natvig was highly active in recommending legislation and establishing administrative bodies for food control. He argued that veterinarians were an important factor in the latter respect (Elvbakken 1997). From the 1960s hygiene lost popularity among medical students and was also given less attention in society at large. Health administration was not one of medicine’s more popular topics. Curative medicine was rapidly growing in parallel with advances in remedial techniques and medical technology, and preventive medicine lost interest and attention. Academic practice with city experience Medicine cannot be viewed as a uniform academic discipline. As Elliot (1972) has pointed out, in attempting to analyse sources of medical legitimacy, authority and power, it is useful to distinguish between various sub-disciplines in the field. In the Norwegian case the hygienists were an important source of expertise for the projects that strove to create a new order in the young Norwegian state. Much the same can be said for psychiatry (Elvbakken and Ludvigsen 2003). The disciplines of hygiene and psychiatry and their leading practitioners also helped to raise the social status and

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authority of other branches of medicine. Professionals in these fields practised in the public arena rather than in hospitals, which were focuses for the specialties of clinical and somatic medicine. They were public employees – civil servants working in asylums and on local boards of health. The importance of their duties within the new state ensured their positions and incomes and afforded them places among the medical elite. The hygienist took care of the sanitary conditions of a city or district in the service of local or central government. The psychiatrist provided medical explanations for mental or behavioral deviations. This too was an aspect of public hygiene. Asylum doctors worked in the field of tension that arose between the medical principle of providing treatment and the need to control behavioral deviation within the population. The classification of someone as mentally ill served a double purpose: it helped to maintain social order through the isolation of difficult and dangerous individuals, and it provided a basis for treatment and therapy. The professors at the Faculty of Medicine were committed to giving the authorities advice when asked, as in cases of epidemics. The discipline of hygiene was closely associated with the state and with the building of institutions. Medical academics made important contributions to the formulation of health service policy. All the professors of hygiene (with one exception) came from the office of the city health authorities in the Norwegian capital. This was an affiliation the professors retained, providing advice both to local and central government wherever relevant. They participated in legislative commissions, promoted the spread of information and functioned as governmental consultants. The Norwegian situation illustrates the relation between medical statistics – the quantification of birth, deaths and mental health – and the rise of the social sciences. The first Norwegian sociologist, Eilert Sundt, acknowledged the work of Holst and his medical statistics as important for the study of social conditions (Sundt 1978). Desrosières (1990) considers the statistical assessment of population as an element in the constitution of a state.

Forming the health administration Denmark-Norway established a health commission in 1803. The first independent Norwegian health commission was set up in 1807, during the Napoleonic wars. This was a difficult period with a blockade of the supply of grain to Norway, which, together with several years of crop failure, caused widespread hunger. The commission’s task

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was to provide annual reports on living conditions, on rates of mortality, sickness and epidemic, and on food supply. The commission, which can be characterized as a collegium, consisted of medical doctors and a pharmacist. It was terminated in 1815, when the young Norwegian state restructured its administration and set up an office for health matters within one of its (few) ministries. None of the doctors from the commission transferred to the ministry. Only the pharmacist was employed there, alongside civil servants trained in law, which at that time was the typical background for civil servants. From 1603 the most important cities in Norway (although not very big) had socalled state medici or state physicians, appointed by the king in Copenhagen, whose task was to enforce city regulations relating to health and order. The first such doctor was appointed in Bergen, Norway’s principle city at the time, following a smallpox epidemic. Outbreaks of smallpox tended to hit the cities hard. The institution of local, state-employed doctors lasted until 1984, when local authorities took over the entire responsibility for primary health services and community medicine. The old strategies against plague – quarantine and isolation – were abandoned in the years of liberalism following after the Napoleonic wars. Deregulation was part of the political climate, and the theory of miasmas encouraged efforts to improve access to light and air; it was no longer considered appropriate to isolate sick people. What mattered was personal freedom – and a free market, unchecked by the regulations of antiquated guilds. The 1830s were cholera years across Europe. In Norway, Christiania and Bergen suffered outbreaks, like so many cities elsewhere. And like cities elsewhere, those in Norway formed commissions to handle the epidemic (Zacke 1991, Cippola 1992). When we consider the views of Norway’s central cholera commission concerning the causes of cholera, published in 1831, the legislation that was introduced to regulate urban life seems rather logical: Causes of the disease. The principle causes of the development of this disease are assumed to be: moist air, body chills, enclosed, damp accommodation, uncleanliness, poor and spoiled foodstuffs, immoderate consumption of food and drink, depressed spirit, physical and mental exertion, lack of adequate clothing to protect against the influence of the air, and indeed anything that leads to enfeeblement. Thus it tends to occur more readily and to be more malignant in areas that are marshy, low-lying and susceptible to flooding than in drier and higher situated localities. The Central Cholera Commission 14 June 1831

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Surveys of living conditions were carried out in many European countries during this period. An important Norwegian example is the survey of the mentally ill conducted by Holst in 1828, an undertaking that also was crucial in the process of formulating legislation to embody society’s responsibility towards this group. Annual reports on medical conditions were published in Norway from 1835 – the first Nordic statistics on medical conditions (Kunhle 1992). These included birth and death statistics and reports by district physicians on local conditions such as rates of illness, harvest and food supply. Statistics also covered vaccination against smallpox. Vaccination became obligatory in Norway in 1815. For a long time a smallpox vaccination certificate was needed in order to marry, with the result that vaccination certificates were kept like valuables. Sweden had a similar rule (Johannisson 1994). The connections between state-building and the introduction of statistical systems in important areas are underlined by many political scientists (e.g. Kuhnle) and historians (e.g. Johannisson). The connection between the Norwegian state and the church is also, as Johannisson has pointed out, very distinct in this case. Some Norwegian clergymen protested against the system, arguing that the practice was unreasonable. Ministers were allowed to make exceptions, and some of them frequently did (Schiøtz 2002). During the period from 1830 to 1880 there were debates and controversies on health administration policy in Norway. In an article published in 1833, Frederik Holst and two colleagues proposed a framework for medical administration, arguing for the establishment of a collegium medicum, with experts to govern health matters. A commission was set up to review health administration in Norway. Holst, together with a fellow professor of medicine and a law professor, presented their recommendations in 1844. These included the idea of a collegium medicum. The commission’s proposals were not approved by Parliament. Economic circumstances were at that time difficult and there was resistance to allowing professionals other than jurists inside the state administration. The new Ministry for Internal Affairs, set up in 1845, was given responsibility for medical issues. The ministry was allowed to appoint two medical consultants, although this provision proved a source of conflict (Svalestuen 1988). From 1858 a medical doctor was appointed to advise the ministry on health issues, and from 1875 a doctor became deputy secretary within the ministry, as head of an office for health administration.

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The Board of Health Act of 1860 represents a milestone in the history of Norwegian public health. This piece of legislation instructed local authorities to form boards of health. These were to be headed by medical doctors who were already employed by the state. The composition of the boards might differ between urban and rural municipalities. The sanitary boards were instructed to attend to “cleanliness ... The condition of the drinking water, sale of unhealthy foodstuffs, ... The commission is to check that no industry is operated in a way that endangers public health more than is unavoidable due to the nature of the business.” The 1860 legislation gave a framework for local regulations, for example with regard to the handling of food in marketplaces. Safeguarding standards of order and hygiene at markets was an important concern for rapidly growing cities all over Europe. Combined with the industrial production of food, which often used dangerous additives to camouflage reduced quality, problems of food supply represented a serious challenge to city authorities. The annual reports on medical conditions – with their statistics on life and death – were based on reports from district doctors. These latter often present interesting pictures of local circumstances and the initiatives taken by physicians to promote health, such as campaigns to stop the widespread occurrence of scab (Sandvik 1993). Some of the writers recorded local weather conditions, including temperature, rainfall and barometric pressure. The range of topics mentioned in the annual medical reports of the local health authorities is considerable. Problems resulting from urbanization such as inadequate food supplies are frequent. In Oslo in the 1880s high infant mortality among children born of unmarried mothers was partly explained in terms of the social difficulties such mothers had to contend with. They had to entrust the care of their children to others and were thus unable to breastfeed them. These children were often fed with diluted cows’ milk. The supply of milk was unstable and it was common for milk to be stretched with water, which itself was rarely clean. In 1878 a critical analysis of the medical statistics by the chair of the Board of Health prompted a survey of all milk shops in Oslo. It was found that milk was being sold from hundreds of small and dirty premises, including cellars and the back rooms of apartments. The Board of Health, which had carried out the survey, was very worried, and proposed the compulsory quality control of milk. In 1891 the local health authority established a milk control unit as part of the Board of Health. This unit collected samples, which it analysed in the laboratory. If the milk were

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adulterated, the shop owner and the farmer selling the milk would be prosecuted and fined. Newspapers were used to publish the names of offenders. This example illustrates the significance of health statistics and their analysis (here infant mortality statistics) for hygienic conditions (here the conditions under which milk was sold). The Norwegian legislation of 1860 gave the legal framework for the introduction in 1891 of the compulsory quality control for sale of milk in Oslo (Elvbakken 1997). Nowadays, it is difficult to imagine what dirty, chaotic and probably also frightening places the rapidly growing cities of the late nineteenth century must have been. There were problems with housing, with supplies of water and food, with waste and noise. Social problems such as alcoholism and poverty were also considerable. Infectious diseases flourished among the poor, and many historians argue that it was only when these plagues threatened the rich that action was taken to assuage the problem. The local sanitary commissions, established during periods of cholera, proved useful in learning how to regulate urban life. They inspired municipal committees, which would be granted extended powers during periods of crisis (Cippola 1992, Porter 1999, Rosen 1958). The local health authorities were also engaged in the building of market halls. Conditions at the traditional marketplaces had become so cramped that they constituted a threat to both order and hygiene. The development of market halls is interesting. From the final years of the eighteenth century, following a surge in urbanization and industrialization, many cities in Britain brought old marketplaces, which had formerly belonged to private landowners, under municipal control (Schmiechen and Carls 1999). Changing a situation in which landowners controlled both production and the sale of food through markets, the local authorities bought some of the markets and imposed regulations on the retail side. There were various reasons why this was considered important. The chaos that resulted from rapid growth created opportunities for dishonest tradesmen to profit from unethical practices such as adulteration. The move to bring order to marketplaces and halls was also intended to hinder revolts by the hungry masses. Early public health regulation in Norway can be seen as an important element in the effort to build a nation. The founding of institutions, the counting and categorizing of the population, the design of measures to deal with cholera epidemics – all helped in the construction of Norway as an independent nation. The fact that the new state lacked institutions might have made it easier to implement new regulations. In Norway

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the medical profession was something new, and not an established elite as it was in Sweden.

Discussion – faculty, city and nation In order to gain a picture of the Norwegian situation, it is necessary to understand the structure of what we can call the hygiene triangle: the Faculty of Medicine, ministerial health administration, and urban regulation and municipal administration. The connections that existed between the Faculty of Medicine and the state health administration in Norway were important. The close relationship might be explained in a variety of ways. For one thing, both the faculty and the state administration were new creations, as indeed were the ministries themselves. For another, Norway’s existing institutions did not include a medical elite. It is important to distinguish between regulatory measures at the city and national levels. Whereas legislation and national institutions were established only after much parliamentary debate, the cities already had long traditions of imposing regulation. City authorities had to maintain sanitary conditions and to guarantee orderly conditions for life and trade by enforcing market rules, trade regulation, quarantines and the like. The civil servants of the day were most probably engaged to develop the administration and its various institutions. Dealing with epidemics was difficult. In her book about the cholera commissions in Stockholm during the 1830s, Zacke (1991) points out that these bodies focused in particular on the supply of water and food. They were concerned about the dirt and stench around places for slaughtering. They tried to motivate cleanliness and encouraged people to seek fresh air. The measures Zacke describes are similar to those adopted by the Norwegian commissions of the day. These measures seem appropriate when judged in terms of contemporary notions of how contagious diseases spread, among which the miasmatic hypothesis was dominant. Cippola (1992) argues that the sanitary commissions set up during the cholera years of the early nineteenth century in several European cities took as their model the commissions that operated in Italian city states at times of plague. The powers of these commissions varied, but what matters in this context is the fact that they were given authority in times of crisis such as during dramatic outbreaks of plague. Cities were of course highly vulnerable to plague, especially when they grew and became densely populated.

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In the history of Norwegian public health, the period from the early 1820s to 1870 is characterized by the building of institutions, both academic and in the field of health policy. Asylums for the mentally ill were built, both by the government and by municipal authorities. These took their inspiration from asylums in other European countries; they were built in an optimistic spirit, in the belief that good care, pleasant surroundings and constructive employment might cure the patients. On the other hand, they involved the confinement of individuals who were unable to care for themselves (Ludvigsen 1998). Similar to the quantification of mental illness, statistical assessment of the general population and its various subgroups became common practice in the framework of health policy from the late eighteenth century. The compiling of population statistics in Norway can be traced back to the duties of the sanitary commission of 1807, although it was not until 1835 that the first official medical statistics were published (Kunle 1992). These latter were based on reports of numbers and causes of deaths supplied by the clergy. A similar method had been used in Sweden, where local priests had gathered information for the government. Johannisson (1994) comments that this alliance between church and state was remarkable and provided the latter with important information about its resources. In various respects, the history of public health in Norway reflected developments in the field in other European countries. In various areas of administration it was common to send young academics abroad to study foreign institutions, in the expectation that they would subsequently apply the insights thereby gained to the construction of new institutions back home. The fact that the new state administration and political life in Norway were influenced by democratic values and a desire to establish the new nation on modern principles also meant that people were willing to learn from the experiences of others, and to implement new forms of organization and administrative structure in both the state and the health authorities. Two points deserve particular emphasis. First, the new nation of Norway, which started building its administration in 1814, was committed to democratic ideals and eager to establish institutions of its own. Throughout Europe in the early nineteenth century, there was a trend towards an increased use of surveys and population statistics and a willingness to discuss and replace old regulations. These tendencies are well reflected in the interests and strategies of the first Norwegian professor of hygiene, Frederik Holst. The practice of sending academics abroad to study foreign institutions

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was highly valuable to the young Norwegian nation. It was thanks to their broad education in political philosophy that Norway’s founding fathers were able to draw inspiration from the French and American revolutions when formulating their own democratic Constitution. The example of the 1814 constituent assembly must have influenced other parts of society, encouraging people to learn from the world’s most modern states when designing domestic institutions. Frederik Holst’s two-year journey around Ireland, England, Germany and France resulted in several initiatives for new institutions. His book of 1823 on the new English prisons may serve as an example. He was impressed by the panopticon prison design and was an eager advocate of more humane conditions for prisoners. Of course, having been under Danish rule for so many years, Norway also retained many features of that country’s administrative system. On the other hand, as a nation just coming into its own, Norway was also eager to establish a new order. The university, named after King Frederik and opened in 1813, was seen as part of the nation-building process. In addition, many aspects of Norway’s health administration were influenced by Swedish practices, for example, the adoption of obligatory vaccination in 1815. By contrast, the Norwegian Parliament passed legislation to implement local municipal boards of health in 1860, whereas Sweden waited until 1876 before adopting a similar kind of system. There might be many reasons for this delay of almost two decades, but it is not impossible that it resulted from different political orientations, in particular a difference in eagerness to modernize the administration. The second and perhaps more general point that deserves emphasis when considering the framing of national legislation and institutions has to do with the regulation of cities. The steps taken in this regard, such as the measures to introduce order at marketplaces and to improve supplies of water and food, influenced the early development of health administration in Norway even more than the problems arising from heavy industrialization. The 1860 public health legislation provided local governments with a regulative framework. This does not imply that from that point onwards the cities were suddenly healthy in all respects, but it did enable the rapidly growing cities to deal with at least some of their problems. In her very interesting book on the history of public health, Dorothy Porter (1999) emphasizes the role of the state. Commenting on early historical research on public health, she argues that historians such as Georg Rosen (1958) tended to portray the development of public health institutions and regulations as something heroic. Porter

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had already explored the relations between the state and health policy in an anthology from 1994 with articles from several countries (Porter 1994). In her view it has been common to argue that public health regulation arose in response to the problems of industrialization. She therefore finds it interesting to note that Sweden established regulations in this field and began to use population statistics long before industrialization had begun to take effect (Johannisson 1994). As Cassel (1994) points out in the case of Canada, discussions of the history of public health also need to take into account the regulation of city environments. In her later work Porter (1999) argues that it is beneficial to study public health from critical perspectives and within a framework that includes the type of state as a factor in the analysis. Relations between the state and public health are very interesting. The aim of the current paper is to contribute some details to this discussion. This article has discussed relations between the academic discipline of medicine and the Norwegian state during the nineteenth century. City regulations often serve as a pattern and framework for regulation on the national level. Public health regulation and policy are an important aspect of statebuilding activities. The liberal and democratic spirit of Norwegian politics in the early nineteenth century meant that it was possible to learn from the most modern health regulations and institutions elsewhere in Europe. The close connection that existed between the professors of hygiene and the state enhanced the standing of the medical profession and gave the hygienists influence within the bureaucracy – not necessarily as clinical experts and hospital doctors, but as designers of legislation and institutions.

References Benum, Edgeir (1979) Sentraladministrasjonens historie, bind 2; 1845-1884, Oslo: Universitetsforlaget. Berg, Ole (1986) “Verdier og interesser - Den norske lægeforenings framvekst og utvikling”. In: Larsen, Øivind et al.: Legene og samfunnet, Oslo: Den norske Lægeforening. Cassel, Jay (1994) “Public Health in Canada”. In: Porter, Dorothy (1994) (ed): The History of Health and the Modern State. Amsterdam: Rodopi. Cippola, Carlo (1992) Miasmas and Disease, Public Health and the Environment in the Pre-Industrial Age, New Heaven/London; Yale University Press. Desrosières, Alain, (1990) “How to Make Things which Hold Together: Social Science, Statistics and the State”. In: Wagner, Peter, Bjørn Wittrock and Roger Whitley (eds.), Discourses on Society: Vol XV, Kluwer Academic Publishers. Elliott, Phillip (1972) The Sociology of the Professions. London and Basingstoke: Macmillan.

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Elvbakken, Kari Tove (1995) Hygiene som vitenskap: Fra vitenskap til politikk. Notat nr.23, Institutt for administrasjon og organisasjonsvitenskap, Universitetet i Bergen. Elvbakken, Kari Tove (1997) Offentlig kontroll av næringsmidler. Institusjonalisering, apparat og tjenestemenn. Rapport nr. 50, Institutt for administrasjon og organisasjonsvitenskap, Universitetet i Bergen. Elvbakken, Kari Tove (2002) “Korrekt vektkontroll – kampanjer i kampen mot overvekt“ In: Elvbakken, Kari Tove and Per Solvang (eds.): Helsebilder. Sunnhet og sykdom i kulturelt perspektiv, Bergen: Fagbokforlaget. Elvbakken, Kari Tove and Kari Ludvigsen (2003) “Hygiene og psykiatri – ordensoppgaver som kilde til medisinens posisjon i staten”, Norsk Statsvitenskapelig tidsskrift, 19, 1, 3–27. Evang, Karl and Otto Galtung Hansen (1937) Norsk kosthold i små hjem. Oslo: Tiden. Falkum, Erik and Øivind Larsen (1981) Helseomsorgens vilkår – Linjer i medisinsk sosialhistorie. Oslo:Universitetsforlaget. Froestad, Jan (1995) Faglige diskurser, intersektorielle premisstrømmer og variasjoner I offentlig politikk. Døveundervisning og handikapomsorg i Skandinavia på 1800-tallet. Rapport nr. 34, Institutt for administrasjon og organisasjonsvitenskap, Universitetet i Bergen. Holst, Frederik (1823) Betragtninger over de nyere Britiske Fængsler, især med hensyn til Nödvendigheden af en Forbedring i Fangepleien i Norge, Christiania. Holst, Frederik (1847) Actstykker angaaende Pestqvarantainen, Norsk Magazin for Lægevidenskaben, Anden Række, 600–675. Johannisson, Karin (1994) “The People`s Health: Public Health Policies in Sweden”. In: Porter, Dorothy (1994) (ed): The History of Health and the Modern State. Amsterdam: Rodopi. Kuhnle, Stein (1992) “Statistikkens historie i Norden”. In: Ervik, Rune and Stein Kuhnle (eds.): Kunnskap, risiko og sosialpolitikk. Institusjonelle perspektiver på skandinavisk utvikling, Bergen: Alma Mater. Larsen, Øivind (2001): “Frederik Holst og fengslene”, Tidsskr nor Lægeforen, 121, 3556–60. Lochmann, Ernst F. (1891) Populære opsatser; Afhandlinger, erindringer og anmeldelser (samlet av A. Chr. Bang), Kristiania. Ludvigsen, Kari (1998): Kunnskap og politikk i norsk sinnssykevesen 1820–1920. Rapport nr. 63, Institutt for administrasjon og organisasjonsvitenskap, Universitetet i Bergen. Norum, Kaare R. and Hans Grav (2002) “Axel Holst og Theodor Frølich - pionerer i bekjempelsen av skjørbuk”, Tidsskr Nor Lægeforen 122: 1686–7. Porter, Dorothy (1994) (ed.): The History of Health and the Modern State. Amsterdam: Rodopi. Porter, Dorothy (1999) Health, Civilization and the State. A History of Public Health from Ancient to Modern Times. London: Routledge. Rosen, George (1958) A History of Public Health, Baltimore and London: The Johns Hopkins University Press. Sandvik, Hogne (1993) “Bekjempelse av skabb i Ytre Nordhordland legedistrikt”, Tidsskr Nor Lægeforen, 113:40–3. Schiøtz, Carl (1933): Lægevidenskapens samfindsopgaver, Universitetets Radioforedrag, trykt i Lægevidenskap og samfund, Oslo: Aschehoug. Schiøtz, Aina (2002) personal information.

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Schmiechen, James and Kenneth Carls (1999) The British Market Hall: A Social and Architectural History, New haven/London: Yale University Press. Skålevåg, Svein Atle (1998): System i galskapen – teori og terapi i norske sinnssykeasyl, 1855–1915. Hovedfagsoppgave i historie, Universitetet i Bergen. Slagstad, Rune (1998) De nasjonale strateger, Oslo: Pax. Steen, Sverre (1951) 1814, Bind 1 i Det frie Norge, Oslo: J.W. Cappelen forlag. Steen, Sverre (1958) Det gamle samfunn, Bind 5 i Det frie Norge. Oslo: J.W. Cappelens forlag. Sundt, Eilert (1978) Verker i utvalg, Bind 2, Oslo: Gyldendal. Svalestuen, Anders (1988) Helsevesenet 1814–1940; En administrasjonshistorisk oversikt, Norsk Arkivforum, nummer 8. Weber, Max (1958) The City. New York: The Free Press. Zacke, Brita, (1971) Koleraepidemien i Stockholm 1834, Stockholm: Stockholms Kommunalförvaltning. Østerberg, Dag, (1991) “Universitetets funksjonalitet. En vurdering”, In: Wyller, Egil A. (ed.): Universitetets ide gjennom tidene og i dag, Oslo: Universitetsforlaget.

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Sanitary Normalization in Portugal: Pharmacies, Pharmacopoeias, Medicines and Pharmaceutical Practices (19th–20th Centuries) João Rui Pita (University of Coimbra, Portugal)

Introduction During the nineteenth century and the first half of the twentieth century a normalizing strategy came to the fore in the world of pharmacy. Portugal was no exception. This normalizing strategy embraced three main domains: First, the normalization of the production of medicines, the control of raw materials and medical prescriptions and the standardization of official pharmacopoeias, expressing the normalizing power of the state in relation to the production of medicines and the therapeutic arsenal. Second, the professional practice of pharmacists: the debate on the training of pharmacists was decisive, and the ownership of pharmacies and their functioning and illegal practitioners of the profession are among various issues that are included here. Third, other problems pertaining to public health, for example the quality of foodstuffs and water. All three domains reflected the ambition of the pharmaceutical profession for control by the state in defence of public and private health. Several of these normalizing concerns are laid out in the theses of the Primeiro Congresso Nacional de Farmácia held in Lisbon from 15–18 December 1927. For Portugal, this is a revealing historical document, reflecting the progress that had been made and the problems that had come to light, against a background of the progressive examination of sanitary normalization typical of the contemporary period.

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Sanitary Normalization in Portugal: Pharmacies, Pharmacopoeias, Medicines and Pharmaceutical Practices (19th–20th Centuries)

The publication of official pharmacopoeias and the normalization of medicines In 1794 the first official Portuguese pharmacopoeia was published, the Pharmacopeia Geral.1 It was written by the professor of pharmacy at the Faculty of Medicine of the University of Coimbra, Francisco Tavares. According to the Estatutos da Universidade de Coimbra of 1772, the Faculty of Medicine of the University of Coimbra was entrusted with the publication of an official pharmacopoeia. This pharmacopoeia heralds the beginning of the publication of official pharmacopoeias in Portugal. The pharmacopoeia of 1794 was re-published in 1823 and 1824 without changes. The study of the pharmacopoeia of 1794 has already been carried out in depth. It should, however, be pointed out that when it was first published, the work was already outdated from a scientific point of view and maintaining it as the official pharmacopoeia was challenged by specialists of that period. Conscious of this shortcoming, the author himself, Francisco Tavares, wrote Pharmacologia, a treatise on medical and pharmaceutical issues, which came out in two editions (in 1809 and 1829, the latter appearing posthumously).2 This work aimed at replacing the official pharmacopoeia, which was insufficient both technically and scientifically. This work by Francisco Tavares was not the only one published as an answer to the out-of-date character of the official pharmacopoeia. Other works can be mentioned, such as Farmacopéa Lisbonense,3 Pharmacopea chymica, médica, e cirurgica, em que se expoem os remedios simples, e compostos, suas virtudes, preparação, doses..,4 Pharmacopea Naval e Castrense5 and Pharmacopea das Pharmacopeas nacionaes e

1

See João Rui Pita, “Um livro com 200 anos: a farmacopeia portuguesa (Edição oficial). A publicação da primeira farmacopeia oficial: Pharmacopeia Geral (1794)”, Revista de História das Ideias, 20, 1999, pp. 47–100.

2

Francisco Tavares, Pharmacologia novis recognita curis, aucta, emendata, et hodierno saeculo accommodata, Conimbricae, Typis Academicis, 1809; Francisco Tavares, Pharmacologia novis recognita curis, aucta, emendata, et hodierno saeculo accommodata , Conimbricae, Typographia Academico Regia, 1829.

3

Manuel Joaquim Henriques de Paiva, Farmacopéa Lisbonense, 2ª ed., Lisboa, Officina Patriarcal de João Procopio Correa da Silva, 1802.

4

António José de Sousa Pinto, Pharmacopea chymica, médica, e cirurgica, em que se expoem os remedios simples, e compostos, suas virtudes, preparação, doses …, Lisboa, Impressão Regia, 1805.

5

Jacinto Costa, Pharmacopea Naval e Castrense, 2 vols. , Lisboa, Impressão Regia, 1819.

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estrangeiras,6 all of which attempted to deal with the innumerable technical and scientific gaps of the Pharmacopeia Geral. The issues which served as the impetus for the publication of the first official Portuguese pharmacopoeia were the following: the normalization of the raw materials and techniques necessary for the production of medicines; the normalization of the medical pharmacopoeia; the normalization of the teaching of pharmacy (this body of work served as the basis for the teaching of pharmacy). For the state, health, be it public or private, would be at risk should the production of medicines not be normalized. The publication of an official pharmacopoeia would therefore contribute to attaining the aims of normalization and accompany the international sanitary movement in favour of public hygiene.7 During the nineteenth and the first half of the twentieth centuries three official pharmacopoeias were published in Portugal: the Codigo Pharmaceutico Lusitano (1st edition 1835), the Pharmacopoêa Portugueza (1876) and the Farmacopeia Portuguesa (1st edition 1935). The Codigo Pharmaceutico Lusitano was written by A.A. Silveiro Pinto, PhD in Philosophy and Medicine. The author presented his work to the Faculty of Medicine of the University of Coimbra with the aim of replacing the Pharmacopeia Geral of 1794.8 The pharmacopoeia of 1835 arose as the continuation of a project begun in 1794.9 The Codigo Pharmaceutico Lusitano has as subtitle Treatise of Pharmaconomy. It is composed of two major parts. The first part is a treatise on pharmaceutical techniques, the Pharmaconomia; the second part is called the Pharmacopéa and is a list of raw materials and medicines. It includes various active substances extracted from plants and salts such as morphine, narcotine, quinine, etc. The work accentuates the standardization necessary for the production of medicines. Therefore the author says

6

B.J.O.T. Cabral, Pharmacopea das Pharmacopeas nacionaes e estrangeiras, 2 vols., Lisboa, Impressão Regia, 1833–1834.

7

See Glenn Sonnedecker, “The Founding Period of the U.S. Pharmacopeia. I. European Antecedents”, Pharmacy in History, Madison, 35(4) 1993, pp. 151–162.

8

See João Rui Pita, Farmácia, Medicina e Saúde Pública em Portugal (1772–1836), Coimbra, Minerva, 1996, p. 229 a ff.

9

Ana Leonor Pereira; João Rui Pita, “Liturgia higienista no século XIX. Pistas para um estudo”, Revista de História das Ideias, 15, 1993, p. 462.

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“That book that comprises the rules, precepts or laws according to which medicines are known, conserved, handled or prepared will have a right to be entitled Codigo Pharmaceutico.”10 The existence of these rules, precepts or laws has to do directly with the function of medicines on the organism, as they are considered “modifiers and reagents of the human body”.11 Various modern authors are referred to, among them Chevreul, Virey, Chevalier, Souberain and others. All the editions of the Codigo Pharmaceutico Lusitano published after 1835 (1836, 1841, 1846 and 1858) follow the same aim as the first edition: to compile an updated list of medicines and how to produce them and to defend the interests of the public health of the population. In the 1858 edition (posthumous), which was organized by the medical doctor José Pereira dos Reis, there is a list of antidotes for poisonings and a set of reagents to evaluate the properties of medicines, including falsifications, which further accentuates the interest of the pharmacopoeia in the defence of public health. In 1838 a commission was set up to draw up an official new pharmacopoeia. Three years later the work was ready, but was never published as an official pharmacopoeia.12 The well-known social convulsions that marked the first half of the nineteenth century in Portugal help explain why the official pharmacopoeia, which was ready by 1841, was never published. Not even the effort made by Francisco Fernandes Costa, Professor at the Faculty of Medicine of the University of Coimbra and commissioned in 1860 by the same Faculty to conclude an official new pharmacopoeia, was enough to bring about the publication of a successor to the Codigo Pharmaceutico Lusitano.13 The Codigo was in force up until 1876. That year the third official Portuguese pharmacopoeia was published, the Pharmacôpea Portugueza. The preparation of a new and original pharmacopoeia no longer depended on the Faculty of Medicine of the University of Coimbra and for the first time it was drawn up by an Official Commission. The pharmacopoeia was essentially made up of a formulary and a list of raw materials, without any section devoted to technical pharmacy, as had been the case previously. The work takes up, energetically, the defence of public and private health

10

Agostinho Albano da Silveira Pinto, Codigo Pharmaceutico Lusitano ou Tratado de Pharmaconomia, Coimbra, Imprensa da Universidade, 1835, p. I.

11

Ibid., p. XII.

12

See J.P. Sousa Dias, “De Pombal ao Estado Novo: a Farmacopeia Portuguesa e a História (1772–1935)”, Medicamento, História e Sociedade, Nova série, 6, 1995, p. 3.

13

Ibid.

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through the normalization of the preparation of medicines and the exercise of professional pharmacy. The function of an official pharmacopoeia was said to be “to perfect and standardize the exercise of pharmacy”.14 One of the most serious problems of the 1876 pharmacopoeia was that it was in force for too long (about six decades) at a time when a pharmaceutical revolution was taking place.15 In this key period of scientific and technical innovation it quickly became outdated.16 There is no reference to modern pharmaceutical forms like pills or injections in the 1876 pharmacopoeia, although they were emerging with as a tremendous presence in medical treatment. Nor does it mention new pharmaceutical operations, new raw materials or excipients such as sulphonal (1885), adrenaline (1894), heroine (1896), acetylsalicylic acid (1899), veronal (1905), luminal (1911), thyroxine (1914), progesterone (1929), stradiol (1929), androsterone (1931), testosterone (1935), etc. The reasons that led to the enforcement of the 1876 pharmacopoeia until 1935 (six decades that were in fact one the most fertile periods in technological and scientific innovation in pharmaceutical history) are still not clear. Some efforts were made to replace the pharmacopoeia but none of them succeeded, probably due to political and socio-professional reasons that overlapped with problems of a technical and scientific nature. In Spain, by comparison, the seven decades from 1884 to 1954 saw six pharmacopoeias published (one of which went through three editions), while in Portugal in that same time span only three editions of official pharmacopoeias were published (one edition of the 1876 pharmacopoeia and two of the Farmacopeia IV, in 1935 and 1946)17. France, Russia, Germany, the USA and Switzerland are only some of the countries that were in a period of renewal of their official pharmacopoeias – as several Portuguese pharmaceutical periodicals announced, pointing out these countries as examples to Portugal.

14

Pharmacopêa Portugueza, Lisboa, Imprensa Nacional, 1876, p. XI.

15

See F.J. Puerto Sarmiento, El mito de Panacea — Compendio de Historia de la Terapéutica y de la Farmacia, Madrid, Ediciones Doce Calles, 1997, pp. 553–621.

16

See F. Chast, Histoire Contemporaine des médicaments, Paris, La Découverte, 1995; F. Chast, “Les médicaments”. In: Mirko D. Grmek (Dir.), Histoire de la pensée médicale en Occident, vol. 3, Paris, Seuil, 1999, pp. 215–233.

17

See Juan Esteva, “Las Farmacopeas Hispanas”. In: Jose Luis Gomez Caamaño, Professor de Historia de la Farmacia de Barcelona , Barcelona , Facultad de Farmacia, 1980, pp. 103–138.

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In 1903 an official commission was appointed to draw up a new pharmacopoeia to replace that of 1876. For seven years this commission devoted itself to preparing the new work but the Republican Revolution of 1910 occurred at the terminal stage of the commission’s activity and the final work never appeared. It seems that the nomination of new members of the commission by direct designation of the revolutionary government, with the replacement of Emílio Fragoso, who was one of the most active members of the team but whose political sympathies were opposed to the Republican movement, prevented the final conclusion of the work. Three years later, in 1913, a new commission was formed to write a new official pharmacopoeia. It was composed mainly of doctors, professors of the Faculties of Medicine and Science, and the pharmaceutical élite understood that little attention had been given to the pharmaceutical professional body. As a result, the commission soon dissolved.. The pharmacopoeia of 1876 was finally replaced by the Farmacopeia Portuguesa, which appeared in 1935. This work was drawn up by a committee of pharmacists and like its predecessors it contained contributions originating from foreign pharmacopoeias and other international reference works. The commission was concerned with the maximum medical and pharmaceutical updating. The Farmacopeia18 had a number of innovations, among them several new monographs referring to opotherapy, serum and vaccines, injections, pills, capsules as well as various instructions regarding dosage, identification and research on impurities in medicines. The existence at the end of the work of a compendium of legislation on pharmaceutical activities and on medicines is symptomatic, and accentuates the normalizing function of Portuguese pharmacopoeias. This pharmacopoeia came out in a new edition in 1946; a supplement was added in 1961. It was officially in force until 1986. A commission composed entirely of pharmacists was set up to prepare the Farmacopeia Portuguesa IV; they met as a group to edit the new publication. This group laboured for five years, continuing the work of another official commission that had been set up in 1925 to carry out a study of the Métodos de análises dos medicamentos destinados ao Exército (Methods of Analysing Medicines for the Army) and that included three members of the Portuguese pharmacopoeia commission. It should be pointed out that all five members of the commission that prepared the 1935 pharmacopoeia were linked to either the pharmaceutical inspection service (two

18

Farmacopeia Portuguesa, Lisboa, Imprensa Nacional de Lisboa, 1935.

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persons) or the pharmacy of the Army and Navy (the other three) and that work on the publication took place just after the revolution of the 28 May 1926, which heralded the end of the First Republic and the beginning of the dictatorship that lasted until 1974.19 Since this was the key publication for the standardization of medicines in Portugal, the second edition (1946) and the supplement (1961) attempted to update the work and take into consideration the most relevant technical and scientific innovations. Several monographs, major entries in the table of contents referring to each medicine, were vital in the control of major public health problems, particularly in the field of preventive medicine. For example, the 1946 edition includes anti-diphtheric vaccine, anti-tetanic vaccine, updated essays on the application of the smallpox vaccine, a monograph on insulin, monographs on several vitamins, monographs on sulfamids, etc. The 1961 supplement, a supplement to the 2nd edition, was included by the Comissão Permanente da Farmacopeia Portuguesa (1957), whose aim in fact was the periodical revision of the Farmacopeia Portuguesa, and it is important to underline the inclusion of monographs on several antibiotics such as penicillin, corticosteroids, several tranquilizers, etc.

The pharmaceutical profession At the end of the nineteenth century and in the first half of the twentieth centuries the pharmaceutical profession was subject to strong disciplinary norms. Various preoccupations motivated the state and the pharmacists (in particular the Sociedade Farmacêutica Lusitana) to devise and pass a set of laws and regulations that were meant to normalize the professional practice of pharmacy. However, there was an awareness that adequate training was necessary for the Portuguese pharmacists so as to ensure complete professional status. Therefore the teaching of pharmacy was subject to discussion. The question that was often raised was whether the teaching of pharmacy should have solid, scientific bases or whether knowledge gained through professional practice was sufficient.20

19

See João Rui Pita, “Um livro com 200 anos: a farmacopeia portuguesa (Edição oficial). A publicação da primeira farmacopeia oficial: Pharmacopeia Geral (1794)”, Revista de História das Ideias, 20, 1999, pp. 47–100; J.P. Sousa Dias, “De Pombal ao Estado Novo: a Farmacopeia Portuguesa e a História (1772–1935)”, Medicamento, História e Sociedade, Nova série, 6, 1995, pp. 1–8.

20

Vide: João Rui Pita, “A farmácia em Portugal: de 1836 a 1921. Introdução à sua história. Parte I. Ensino farmacêutico e saúde pública — formação e actividade dos farmacêuticos portugueses”, Revista Portuguesa de Farmácia, 49(1)1999, pp. 11–20. João Rui Pita, “Breve história da Faculdade de

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In 1836 the Schools of Pharmacy of Lisbon, Porto and Coimbra had been created with a specific curriculum for training pharmacists. This system was in force until the 1902 reform of schools and curricula (the Law of 2 July 1902 and Regulation of 27 November 1902), where for the first time in Portugal Pharmacy was considered a higher education degree. This reform of studies and of the Schools of Pharmacy was the beginning of a set of successive reforms and changes in Portugal during the first half of the twentieth century. In 1911 (Decree of 26 May 1911) pharmacy studies were offered by a new faculty independent from the Faculty of Medicine and a new curriculum was established. In 1918 (Decree no. 4653) there was an alteration to the curriculum. In 1919 (Decree no. 5463) the Schools of Pharmacy started to award Master’s degrees. In 1921 (Decree no. 7238) the Schools were transformed into Faculties. In 1926 (Decree no. 12,698) there was a new alteration to the curriculum. In 1928 (Decree no. 15,365) the Faculty of Pharmacy of the University of Coimbra was dissolved. In 1930 (Decree no. 18,432) a reorganization of the Faculties of Pharmacy and of the curriculum took place. In 1931 (Decree no. 20,294) some alterations to the organization of the faculties were made. In 1932 (Decree no. 21,863) the School of Pharmacy of the University of Coimbra was re-established and the Faculty of Pharmacy at Lisbon was transformed into a School; the Faculty of Pharmacy at the University of Porto maintained its status. This decree established a new organization of the curriculum, dividing it into two cycles, a first cycle of three years (professional course in pharmacy) and a second cycle of two years (Master’s degree and PhD). Only the Faculty of Pharmacy of Porto could grant Master’s degrees and PhDs, while the Schools of Coimbra and Lisbon could only teach the professional course. It should be pointed out that in the introduction to the 1932 Decree, already promulgated by António de Oliveira Salazar, the existence of two cycles was justified for economic, technical and scientific reasons. In the first place, owing to the lack of pharmacists in Portugal, it was necessary to organize a course with easy access and a short duration to guarantee the training of pharmacists in a shorter period of time so as to improve the pharmaceutical coverage of the country and to avoid the illegal exercise of the profession. In the second place, there was no reason for the existence of three faculties to grant Master’s degrees because there would not be enough students to sustain the three institutions and this would be too onerous for the state.

Farmácia da Universidade de Coimbra”, Munda , 24, 1992, p. 3–16. João Rui Pita, “A Faculdade de Farmácia de Coimbra em 1921”. In: A.P. Brojo, M.L. Rebelo and J.R. Pita (eds.), Farmácia, Ciência e Universidade. A fundação da Faculdade de Farmácia de Coimbra em 1921, Coimbra, Minerva, 2000, pp. 47–63.

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Finally, the Faculty of Pharmacy at the University of Porto was maintained because it was the best equipped materially. This state of affairs continued until 1968, when the Schools of Pharmacy at Coimbra and Lisbon were transformed into Faculties of Pharmacy. During this period, the Sociedade Farmacêutica Lusitana gave way to the Sindicato Nacional dos Farmacêuticos and the Grémio Nacional das Farmácias (1940), two corporations that would fit in with the corporative regime of the New State. It should be noted that not all Portuguese pharmacists agreed when it came to the question of the reform of pharmaceutical teaching in the country. Ever since the 1836 reform there had been opposed positions among Portuguese pharmacists and between the pharmaceutical community and the government. For example, when in 1836 the existence of 1st class and 2nd class pharmacists was established, pharmacists were divided. Some called for an end to these two classes while others supported their existence. The 1902 reform of studies formally extinguished the existence of two classes of pharmacists. The successive reforms until 1921, which culminated with the creation of the Faculties of Pharmacy, were also a way of stimulating a reorganization of pharmaceutical practice in Portugal. The pharmaceutical élite was conscious of the fact that a good scientific training was the basis for good professional performance, and that this would benefit both private and public health. Therefore, after the 1902 teaching reform, people called for a reform of professional practice, which according to testimonies of the time presented deep problems that could not always be easily solved and that were strongly rooted in Portuguese society and the pharmaceutical class. Portuguese pharmaceutical periodicals between the last twenty years of the nineteenth century and the first thirty years of the twentieth century contain many articles that display an awareness that it was necessary to introduce reform and to create a new legal basis for the practice of the pharmaceutical profession in Portugal. This eventually came to pass at the end of the 1920s and during the 1930s. Very briefly, between the mid-nineteenth century and the first half of the twentieth century the main problems in the practice of the pharmaceutical profession were the following.21

21

João Rui Pita, “A farmácia em Portugal: de 1836 a 1921. Introdução à sua história. Parte I. Ensino farmacêutico e saúde pública — formação e actividade dos farmacêuticos portugueses”, Revista Portuguesa de Farmácia, 49 (1) Jan.–Mar., 1999, pp. 11–20; “A farmácia em Portugal: de 1836 a 1921.

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First, there was the existence of unqualified individuals illegally practising the profession as well as competition from other professionals such as druggists. In 1932, of the 1300 existing pharmacies in the country only 800 worked under legal conditions.22 This matter was a major concern for Portuguese pharmacists as there was a perception that the pharmaceutical profession should only be exercised by pharmacists qualified for that purpose, for reasons of a technical and scientific nature and to ensure the protection of public health. As a matter of fact, there was an awareness that the preparation of medicines and their supply to the public was of crucial importance in the domain of public health. It is in this light that the legislation approved at the end of the nineteenth century pertaining to the functioning of pharmacies, inspection and ownership rights, etc. should be considered.23 We only need to take a look at periodicals like Gazeta de Farmácia, Boletim Farmacêutico, A Acção Farmacêutica and more recently Notícias Farmacêuticas to verify that the question of pharmaceutical professional practice was a strong concern among Portuguese pharmacists. Several cases of individuals who illegally practised the profession – individuals who were not qualified to carry out pharmaceutical activities, doctors and druggists among them – are denounced in the pages of these periodicals. Many cases of illegal activities by pharmacists themselves are also pointed out. There are references to negligence by several pharmacists in the exercise of their profession. And all this without any kind of control of professional practice. The measures in place were considered insufficient for ensuring proper pharmaceutical standards to guarantee the population’s well-being and protect public health. Some decrees were shaped the organization of the pharmaceutical profession in Portugal and warranted the support of the Sociedade Farmacêutica Lusitana (a body that defended the interests of the pharmaceutical class) and of other class unions: Decrees no. 9431 of the 6 February 1924 and especially Decree no. 12,477 of 12 October 1926,

Introdução à sua história. Parte II. Exercício profissional, industrialização do medicamento e literatura farmacêutica” Revista Portuguesa de Farmácia, 49(2)Abr.–Jun., 1999, pp. 61–70. 22

Decreto nº 21.853, 8 Nov. 1932. In: M.D. Tello da Fonseca, História da Farmácia portuguesa através da sua legislação, vol. 2, Porto, Empresa Ind. Gráfica do Porto, 1936, p. 487.

23

See João Rui Pita, “A farmácia em Portugal: de 1836 a 1921. Introdução à sua história. Parte II. Exercício profissional, industrialização do medicamento e literatura farmacêutica”, op. cit., p. 62 and ff.

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which reorganized the Pharmaceutical Services and created the Inspectorate of Pharmaceutical Practice, as well as Decree no. 13,470 of 12 April 1927, which regulated the practice of the pharmaceutical profession. The reason these were welcomed so warmly by the pharmaceutical body was precisely because they introduced standards for professional practice. Establishing objective norms on who could exercise the profession and on the conditions surrounding it was even more marked in Decree no. 23 422 of 29 September 1933, which regulated how the pharmaceutical profession was practised and the property of the pharmacy, the retail shop where medicine and other articles are sold, until 1968. Above all, the pharmaceutical class longed for norms that could guide the pharmaceutical profession in Portugal. In an article entitled “A Socialização da Farmácia” (“The Socialization of Pharmacy”), Tello da Fonseca, a prestigious Portuguese pharmacist and director of the newspaper A Acção Farmacêutica, suggested that Portugal should carry out an experiment similar to that in Russia, where the pharmacies belong to the state. This pharmacist said that it was a way of eliminating “disorder in the life of the pharmaceutical profession, a branch of the art of healing that the public cannot do without”.24 The second urgent issue facing the pharmaceutical profession was establishing a limit to the number of pharmacies. Portugal had too many of them, especially in Lisbon and Porto. At the beginning of the twentieth century Lisbon had the same number of pharmacies as Sweden or Norway and only twenty-six pharmacies fewer than Denmark. So it is no surprise that among the pharmaceutical class the call was heard for a limit to the number of pharmacists, a development that was also happening elsewhere in Europea.25 The reasons were evident: first, a minimum economic guarantee for each pharmacy; second, the desire to avoid unfair competition between pharmacies arising from the lack of clients and subsequent disrespect for the profession; third, the need to guarantee a uniform distribution of pharmacies among the population, for the good of public health. But the problem of limiting the number of pharmacies interfered with the status of pharmacy as a liberal profession. A third problem was related to the industrialization of medicine and its consequences on the way the profession was exercised. With the industrialization of

24

Tello da Fonseca, “A socialização da farmácia”, A Acção Farmacêutica, 1 Sept. 1930, p. 1.

25

See Tello da Fonseca, “O limite de pharmacias”, Boletim Pharmaceutico, 1(3) 1902, pp. 43–45. “Limitação de pharmacias”, Boletim Pharmaceutico, 5 (10) 1906, pp. 145–146.

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medicine, pharmacies were no longer the exclusive sites for the production of medicines. Workmanship started giving way to industrial production. The development of biology, chemical pharmacy, chemical synthesis, pharmaceutical technology and the appearance of new pharmaceutical forms such as capsules, pills and injections brought consequences not only on the technical and scientific front, but also on the way the profession was carried out. Pharmaceutical firms offered new places for exercising the profession. With the industries business logic came to the fore, distinct from the functioning of pharmacies.26 Advertising became a fundamental and decisive aspect of medication. The first major pharmaceutical firm was established in 1891, the Companhia Portuguesa de Higiene.27 Other Portuguese pharmaceutical companies included the Laboratório J. Neves (1892), Instituto Pasteur de Lisboa (1895), Laboratório Normal (1904), Laboratório Sanitas (1911), Laboratório Farmacológico J. J. Fernandes (1918), Laboratório Saúde (1919), Laboratório JABA (1919), Laboratório Andrade (derived from Freire de Andrade & Irmão Pharmacy, founded in 1885), Sociedade Industrial Farmacêutica (which originated in Laboratórios Azevedos), Laboratório Bial (1924), Laboratório Andrómaco (1931), Laboratórios Vitória (1934), and many others.28 In this connection, legislation linked not only to the production of medicines but also to their import, export and sale came into being. An aspect that deserves special attention is the reception of foreign medicines in Portugal, a problem that was overcome with time but caused a great deal of surprise and preoccupied concern among the pharmaceutical class in Portugal. There were three main reasons for this. Firstly, it was thought that the foreign medicines would ruin the Portuguese pharmaceutical industry; second, because people mistrusted the quality of foreign products; finally, because there was a notion that it was not necessary to import medicines since national products were

26

See F. Javier Puerto Sarmiento (Coord.), Farmacia e industrializacion. Libro de homenaje al Doctor Guillermo Folch Jou, Madrid, Sociedad Española de Historia de la Farmacia, 1985; Jonathan Liebenau, Gregory J. Higby and Elaine Stroud (eds.), Pill Peddlers. Essays on the History of the Pharmaceutical Industry, Madison, American Institute of the History of Pharmacy, 1990; Georges Dillemann, Henri Bonnemain and André Boucherle, La pharmacie française. Ses origines, son histoire, son évolution, Paris, Tec&Doc-Lavoisier, 1992, pp. 114–122.

27

See J.P. Sousa Dias, “A formação da indústria farmacêutica em Portugal: os primeiros laboratórios (1890–1914)”, Revista Portuguesa de Farmácia, 43(4) 1993, pp. 47–56.

28

See J.P. Sousa Dias, “Contributo para um dicionário das empresas da indústria farmacêutica portuguesa na primeira metade do século XX”, Medicamento, História e Sociedade. N. Série. 6(12) 1997, pp. 1–12.

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sufficient for the Portuguese continental market and the Portuguese colonies in Africa and the Far East. The 1st National Pharmacy Congress in Lisbon in 1927 also offered a platform for the Portuguese pharmaceutical industry and had a clear nationalist orientation.29 During the period of the industrialization of medical production in Portugal in the first half of the twentieth century, various laws were passed imposing excise taxes on pharmaceutical specialities, regulating the establishment of pharmaceutical firms, controlling the sale of industrialized medicines, and so on. Also relevant was the creation in 1940 of the Comissão Reguladora dos Produtos Químicos e Farmacêuticos, whose aims included normalizing activities related to the import, sale and industrial production of medicines. This is an issue of great interest and one that demands detailed studies in Portugal for a better understanding of the history of the Portuguese pharmaceutical profession in the twentieth century.

Other problems of interest to public health With the 1902 reform of studies the Portuguese pharmacists started to have scientific arguments to provide an answer to sanitary problems of public interest like the analysis of water, food, and so on. In fact, this reform and later the 1911 reform offered the Portuguese pharmacist scientific subjects in the area of chemical, toxicological, hydrological, bromatological and bacteriological analysis that officially made him an agent of public health. This does not imply that the Portuguese pharmacist was not concerned with analyses applied to public health before the twentieth century. It is enough to look into different pharmaceutical publications to see that this has been a clear concern since the mid-nineteenth century. What we mean is that it was in the twentieth century that the pharmacist consolidated this dimension with the official inclusion of these scientific areas in the curricula. And it is possible to say that it was with the extension of their professional performance that pharmacists further emphasized their role as agents of public health. The falsification of medicines, the quality and the analysis of foodstuffs, the quality and analysis of water, the production of vaccines and the analysis of toxic products are some of the areas in which pharmacists were in a position to provide adequate

29

See João Rui Pita and Ana Leonor Pereira, “Nos 75 anos do primeiro Congresso Nacional de Farmácia (Lisboa, 1927): farmácia, saúde pública e normalização social”, Revista Portuguesa de Farmácia, 52 (1-supl.) 2003, p. 199.

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responses. In fact the training of pharmacists provided them with the capacity to work not only in the preparation of medicines but also as specialists in applied analysis in public health. This is evident if we examine several publications of that time (the transition from the nineteenth to the twentieth centuries) such as Gazeta de Farmácia, Jornal da Sociedade Farmacêutica Lusitana, Boletim Farmaceutico, Revista QuimicoFarmacêutica and later A Acção Farmacêutica and Notícias Farmacêuticas in order to check the role of the pharmacist in analyses relevant to public health. This extension of his role to the field of analysis (chemical and microbiological) gave him a leading role in the dynamics of public health. It also accentuated the awareness that it was necessary to pass more legislation so as to avoid the falsification of medicines and the adulteration of foodstuffs and to ensure the proper assessment of the quality of water and foodstuffs, and so on. Various pharmacists and chemists became prominent in this area, among them Santos e Silva, Charles Lepierre and Ferreira da Silva.30 In a process similar to what was happening abroad, in Portugal too various laboratories appeared that dealt with chemical and microbiological analyses as applied to public health, the purpose being to carry out clinical analysis and also analyse and normalize foodstuffs, water, and so on. This was the case of the Instituto Bacteriológico Câmara Pestana (Lisbon) and the Gabinete de Microbiologia (Coimbra)31 as well as of the Laboratório Chimico Municipal do Portoin, which in 1903, for example, carried out 1021 analyses, on foodstuffs (974), commercial and industrial products (18) and medicines and mineral waters (8), and in the fields of toxicology and legal medicine (20) and medicine (1).32 The Instituto Bacteriológico was created in 1892 and its first director was Câmara Pestana, a young doctor from Madeira who had been sent to France the previous year by the Portuguese government in order to study at the Pasteur Institute in Paris. The king, the queen and the governing authorities were aware of the importance of creating an

30

See Ana Leonor Pereira and João Rui Pita, “Charles Lepierre au Portugal (1867–1945). Son influence décisive sur la santé publique, sur la chimie et sur la microbiologie”, Revue d'Histoire de la Pharmacie, 328, 2000, pp. 463–470.

31

See Ana Leonor Pereira and João Rui Pita, “A ‘nave’ dos micróbios na Universidade de Coimbra”. In: Património Cultural em Análise (Actas do Encontro Nacional), Coimbra, 1998, pp. 113–127. Ana Leonor Pereira and João Rui Pita, “A ciência higiénica em Portugal no século XIX. Alguns traços no meio coimbrão”, Munda, 37, 1999, pp. 77–84. Ana Leonor Pereira and João Rui Pita, “Institucionalização da parasitologia em Portugal”, Revista Portuguesa de Farmácia, 51(4) 2001, pp. 175–182.

32

See “Laboratorio chimico municipal do Porto”, Revista Chimico-Pharmaceutica, 1903, pp. 236–237.

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official institution to study and be responsible for the teaching of bacteriological issues with an application to public health. The study of rabies and cholera and the bacteriological study of water were some of the main initial concerns of the Institute. Câmara Pestana soon assumed an important role in Lisbon and in Portugal in the development of bacteriology, creating a school of bacteriologists. He carried out microbiological research in the Bacteriological Institute of Lisbon, which after his death in 1899 gave his name to an independent building that Câmara Pestana himself would never know. Pestana died prematurely at the age of thirty-six when he was in the city of Porto as part of an international scientific committee studying a local plague epidemic. The study of the history of the Instituto Bacteriológico Câmara Pestana, an institution that still exists today, is essential in order to evaluate the way Pasteurian scientific innovation was received in Portugal. Less important than the Instituto Bacteriológico was the Gabinete de Microbiologia of the Faculty of Medicine of the University of Coimbra, which was conceived in 1882 and brought into existence in 1886; in 1890 it obtained independent facilities. The initial promoter of the body was a professor at the Faculty of Medicine of the University of Coimbra, Augusto Rocha, who tried to bring to the university what would later be established in Lisbon, the Instituto Bacteriológico. In any case, however, the Gabinete de Microbiologia was a pioneer in bacteriological studies in Portugal and in bacteriological work applied to public health. The first sign of this was the work done in this laboratory by Filomeno da Câmara and Augusto Rocha, “Bacillus Typhicus” Research on Coimbra’s Potable Water,33 ordered by Coimbra’s municipal government, whose results were published in the magazine Coimbra Médica (1887).

The First National Pharmacy Congress (1927) Various concerns pertaining to normalization are laid out in the theses and communications of the First National Pharmacy Congress, which took place in Lisbon

33

Filomeno da Câmara Melo Cabral; Augusto Rocha, “Investigação do Bacillus Typhicus nas Aguas potaveis de Coimbra”, Coimbra Médica, 7(18)1887, p. 277–283; 7(19)1887, p. 293–296; 7(20)1887, p. 309–316; 7(21)1887, p. 325–331; 7(22)1887, p. 341–347; 7(23)1887, p. 363–365; 7(24)1887, p. 377–379; 8(1)1888, p. 6–9; 8(2)1888, p. 35–38; 8(3)1888, p. 49–51; 8(5)1888, p. 82–86; 8(6)1888, p. 93–98; 8(10)1888, p. 157–163; 8(17)1888, p. 269–271; 8(21)1888, p.336; 9(1)1889, p.12–14.

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in 1927.34 The Congress was divided in three sections: general issues, pharmacy and chemistry. The organizers of the Congress proposed 65 themes for debate: 16 on legislation and pharmaceutical deontology, 14 on applied analysis relating to medicines, food stuffs, water and clinics; 12 on medicines and the pharmaceutical industry; 5 related to the progress in pharmaceutical techniques; 4 on cooperativism; mutualism and social pharmacies; 10 on other themes. Close to 70 percent of the themes suggested had to do with prominent pharmaceutical concerns of the time and were well-reflected in the pharmaceutical press. Forty-two papers and communications were presented at the Congress: 23 were related to matters of legislation, deontology and professional practice; 8 had to do with applied analysis relating to medicines, foodstuffs and water; 3 dealt with the teaching of pharmacy; 2 treated mutualistic and cooperative pharmacies; 2 were concerned with the practice of pharmacy; 4 examined other themes.35 From the papers and communications we can verify that themes such as the falsification and quality of medicines, foodstuffs and water, the illegal practising of the pharmaceutical profession, limitations on the number of pharmacies and the functioning of the pharmaceutical services of the Navy and Army were objects of consideration. It is instructive to look at some cases that reflect the concerns of Portuguese pharmacists in the first thirty years of the twentieth century when they were faced with the new conditions shaping the practice of pharmacy and the production of medicines. In fact, in the first quarter of the twentieth century Portugal saw the emergence of several pharmaceutical companies, the introduction of industrialized medicines, the reception of industrialized medicines coming from abroad, the attempt to protect the fragile Portuguese pharmaceutical industry, which had just begun to assert itself, the adaptation of pharmacies and the practice of the pharmaceutical professional to the new realities of the medical world. It was also at the end of the nineteenth and first half of the twentieth centuries that new medicines, active substances and pharmaceutical forms appeared, forming the basis for a true pharmaceutical revolution. This could be seen, for example, in the emergence of the aspirin and sulfamids, or in penicillin in the 1940s. Various kinds of pills and injections can also be pointed out. Furthermore, new

34

See João Rui Pita, “Primeiro Congresso Nacional de Farmácia – 60 anos depois”, Boletim da Faculdade de Farmácia de Coimbra , 10(2) 1986, pp. 59–82.

35

See Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927.

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analytical, bacteriological and physico-chemical methods offered a deeper knowledge of medicines and also allowed the normalization and standardization of the production of medicines. Therefore, it is not surprising that in the first thirty years of the twentieth century several reforms in the teaching of pharmacy took place, their aim being better preparation of pharmaceutical professionals with these goals in mind. These concerns are clear in several lectures delivered at the Congress. Carlos Cândido Coutinho delivered a lecture entitled “Sobre a dosagem da morfina pelo método de Portes e Langlois” (“On the dosage of morphine through the method of Portes and Langlois")36 that reflected a concern with the falsification of medicines containing morphine, such as tincture of opium. Also in this context, Alberto de Oliveira Malta delivered a lecture on “Modificação ao processo de Portes e Langlois para o doseamento da morfina” (“Modification of the process of Portes and Langlois for the dosage of morphine”).37 António Maria da Gama Júnior presented “Algumas considerações sobre o exercício profissional de farmácia e indústria farmacêutica:” (“Some considerations on the professional exercise of pharmacy and the pharmaceutical industry”),38 pointing out several problems linked to the normalization of the industrial production of medicines in Portugal, their import (for example customs duties) and their export to the Portuguese colonies. Also of special relevance here is the problem of the import of foreign medicines coming from Europe and the protests this elicited from Portuguese pharmacists, who stated that Portuguese products were as good as foreign ones and that the import of foreign products would provoke a serious crisis in the Portuguese pharmaceutical sector. Ester Nogueira e Elvira Magro delivered a lecture on the detection of the adulteration of milk with water,39 claiming that there were various examples of this fraudulent practice in Portugal.

36

Carlos Cândido Coutinho, “Sobre a dosagem da morfina pelo método de Portes e Langlois”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 123–127.

37

Alberto de Oliveira Malta, “Modificação ao processo de Portes e Langlois para o doseamento da morfina”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 127–130.

38

António Maria da Gama Júnior, “Algumas considerações sobre o exercício profissional de farmácia e indústria farmacêutica”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 156–163.

39

Ester Nogueira and Elvira Magro, “Aguamento dos leites – Metodos gerais de pesquisa – a determinação da densidade do sôro, factor base para a apreciação”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 208–211.

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But where normalizing concerns were most deeply reflected at the First National Pharmacy Congress was in the area of professional practice. António José da Silva’s paper on “Federação Nacional de Farmácia” (“The National Pharmacy Federation)40 is extremely significant: for the good of the pharmaceutical profession and public health, da Silva called for laws to regulate pharmaceutical professional practice, saying that “only chemists should prepare and sell medicines; this is demanded by the law, by public health needs and by the morality of the profession.”41 Cisneiros de Faria dealt with the need for extensive regulation of pharmaceutical assistance to rural areas.42 João Martins do Rego and Augusto de Oliveira Mendes expressed their views on the organization of municipal pharmacies.43 Another burning question for Portuguese pharmacists of that period was the limitation of the number of pharmacies; this was the problem that Tello da Fonseca dealt with at the Congress,44 making an appeal to the authorities to limit the number of pharmacies for the good of the pharmaceutical profession and of public health in Portugal, since there was an excess number of pharmacies in the country. The author gave as examples countries like Russia, Norway, Sweden, Denmark, Finland, Germany, Austria and Czechoslovakia. José Gonçalves Bandeira45 also agreed on the need for a limitation on the number of pharmacies, saying that there were too many pharmacies and this was one of the reasons for the bad state of pharmacy in Portugal. He therefore proposed normalization measures in this area similar to what had been introduced in other European countries. Jaime Valongo46 delivered a lecture in which he defended the existence of laws for auxiliary pharmacy

40

António José da Silva, “Federação Nacional de Farmacia”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 130–135.

41

Ibid., p. 131.

42

José Alemão de Mendonça Cisneiros de Faria, “Assistência farmaceutica rural”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 149–150.

43

João Martins do Rego, “A municipalisação da farmacia portuguesa”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 167–171; Augusto de Oliveira Mendes, “A assistência farmaceutica aos pobres e a criação de partidos farmaceuticos municipais em todo o país”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 186–190.

44

Manuel das Dores Tello da Fonseca, “Esboço de projecto para a limitação de farmacias em Portugal”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 190–195.

45

José Gonçalves Bandeira, “Algumas causas que teem contribuido para a decadência da farmacia em Portugal”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 212–222.

46

Jaime Valongo, “Os auxiliares de farmacia – como deve ser definida a sua situação perante a lei”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 223–225.

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professionals. Joaquim Mendes Ribeiro delivered an extremely objective lecture entitled “Considerações sobre o exercício ilegal de farmacia” (“Considerations on the illegal practice of pharmacy”)47 in which he stated that it was common to find illegal practitioners of pharmacy in Portugal and that this was one of the main reasons for the unfortunate state of the profession. In his lecture he offered some recommendations and suggestions to the public authorities, important contributions for the normalization of pharmaceutical practice. Still within this frame was the lecture delivered by Augusto de Oliveira Mendes,48 who proposed the creation of pharmaceutical inspection bodies for each district. A number of other presentations also showed some concern with the laws regulating the practice of the pharmaceutical profession. Among the most important, which were published in the Congress Proceedings, were those by Guilherme de Barros e Cunha, “O direito da profissão farmaceutica” (“The law of the pharmaceutical profession”);49 José Pereira da Silva, “De uma nova organização social obrigando o estabelecimento de farmacias em todo o continente da República” (“On a new social organization that demands the establishment of pharmacies in the whole territory of the Republic”);50 José Bastos da Costa, “Reorganização dos serviços farmaceuticos em Portugal” (“The reorganization of pharmaceutical services in Portugal”);51 António de Melo Pereira Pinto de Azevedo, “Exercício farmaceutico nas colonias” (“Pharmaceutical practice in the colonies”);52 Antero Mendes Namora, “A profissão

47

Joaquim Mendes Ribeiro, “Considerações sobre o exercício ilegal de farmacia”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 235–237.

48

Augusto de Oliveira Mendes, “O exercício ilegal de farmacia, a sua repressão pela criação de subinspecções distritais do exercício farmaceutico”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 237–243.

49

Guilherme de Barros e Cunha, “O direito da profissão farmaceutica”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 251–253.

50

José Pereira da Silva, “De uma nova organização social obrigando o estabelecimento de farmacias em todo o continente da República”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 253–257.

51

José Bastos da Costa, “Reorganização dos serviços farmaceuticos em Portugal”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 258–260.

52

António de Melo Pereira Pinto de Azevedo, “Exercício farmaceutico nas colonias”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, p. 266.

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farmaceutica e o Decreto 13.470” (“The pharmaceutical profession and Decree no. 13,470”).53 The “conclusions and votes of the Congress” are also revealing: the fourteen points mentioned have as backdrop the normalization of he pharmaceutical institutions and the teaching of pharmacy. It was more of a socio-professional Congress than a scientific Congress. In other words it was a Congress that essentially debated and reached conclusions on professional problems, having as its backdrop the scientific progress of the time. The need for the normalization of pharmaceutical professional practice and medicines, under the guiding hand of the state, for the good of public and private health, was underlined.

Conclusion From what has been said here it is possible to conclude that in the second half of the nineteenth and beginning of the twentieth centuries Portugal attempted to follow the progress achieved abroad in the area of pharmacy and medicines. Both the state and the pharmacists were conscious that the question of the production and sale of medicines was a problem of both private and public health. There was also an awareness that the professionalization of pharmaceutical practice and the consolidation of pharmaceutical professionals as a group were vital not only for the pharmacists themselves but also for the quality of the service offered the public. The pharmacists consolidated their function as public health agents because they extended their performance to (chemical and microbiological) analyses applied to public health. The pharmaceutical class has not always been in complete agreement on the solutions to pharmaceutical problems and it is also possible to see socio-professional divergences between pharmacy and the state bodies responsible for taking decisions in the field. A number of the socio-professional problems that troubled Portuguese pharmacists continued to exist from the end of the nineteenth century to the first half of the twentieth century and some possible solutions were only achieved at the end of the 1920s and during the 1930s, in the period of the clear rise of the New State.

53

Antero Mendes Namora, “A profissão farmaceutica e o Decreto 13.470”, In Primeiro Congresso Nacional de Farmacia. Relatorio, Lisboa, 1927, pp. 266–267.

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Section 4 Choices of Welfare Policies and their Consequences: Local and Regional Environmental Health Effects Presented by Laurinda Abreu

The papers presented at the session on “Reasons for different choices of welfare policies and their consequences: local and regional environmental health effects” addressed the problem of the impact of political decisions on the population's health and welfare. Due to the rapidly growing need for social welfare among the population and the new problems that modern societies must face, political decisions and the opinion of the policymakers that support them acquire a new importance. The same can be said about the knowledge of past experiences – which lessons could help us to avoid making the same mistakes over and over again. Yet political decision-makers tend to act in quite the opposite way. That is to say, they ignore the past and end up repeating the same errors. This is, roughly speaking, the central thesis of the articles on Hungary and the United Kingdom. Bence Döbrössy and Péter Molnár first analyze health policies in Hungary in the last decades, dividing them into five different periods: Hungarian-style Soviet-type socialist health policy (1970–1985); the reform attempts of declining socialism (1985–1990); the

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hesitant reform attempts of the conservative government after the political changes and system reform in health care (1990–1994); restrictive health and social expenditures as part of the constraints of stabilization (1994–1998); and breaking with the past (again – 1998–2002). They go on to identify two features that run like a thread through all the attempts at reform of the sector: excessive politicization and the same degree of inefficiency. Given this, and because they change in rhythm with the governments, the health policies have not contributed to the improvement of health nor to access to health care. The situation has become even worse in the last fifteen years, all the more so in that privatization policies are still far from what might be expected. According to the authors, because the Hungarian system nowadays ignores the actual outcomes and costs of health services and the real needs of the population, “rational policymaking is impossible.” Following a similar interpretation path, but assuming a frontal critical attack on the system, Tony Warn, David Skidmore and Susan McAndrew attempt to show how the successive governments in the United Kingdom, both Labour and Conservative, have been moulding the National Health Service according to their political and ideological preconceptions instead of promoting people’s health. As was the case in Hungary, these authors also affirm that health policies in the United Kingdom change according to cyclical government changes without bringing about any improvement in health policies. In their opinion, “A new convergence is required that will bring together the policy makers and practitioners in an agreed set of intentions. We recommend that real partnerships be developed between those who are charged with delivering the policy and those who are responsible for making policy decisions. This would help to ensure that the healthy rhetoric is translated into a health reality where individuals are enabled and empowered to deliver a meaningful, quality service for all.” This is an idea that is also implicit in the text on Norway by Øivind Larsen. In his historical analysis of the evolution of the welfare state in Norway after its independence from Denmark in 1814, Larsen highlights the role of preventive medicine, especially from the end of the nineteenth century, so that he can then centre his attention on the work of Dr Karl Evang, General Director of Health between 1938 and 1972, and the Evang model. This was a model that after the Second World War created a decentralized primary health service based on a highly structured hierarchy of defined functions and duties, financially supported by the state. This was a model dependent on a single man, reflecting his own choices and convictions but nonetheless having undeniably positive consequences both at the medical practice level as well as at the

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Section 4 – Choices of Welfare Policies and their Consequences: Local and Regional Environmental Health Effects

public health level. In the second part of his text, Larsen suggests that owing to the complex present-day situation and to the new problems that society must face now and will have to face in the future, an approach will be necessary between public health and community medicine, and that the measures to be adopted will have to take into account the political, educational and administrative levels. Ann-Sofie Olander comes to a similar conclusion in her evaluation of the parental role in Swedish families from 1940 up to the present. After a brief report on the transformation of society and the progressive strengthening of women’s position in the labour market, she analyzes the effects of these changes on the development of men’s parental role – which, although it has increased in recent decades, is still generally low – and concludes that shared parental responsibilities will only be entirely effective once they are accompanied by an equal division of the corresponding inherent social costs. From the USA, and from his experience as a policymaker and researcher, Daniel Fox draws attention to the centrality of politics and political culture to the formation of health and social policy. In order to understand this centrality better, the author considers it a priority to study systematically the politics of policy choices as well as the technical content of those policies. In order to contribute to an understanding of the politics of health and social policy, Fox proposes questions on the way policymakers make decisions to help guide research and analysis. At the present time we are witnessing the crisis of the welfare state. With no intention of presenting any solutions to overcome the complex situation we are going through, this session of the conference highlighted two main ideas. The first is that reforming health is not confined to the reform of a country’s national health system, but should entail acting in a structured and continuous way on the whole system in order to make it efficient and rational without the state abdicating its social function. The second is that cross-country studies and interrelated work between policymakers and citizens are absolutely necessary at a time when the healthcare systems of the developed countries seem to be unable to find answers to the needs of their populations.

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A Hard Row to Plough: A Historical Overview of Health Policy Dynamics in Hungary Bence Döbrössy and Péter Molnár (University of Debrecen, Hungary)

Introduction Hungarian health care reform, in progress since the mid-eighties, is characterized by stumbles, contradictions, conscious reforms and spontaneous changes. Experts plan and politicians decide. To its disadvantage, this is a highly politicized issue in Hungary. (In Hungary most issues are highly politicized.) This is unfortunate. It makes continuity in policies and programmes problematic in the four-year cycles of changing governments. Public health programmes, action plans and initiatives are discontinued as soon as a new government comes to power, putting everything on hold while the new administration creates its new version of what is (almost always) the same. As a result, a good number of initiatives planned and evaluated as far back as the mid-nineties are yet to be operationalized because current decision-makers are suspicious of them. They approach with caution (as well as political misgivings regarding their predecessors), which means stopping everything in progress. The change that would have mattered, a switch to rational, evidence-based policy-making has not happened yet. As Gulácsi has written: The Hungarian healthcare system has remained relatively uninformed by developments in recent decades in the area of health economics, health service management, health informatics, environmental health and health promotion. The almost complete negligence of these areas may have had a greater negative impact on the development on the healthcare system than did financial and economic difficulties.1

1

Gulácsi, L. Hungarian Health Care in Transition. Academisch proefrschrift, University of Amsterdam, 2001, p. 39.

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A Hard Row to Plough: A Historical Overview of Health Policy Dynamics in Hungary

Without real changes in perception it is possible to argue that what has happened in Hungary is not a reform but a reshuffling. All this took place at a time when resources were extremely scarce. After the economic stagnation of the eighties, GDP dropped dramatically between 1989 and 1993. The drop was more serious than in the crises of 1929 and 1933. This led to unemployment, polarization and constant political attacks almost from the day after the first democratic elections. Healthcare reform was undertaken while a state debt of 21 billion dollars had to be paid off. This meant of course that less and less money was given to health care. Lack of sufficient capital is still one of the major problems affecting the Hungarian Health Service. Although Hungary’s health system consumes 5.6 percent of the GDP (about $320 per capita, which is not bad), it has been ineffective in promoting good health.2 Hungary’s life expectancy (74 years for women and 65 for men) is among the lowest in industrial countries. By comparison, life expectancy at birth in Western Europe is around 77 years for women and 71 years for men. This worsening trend started around 1960 and is still getting worse. Mortality from cardiovascular disease, nearly the highest in the world, is increasing, particularly for males between 35 and 55. The major causes of death are cardiovascular disease, cancers, chronic respiratory diseases, cirrhosis and suicide. During the past two decades, life expectancy at birth has fallen by 0.9 year for Hungarian males and life expectancy for males at age 30 by 4.2 years. The middle-aged Hungarian male is an “endangered species”. But at the core of this grim reality in Hungary are the high and increasing mortality rates from noncommunicable adult ailments such as heart disease, stroke and cancer. 3 Obviously this terrible epidemiological scenario is not caused by health care, although health care could play a better role in limiting suffering by providing better service. The real causes are in the nature of the social fabric, life experience and living conditions in this part of the world. It is no wonder that since 1960 epidemiologists have been talking about the East-West mortality divide. There is something about living life

2

A good description of these well-known epidemiological facts can be found in “Investing in People, the World Bank in Action”, 2001 at www. Worldbank.org (website of the World Bank Group).

3

http://www.gallup.hu/olef/olef.html contains a lot of recent statistics.

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Bence Döbrössy and Péter Molnár

in the socialist block that causes people to die early and be sick more often.4 Hungary's unfavorable health status can largely be attributed to socio-economic factors such as unhealthy lifestyles, overwork and related stress, and occupational and environmental hazards. The population has a traditionally permissive attitude with respect to the consumption of alcohol and tobacco products and health-promoting life styles (and the structures making this feasible) are not widespread. Healthcare decision-makers and reform-minded politicians of the new Hungarian democracy inherited a hard row to plough from their socialist predecessors in 1990. Three different types of challenges had to be faced simultaneously. First, they had to keep the inefficient and inflated healthcare system that they inherited in operation. You cannot put up an “out of order” sign, shut down a healthcare system for maintenance work and start afresh. Second, the problems inherited from the state socialist system had to be solved or at least tamed. Third, a healthcare system compatible with a democratic market economy had to be established and operationalized.5 Despite the concentrated reform activities of four consecutive governments these problems have still remained. Health care is still underfinanced, real performance unevaluated, doctors and nurses underpaid, quality unassured, and everyone is generally dissatisfied. Many of the debates relevant in 1990 about performance indicators, mode of financing, privatization in health care, the role of compulsory and private insurance and gratitude money are just as relevant today. An expert group of the World Bank Health Project Mission summarized the main problems of the Hungarian healthcare system in 1991 in the following way: Short life expectancy, high infant mortality rates and other indicators of poor health status compared with Western countries is a serious indictment of the low performance of the existing Hungarian health system. There is a considerable disillusionment with the curative services. Entitlement to universal and free health care is meaningless in the face of widespread informal gratitude (payment). The rigid centrally organized National Health Service creates many barriers to access and

4

Bobak, M. and Marmot, M. “East-West Mortality Divide and Its Potential Explanations: Proposed Research Agenda”. BMJ Vol. 312, 17 February 1996, pp. 421–425.

5

See Orosz, Éva, Féluton vagy tévuton [The Alternatives of Health Policy], Egészséges Magyaraországért Alapitvány [Foundation for a Healthy Hungary], Budapest, 2001, for a discussion of this question.

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continuity of care. Health services in Hungary are administered inefficiently without any management in the Western sense of the word and central bureaucratic dictates still leave little latitude for responding to local needs. Despite the extensive network of clinical facilities, which has more beds and doctors per capita than many Western countries, shortages in some critical drugs, equipment and supplies lead to ineffective and low quality services. At the same time, imbalance between different levels of care among different groups of healthcare providers often lead to inappropriate care. Although it is generally recognized that scarce financial resources are wasted by excessive utilization of services, there are few deterrents to such practices other than waiting lists and gratitude (payments).... Controlling expenditure on drugs and imported equipment will be especially important during the liberalization of prices and the present period of high inflation… uncontrolled increases in healthcare sector expenditure would threaten the government’s economic reforms. 6

These observations were made in 1991 but, as many experts agree, they could have been made today. According to a government report prepared in early 2000 for the European Union’s Commission, the major tasks of the healthcare system for the immediate future are to improve public health, to increase the efficiency of financing healthcare providers, and to eliminate regional differences in the quality of services.7 Nothing much has changed. It is not only the persistence of old problems that causes difficulties but the arrival of new ones, too. Many of these problems were caused by the stop-go nature of those reforms that were implemented. Just to illustrate the lack of continuity, in the past eight years we have had six different Ministers of Health. The Ministry itself has been renamed four times in the past ten years. Gulácsi sums up and illustrates the problem of discontinuity as follows: At different stages of the transition of the Hungarian healthcare system various elements and mechanisms were imported from abroad and implemented in the system without adaptation. …Diagnosis Related Group financing mechanisms (475 DRG categories in the beginning) were implemented, for example, to reimburse all hospitals and a rather complicated German point system was introduced for primary health care in Hungary. However, the implementation of these techniques has been

6

World Bank, “Health Project Mission”, 23–31 May 1991. Quoted in Gulácsi, L. Hungarian Health Care in Transition. Academisch proefrschrift, University of Amsterdam, 2001, p. 57.

7

Governmental Report to the European Union Commission, 2000.

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fraught with several contradictions, also implementation of different methods has stopped at different levels of completeness. For example the DRG system has never been introduced in completeness… Market competition, free patient choice, privatization, liberalization of drug imports, various and often changing insurance ideas and licensing were implemented at least partly without a coherent health policy and clearly defined goals. 8

Although the solutions were short-lived and haphazard, the challenges that faced Hungarian health policy in the past fifteen years were in many respects continuous. The characteristic components of this continuity include: • The deteriorating health status of the population • Growing inequalities (regional and social class) in health status and in access to health care • The marginalization and misfinancing of the health sector • Technical backwardness • Reluctance to define and rank priorities and evaluate outcomes so vital for rational policymaking • The significant role played by “into the pocket gratitude payments” to doctors from patients • Lack of rational decision-making in health care The reform experience we are about to discuss is in no way unique to Hungary. Many welfare states with more or less nationalized health services went through or are going through similar processes to some degree. Characteristic of developed societies since the 1960s is the welfare state. The welfare state’s high public expenditure on health, education and well-being was made possible in Europe by the steady economic growth of the period. In this period of expansion the average healthcare expenditure of the OECD countries grew 40 percent faster than the GDP. The growth was due solely to state financing.9 The two main health policy aims were to provide high quality health care to all regardless of the ability to pay for it and to limit inequities in access and regional differences in healthcare provision. In the mid-seventies, as a result of arrested economic growth and other changes in the global economy, the state’s role (and means) in caring and providing for people

8

Gulácsi, L. Hungarian Health Care in Transition. Academisch proefrschrift, University of Amsterdam, 2001, p. 58.

9

Orosz, Éva. Féluton vagy tévuton [The alternatives of Health Policy]. Egészséges Magyaraországért Alapitvány [Foundation for a Healthy Hungary], Budapest, 2001.

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changed. In a period of all-round economic hardship, energy crises and a demographic structure where inactive people slowly began to outweigh active ones, this welfare model of the sixties and early seventies became impossible to finance. The contradictions between welfare (meaning free universal health care, antipoverty strategies, social services) and economic productivity became apparent. In a time of severe economic stringency, traditional welfare-minded health policies had to be reoriented. The major policy change was the emphasis on limiting state expenditure on health care. Not only were governments unable to allocate the resources needed for national health services (in its first two decades the level of spending on the NHS in the UK increased 2.7 times in real terms), it was also realized that putting more money into the health services does not mean better health because “it is dangerous to assume that wellestablished medical therapies are always effective.” 10 As Donald Patrick observes: Politicians of all political parties think it is no longer feasible to continue pumping a greater proportion of resources into the healthcare system without increased accountability. How much money should be spent on health and technology …[is a question] of increasing concern to both the government and the opposition. They seek optimum results in the form of the benefit and the cost to the population of a particular type of health activity.11

Cost control was attempted in a number of ways. Welfare pluralism, the introduction of market forces and privatization was attempted in many countries. It was hoped that the state’s share of healthcare expenditure would decrease through the introduction of privatized health care, private insurers or a system of co-payment. It was hoped that market forces would achieve the optimal allocation. This approach has not lived up to expectations because the segment of the population most in need of health care (the old and the needy) is also the segment the state is obliged to look after in democracies.

10

Quoted in Gabe, J., Calnan, M. and Bury, M. The Sociology of the Health Service. London: Routledge, 1991.

11

Patrick, D. “Accounting for Health Care”. In Patrick, D. and Scrambler, G. (eds.) Sociology as Applied to Medicine. London: Balliere Tindal, 1986, p. 239.

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Managerial power, legal and administrative attempts at cost containment were to some degrees implemented in most countries. Healthcare managers have been given two responsibilities: to control expenditure and improve quality. Evaluation of the effectiveness and efficiency of procedures, technology assessment and productivity-based financing are now seen as the components of rational policy making. Finally, in terms of health promotion and disease prevention, the new public health has received a lot of political attention since the eighties. As Allsop writes, the rising cost of scientific medicine, disillusionment with its ineffectiveness in curing the “diseases of civilization” (predominant among which are cancer and heart disease) and the widespread acceptance that the origins of those diseases are located in social conditions and are preventable through the avoidance of certain behaviours and the modification of the risk- producing social and material environment have led to the realization that the way to achieve health is to prevent disease instead of curing the sick.12 Although the new public health movement has a wide political appeal, ranging from those who see it as an ideal tool to reduce government involvement and public expenditure to those for whom it is a means of reducing the social ills of capitalism, there is considerable disagreement on how to convert these broad ideas into effective public policy. The Hungarian situation is somewhat similar. One of the main driving forces behind the reform attempts is the state’s desire to pull out from public financing. It wants to spend less and less on health care. State expenditure on health care has been steadily dropping since the early nineties. The reform attempts are basically about finding alternative sources of finance and limiting costs. The following five periods of Hungarian health policy can clearly be distinguished: 1. Hungarian-style Soviet-type socialist health policy (1970–1985) 2. The reform attempts of declining socialism (1985–1990) 3. The hesitant reform attempts of the conservative government after the political changes and system reform in health care. (1990–1994)

12

Allsop, J. Health Policy and the National Health Service. London: Longmans, 1984.

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4. 5.

Restrictions on health and social expenditure as part of the constraints related to stabilization (1994–1998) Breaking with the past (again) (1998–2002)

Hungarian-style Soviet-type socialist health policy (1970–1985) In the period between the end of World War II and 1950 less than half of the population was covered by compulsory health insurance. The rural population, the majority of whom were poor agricultural workers, was left uncovered.13 In the early 1950s healthcare provision, together with the rest of the economy, was modelled along Soviet lines. Funds and insurance companies, private practices and other healthcare institutions were either dissolved or taken over by the state. All aspects of market mechanisms (save for the informal and almost illegal gratitude payments slipped into doctors’ pockets) were dissolved. The government became the sole owner and decisionmaker in health care. The state had the responsibility of equipping and financing health care. A National Health Service came into being. Doctors and nurses were salaried state employees and patients received health care free of charge (except for the often considerable gratitude payments) as a citizen’s right. The Ministry of Health was responsible for planning professional standards and coordinating policy. The Ministry of Finance allocated revenues in health care through negotiations with the local councils. Local government bodies provided financial reports accounting for their expenditure. A government body, the Social Insurance Fund, collected employer and employee contributions, a kind of tax that went into the state budget. Health policy was planned in units of five years as part of the overall five-year plans. Anyone aware of the realities of socialism will know that five-year plans in health care were more of a political wish list than a rigid plan. Health care was always the stepchild of a regime that never had enough resources to deal with the real, underlying problems. In the yearly debates on central budget allocation, health care was always deemed as being of lesser importance. And, with the only accepted indicator of healthcare performance being the number of doctors and hospital beds per capita, there was a cheap and ineffective way to be successful (on paper, by their own evaluation): increase the number of doctors and

13

This section is based on Makara, Peter. Four Variations on One Topic – Changes in Hungarian Health Policy. Working paper for the National Institute for Health Promotion, 1997.

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beds until the country had more than in the decadent West. It is safe to say that this over-inflated system was more of a problem than a solution. Around 50 percent of the existing hospital beds were created in the past thirty years, most of them (60 to 70 percent) by means of additional beds being allocated to existing wards without investment in additional infrastructure. Without any real capital investment, the system was diluted. The number of doctors and beds only succeeded in suppressing the capacity of more modern diagnostic machinery. Quantity was all that mattered. There were neither tools nor intentions to evaluate quality.14 Since health care was financed from the central budget it was also in competition for resources with the other branches at the national and local levels. Institutes were financed based on the previous financial year. As a result, there was no real relationship between its activities and the financing of an institution. Development decisions were ad hoc, often the results of informal negotiations. A lot depended on who knew whom. Save for university hospitals and those of the ministries, local councils operated hospitals. Developing healthcare infrastructure was not at the top of the list for most councils. Most municipal and council hospitals were hence much less developed than state and university ones, leading to the system of stratification reinforcing itself. On the one hand non-financial capacities (doctors and beds) constantly increased up until the nineties; on the other, health care was heavily under-financed. This led to a growing gap between the resources available and the resources needed by the system. Without real measures of output and performance, rational healthcare planning was impossible. The Hungarian Communist politicians and health decision-makers found themselves in a tight and uncomfortable situation when the data on the worsening mortality situation became publicly known. The superiority of socialist health care and health services was one of the basic ideological concepts of the system. The drastic improvement that epidemiological figures had shown from the end of the Second World War to the late fifties seemed to support this idea.

14

Ajkay, Zoltan and Kullmann, Lajos. A magyar kórházügy [The Hungarian Hospital Case]. Magyar Kórházszövetség [Hungarian Hospital Association], Budapest, 1995.

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The system of health statistics used by socialist countries in the sixties contained detailed information on successes but data on problems were almost completely lacking. Such statistics allowed health policymakers of the time to pretend that the health situation in Hungary was among the best in the world. Doctors and hospital beds per capita were taken as the sole indicators of the healthcare system and Hungary was at the cutting edge in this respect. Nevertheless, the mortality data could not be made to disappear nor could they be hidden from the health experts. The first strategies of the government in response to this situation included secrecy and an off-hand minimization of trends. They may have hoped that the increase in mortality was only a temporary phenomenon. No real steps were taken to reform healthcare provision or encourage a better public health system, not to mention changing the socio-economic factors that had caused a rise in mortality unprecedented in peacetime. In fact the question of mortality was completely ignored. Faced by the demographic decline in population only the question of natality was raised in public. In the second half of the seventies it became impossible to keep the lid on the problem, which had been apparent for more than a decade. It was no accident that the first conference of the newly formed Hungarian Sociological Association was entitled “Health and Society”. International comparative studies, which saw the light for the first time in the eighties, included East-West differentiated comparative mortality and morbidity studies. The fact that mortality trends were worsening in all of the socialist countries but nowhere else in the industrial world had to be faced. The dramatic decrease of life expectancy in times of peace did not become one of the major glories of communism. Political rhetoric took the form of looking for scapegoats. Relying on a closed mind interpretation of risk factors allowed holding people responsible for their own health. Public health and disease prevention were in a disadvantageous position even within the health sector. The diminishing financial resources, dysfunctional organizational frameworks, inadequate and unsuitable personnel and outdated methods and low status of prevention were in sharp contrast with the population’s deteriorating health status. Reducing the notion of public health to lip service only aggravated the situation. All this induced a deep suspicion of any real initiative in the field of health policy. Traditional public health could not respond to the challenges of the new epidemiological era. The era of reforms had arrived.

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The reform attempts of declining socialism (1985–1990) By the mid- to late eighties the economic problems of state socialism were far too serious to be swept under the rug. The ship was sinking and a last-ditch attempt was made to save the system. The main health related problems were as follows: • the poor health status of the population • the structural efficiency problems of the state healthcare system • the inability to finance this inflated healthcare system • the dual structure of financing (due to the semi-legal systems of gratitude payments), where doctors’ interests were (and indeed still are) very often contrary to official health policy. This is one reason for over-hospitalization, for example. By the mid-eighties it was impossible not to realize that the policy followed so far was incapable of handling the crises of the healthcare system and that this health policy was of no help in the face of the deteriorating health status of the population It was a ruling by the State Planning Committee in 1985 that started the reform process. The ruling stated that the possibility of productivity evaluation, financing through social security and the modernization of financing must be examined. In 1988, the Minister of Health and Welfare established a healthcare reform secretariat. The most important reform of the period was the separation of the health insurance fund from the central budget, the transition to an insurance-based system of healthcare financing and the opening up of healthcare services to privatization and the entrance of the market. The aims of the reform concepts formulated in 1989 were as follows:15 • sustainable, stable financing • the preparation of conditions for a system of public-private ownership • performance-based financing

15

Orosz, Éva. Féluton vagy tévuton [The alternatives of Health Policy]. Egészséges Magyaraországért Alapitvány [Foundation for a Healthy Hungary], Budapest, 2001, p. 66.

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• • • • •

the restructuring of service provisions in favour of primary care and prevention the restructuring the professional systems of control increased autonomy of institutional management an increased role for supplementary insurers a strengthening of patients’ rights

These targets remained the reform aims all the way through the nineties and are still very close to the political manifesto of the current government. As in any situation of economic hardship, the most important question is securing the resources necessary for the operation of the system. (It should be remembered that at the time the country was in recession.) One major step was the governmental decree making private enterprises possible in the health and social fields. Selling off healthcare institutions is still very much at the top of the wish lists of some decision-makers because capital investment in hospitals is the task of the government (via the local authorities today.) Since many hospitals are heavily in debt (some cannot even send out letters because they owe the postal services too much money), the government’s view is that private ownership would solve the problem. Although all Hungarian governments talk about allocating large capital infusions to health care to improve salaries and infrastructure, this has not really happened as yet. The ministerial document of 1989 entitled “Recommendation for the Renewal of Health Care” did not opt conclusively for a social insurance mode of financing. That was still some time away. The goal was clearly stated: a situation where “the resources that may be allocated to health care are not determined by the yearly and mid-yearly fluctuations of the position of the state’s central budget.”16 But the mode of achieving this was not clear as yet. The document went on to state: The professional debates about the possible models to be used are still going on. Based on examinations undertaken so far, there are two possible models: a model basically relying on insurance-based solutions, and a model relying on the local authority. …The choice made must be made within the context of the comprehensive reform process.

16

Ministerial document, “Javaslat az egészségügy megújúlására” [“Recommendation for the Renewal of Health Care”], Budapest, 1989.

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Regarding the insurance model, the recommendation mentioned the following characteristics: “It builds on the centralization of resources. Being contribution-based, it makes possible an increase in resources with an increase in wages. It enforces unified professional standards and financial norms.” In support of a mandatory social insurance system was the consideration that in modified form it was a continuation of the centralized bureaucratic control decision-makers were used to. Also, the performancebased hospital financing methods favoured were more suitable in the centralized system the mandatory insurance had to offer than a decentralized local authority model. In support of the local authority mode of financing was the reform of the system of local governments. This model suited the reform of public administration underway and the growth of the importance of the civil sphere. Breaking with a totalitarian regime, this seemed more politically correct. (Analyzing the role ideology played in the formation of health policy is an exciting topic for another paper!) Typical of the reform process is that the decision made was not the result of a societal discussion process. It was a choice made in the Ministry. Not surprisingly, the Ministry adapted the centralized system of mandatory social insurance. Healthcare provision became a part of the social security system. Instead of taxation it was to be financed from contributions set aside by social security. The National Health Insurance Fund was established to handle the financing. (This fund was designed to handle operating costs only. The owners of the healthcare facilities, which in most cases are the local governments, cover capital expenditures.) Nevertheless, this was the only decision made. Everything else was left undecided. 17 In December 1987 the Hungarian government announced a comprehensive health promotion programme by decree in an attempt to improve the terrible health status of the population through social engineering. The programme, entitled “A Long-Term Societal Programme for Health Promotion”, adapted the WHO “Health for All” strategies. Participants later stated that this adaptation was well meant even if a bit naïve.18

17

Orosz, Éva. Féluton vagy tévuton [The alternatives of Health Policy]. Egészséges Magyaraországért Alapitvány [Foundation for a Healthy Hungary], Budapest, 2001.

18

Makara, Peter. Four Variations on One Topic – Changes in Hungarian Health Policy. Working paper for the National Institute for Health Promotion, 1997.

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The planning and initiation of the programme was made possible by a number of unique circumstances within a regime that was considered soft in Eastern Europe. Although Hungarian epidemiological figures were tragic even for this part of the world, Hungarian decision-makers very quickly made the HFA principles their own. The Ottawa Charter for Health Promotion inspired Hungarian public health policy in this period. (The feasibility of the Ottawa principles is another question. One might put forward the argument that the Ottawa Charter is more abstract philosophy than guidelines for policy making.) The government decree not only accepted the long-term programme but also established the National Council for Health Promotion and the National Health Promotion Fund. Led by the Deputy Prime Minister, the interdisciplinary National Council for Health Promotion set the following eight areas as priorities: • AIDS • Tobacco or health • Drug abuse • Alcohol abuse • Hypertension prevention • Mental health • Mass media • Accident prevention Specific action programmes that were planned between 1988–1990 addressed these priority areas. The National Institute for Health Promotion was set up to coordinate activities. Some programmes, mostly in the area of AIDS and hypertension, had quantifiable positive results. The programme was also a success in as far it drew attention to prevention and cost effectiveness in primary care as opposed to hospitals. There were, however, signs of difficulty, only some of which were linked to the political system. The programme lacked legitimacy. There was no real political dedication behind it. The centralized political and social structure did not help either, because it was against local, autonomous communities. The medical profession and the majority of other health professionals were hostile to health promotion. It could not step over the boundaries of traditional health services. The programme failed to implement actions that would serve the population’s health status in a direct and obvious way. Hence popular support was not secured. In the absence of a comprehensive system of societal policy objectives and the means to

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achieve them, the programme lacked real support. Initiating social and economic changes that could really have counted was beyond the power of the programme’s initiators. Even within the Ministry of Health and Welfare no real efforts were made to harmonize prevention and welfare policy. Trapped by the contradiction of the targets and the real possibilities of achieving them, the programme was not taken seriously and was increasingly pushed back within the boundaries of the traditional healthcare sector. Despite some positive grassroots initiatives at the local level, no nationwide movement to promote health emerged. The programme failed to identify key players and interests in health. The program also lacked sufficient resources to induce the desired effects. There was neither real programme planning nor management at the appropriate levels. Targets, strategies, methods and organizational requirements were not determined. Financial, personnel and organizational resources were hopelessly scarce and the plans were over-ambitious. Complete subjectivity flourished, which hindered implementation. The committee took comfort from the idea that whatever was achieved was good because it was better than nothing, but this is not always the case. Partly initiated programmes often lost popular support. The implementation of the program would have coincided with the political changes. During the turmoil of the changes this programme held no interest for people and it became marginalized.

The hesitant reform attempts of the conservative government after the political changes (1990–1994) Health policymakers of this period were rather hesitant and unsure. Reform concepts and policies were formulated and discarded frequently. They were up against strong public and professional expectations and fears. When evaluating the reform activities of this government we must remember the financial and structural mess they inherited and the conflicts they had to face. The reforms mentioned below all took place in an era of severe economic recession. We must also remember that the government was under political attack from day one. It had to act in an extremely hostile environment.

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In the period of the first freely elected government the question of financing healthcare provision, privatization and modes of insurance marginalized the question of public health policy.19 Health policy focused on these elements of healthcare reform in a clear crisis management approach. It is not easy to detect long-term rational planning in the policies made. The 1991 “Action Programme” of the government was a compromise between the old and the new. There was change but continuity was more evident. The creation of a controlled “internal market” was the main aim of this programme. This concept is a mix of social and market aspects. On the one hand the equity of access to health care had to be guaranteed as before. Adequate care had to be assured for even the poorest citizen. So there was no market in the consumption of services. (There was talk about creating a top market with luxury services for those rich enough to pay for it.) On the other hand, market forces appeared as incentives in the provision sphere, where different service providers might in theory compete with each other. This was also supposed to ensure quality in the tradition of the Adam Smith way of thinking. After the political reforms, the legislation, financing and regulation of the healthcare system changed in accordance with these principles. By 1992 the former civil-right-tohealth-care approach was replaced by mandatory insurance. One way or another, every citizen is somehow insured in this contribution-based state-run form of dealing with health insurance (through working family members or as part of welfare packages to pensioners, the unemployed, the poor etc.). Its solidarity-based nature is the main reason this sort of financing was chosen. Although a wide range of alternatives was debated, this was the only politically feasible one. Employees and employers pay contributions to the National Health Insurance Administration, which is under the control of the Ministry of Finance and the Ministry of Health (it was independent of direct ministerial control through most of the nineties; centralization was only reintroduced in 2000). In effect, this is a kind of tax and has not got much to do with insurance. As will be discussed below, this change is far from an

19

See for example Kincses, G., Drága egészségünk (Az egészségügy gazdasági összefüggései) [Our Expensive Health. The Economic Aspects of Health]. Praxis Server Kft, Budapest, 1994.

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optimal one. It has not solved under-financing, gratitude money or the burden on the state. The number of those who pay contributions has been declining (the working population) and the number of those in need of social support (the elderly, the unemployed and the ill) is steadily increasing. The annual deficits of the Fund are usually huge and covered by the state. Depreciation and other capital expenditures in the hospital sector are also for the state and the local authorities to pay. This is not covered by the Fund. (We can talk about first-, second- and third-class hospitals, depending on ownership. Most of the population is covered by third-class hospitals in rural areas.) So the insurance system has not really improved the eoverall situation that much. The National Health Insurance Administration, created in 1989, remained a centralized institute under the direct control of the Ministry of Welfare. In 1992 the Health Insurance Fund and the Pension Fund were separated. There were strong moves to decentralize this fund and in 1993 the Self-Government of Social Insurance was formed. The relationship of the Ministries of Health and Finance and the Fund is still unregulated, causing numerous problems in practice. The reform is far from finished. Since 1993 the market has been open for voluntary mutual health insurance, but this does not figure strongly in healthcare provision. The financing mechanisms of hospitals changed from receiving finances from the central budget based on the previous year to a performance-based modified Diagnosis Related Group system In 1993 hospitals were first reimbursed on the basis of this new system. Deviations in budget were compensated for according to the previous budget to avoid hospitals having to face large deviations from their customary turnover. Today, these corrections are still being made. As Kroneman and Zee pointed out in 1997, “The proposed gradual adaptation in practice is yet to start; budgets are still based on a historical budget. There also appear to be control problems; there is no check between a patient’s actual illness and the declared illness. Hospitals are therefore motivated to present the illness as seriously as possible.”20 This new prospective payment system established reimbursement rates for 440 diagnosis-related groups. These rates were developed from the historical global budget

20

Kroneman, M. and Zee, J. “Health Policy as a Fuzzy Concept”. Health Policy 40:2 (1997), pp. 139–155.

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of the hospital. The DRG system classifies patients according to principle diagnosis, the principle intervention undertaken, complications and/or comorbidity. This new system has not solved the problem. Twenty-one out of the 166 formerly state-owned hospitals have had serious financial deficits, three have gone bankrupt and the rest have struggled to stay solvent. In the real world of Hungarian hospital practices, problems arose as soon as DRGs were implemented. “DRG creep” – cheating with reporting – appeared. Two systems of administration appeared in Hungarian hospitals. There is an unofficial one for medical purposes for inside use only and one for reporting to the National Health Insurance Administration. Because of the perverse financial incentives induced by the DRG financing mechanism. the volume of different services increased dramatically. The incentive to increase output artificially is significant. This clearly leads to overtreatment and over-hospitalization. All births are complicated in Hungary. There are no simple appendectomies. We may state, somewhat cynically, that the system has created new problems for financing without solving the old ones.21 Hospital doctors are salaried employers. The reforms were more significant concerning GPs, renamed “family doctors” after the Family Physician Service was created in 1992. The majority of family physicians became private entrepreneurs and are financed through a modified German point system. People are free to choose their family doctors, who are reimbursed based on the number of people in their practice. There is a very strong referral system in Hungary, so family doctors are in a strong market position. To sum up, the period of 1989–1994 saw a major macro-structural change of the healthcare system; this was the period when the main features of our present system took shape. These characteristics include private family physician practices, centralized mandatory social- security-based financing, performance-linked financing and the existence of private and public ownership. An examination of the system in operation reveals that the reform was sadly limited to restructuring the processes of financing. This restructuring had less positive effects

21

See Gulácsi, L., “A Medicare Prospective Payment System ismertetése” [“Lesson for Others. The Prospective System Payment in Hungary”]. Népjóléti Szemle [Public Health Review] 11, 1993, pp. 3–18.

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than hoped for and much more negative effects than expected. The other reform aims often mentioned in policy papers such as a system of quality assurance, evidence-based medicine and a management structure did not receive any real attention. Privatization is still an open question. It has figured very strongly in political wishful thinking since 1989 and it is still seen by many as a cure-all. Since many hospitals are really run-down and heavily in debt but still in need of improvements, the government and the local authorities would like to sell them off as fast as possible. Various governments often promise large capital infusions to improve salaries and infrastructure but economic realities do not really allow for this. The situation is hard to resolve because the capital influx of privatization is needed but many are afraid of letting profit motives come into play. Since neither health nor health care was among the major political issues of the day, real reforms did not receive sufficient resources. Some public health reforms were also initiated in this period. The health-promotion attempts of the socialist reformers had a boomerang effect here. Because the Ottawa Charter-based “Long Term Societal Programme of Health Promotion” was created in 1987, it had socialist connotations, so the new conservative government opted for the more traditional public health approach. As Makara notes cynically, “Idealizing the public health system of the thirties.., the centralizing logic of crisis management, bureaucratic reflexes and mistrust of the local authorities led to the formation of the National Public Health Centre and Medical Officer Service (NPHCMOS) in April 1991. The Service was to guide and supervise epidemiology and health protective activities.”22 NPHCMOS was created as a state agency (with national, county and city level agencies) to assume the responsibility of the government in the field of health promotion, disease prevention, epidemiology, infectious disease control hygiene, environmental and occupational safety and the quality of medical care.23 Its tasks include: • continuous monitoring of the health status of the population and the effect physical, chemical, biological and psychosocial phenomena have on it in the natural,

22

Makara, Peter. Four Variations on One Topic – Changes in Hungarian Health Policy. Working paper for the National Institute for Health Promotion, 1997, p. 6.

23

For a good summary, see the homepage of the site at http//www.antszbar.hu.

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• • •

•

residential, workplace and social environments; this includes food hygiene, environmental health, occupational health and radiation provision of a scientific basis for public health standards and criteria for the prevention of environmental hazards and damage to health inspection and enforcement of hygienic and epidemic requirements and supervision of the effectiveness of such requirements direction, coordination and participation in the implementation of tasks and programmes for the prevention of diseases widely affecting the population as well as shaping people’s attitudes with regard to health promotion health administration and coordination

This is performed in 114 town and 22 district institutes, 19 county and one capitalcity institute and at the national level by the Office of the Chief Medical Officer. The NPHCMOS has not fulfilled the expectations attached to it. This is partly because of the outdated infectious disease orientation it has. It could not provide its own social engineering approach characterized by the new public health needed to fight the disease of civilization. In order to produce results, a more modern orientation must be achieved. Most experts agree that a major renewal of the service will be needed in order for it to be more efficient. A shift towards a modern notion of health promotion is needed. In the major policy document of the new government, the 1991 “Program of National Renewal”, health promotion received but a brief mention. But this government, just like all the others, had its own long-term health promotion programme.24 This document, written by Dr Pál Kertai, the Chief Medical Officer, was entitled “The Principles of Long-term Health Promotion Policy in Hungary” and came out in 1994, only weeks before the government was voted out of office. This offered an action plan until the year 2000 with twenty useful prevention programmes but lacked parliamentary legitimacy. Also, it was mostly an action guide to the NPHCMOS, not a wide-scale health promotion strategy. The five national targets and ten national goals are quite well-meaning but not much was achieved – the next government ignored it – even

24

See Gyárfás, Iván, “Egy kormányhatározat előzményei, megvalósulása és tanulságai” [“Preconditions, Realization and Lessons of a Governmental Decree”], in Népegészségügy [Public Health] 81:5, 2000, pp. 38-45.

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though there were some successes. For example, the Debrecen School of Public Health offers state-of-the-art training, adequate health-related data is collected, and public awareness is better than before. This programme is no less professional in many respects than the ones that came later. Despite criticism (both political and professional), Hungary’s healthcare system was more or less formed by this time. What followed were only modifications.

Restrictions on health and social expenditure as part of the constraints related to stabilization (1994–1998) The “Coalition Agreement” of the Socialist-Liberal government elected in 1994 stated that “real reform is needed in health care. For this reason we are establishing new structural frameworks and decision-making mechanisms that will serve health policy consensus and harmonization of interests. Decentralization of health insurance and control is of special importance.”25 The Modernization Programme of the new Socialist-Liberal government contained large sweeping general reform conceptualizations. It promised an inter-sectorial health policy to improve the population’s health status. A new decision-making mechanism for consensus- situated health policy in the form of a National Health Care Council and its regional equivalents was planned. The government intended to reform the provision sector and increase institutional autonomy. Increasing the rights of patients was also at the top of the agenda. This was the promise. The reality was different. The main characteristic of this government was its severe limitation of public expenditures. Centred on the 1995 Economic Stabilization Package, health and welfare expenditure was severely restricted. All sorts of social benefits were abandoned. Tuition fees were introduced in higher education, free dental care abolished, unemployment benefits severely limited, child benefits scratched. It is safe to say that such extreme anti-welfare measures were in no way health-promoting or conducive to good health. Resources allocated for health care were 20 percent lower (in real terms) than previously. No general reform took place in this framework of drastic cuts in resources. What this administration did was to attempt

25

Koaliciós megálapodás [Coalition Agreement], 1994. This was a policy paper of the newly elected coalition

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the management of the deficit of the Health Insurance Fund and the hospitals through administrative means like eliminating hospital beds and limiting capacity. These measures were so severe that when the stabilization package was initiated Dr Pál Kovács, the Minister of Welfare, resigned saying it was cynical to talk about welfare in such circumstances. The government attempted to contain hospital expenditure by closing down hospitals, reduce hospital beds and cut specialist working hours administratively through directives. In 1996 the capacity reducing efforts of the government were made into law. The law entitled “On the requirements and financing norms of healthcare provision” regulated how much the County Health Insurance Funds could cover. The capacity law was based on a rather complex calculation on the extent by which hospital beds must be limited in a county.26 The hospital bed closing efforts met with large-scale and fierce public dissatisfaction, especially in cases where whole hospitals were to be shut down. In most cases, in fact, the government had to back off in view of the popular uproar. In addition, using administrative methods instead of financial incentives was a step back. It was against the spirit of reforms undertaken up to that point. Everywhere in the Western world hospital capacity has been greatly reduced in the past decades. But the way it was done was not through shutting down beds administratively but through offering alternatives to hospital stays. These were technological improvements, the spread of home care, the incentives for one-day surgery, more modern interventions needing shorter hospital stays and the better use of outpatient clinics. Furthermore, in performance-based financing, limiting capacity does not necessarily save resources. Fewer beds can produce the same performance costs, too. All this law achieved was to weaken the position of the insurance fund by intervening through legislation. What of the other reforms planned? Basically what we saw was a continuation of the hesitation of the previous administration. The planned decentralization did not really happen. The autonomy of the local health authorities was enhanced on paper only. In practice control stayed centralized. The enormous need for external capital laid the

26

For a criticism of this law, see Pulay, Gyula “Gondolatok az Egészségügy Jövöjéről” [“Thoughts about the Future of Health Care”], Magyar Nemzet [a political daily newspaper], 2 July 2001, p. 6.

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ground for the support of privatization. The government created the conditions for private enterprises to receive reimbursement from the Health Insurance Fund. The need for capital was so great that the government risked having money leave the system. By the mid-nineties it was not only hotel services (laundry, catering, etc..) that hospitals contracted out to private entrepreneurs (usually the same people who had been doing it before): diagnostic and treatment services also went to private limited companies. This mixed ownership often makes decision-making and management hard. A major achievement of this period was the Health Care Law of 1997. Certain parts of this law will have far-reaching consequences. For example “The Rights of Patients” is a very comprehensive piece of legislation satisfying ethical expectations to the maximum. This government, just like the previous one, passed a law on health promotion and public health shortly before leaving office. The National Health Promotion Programme makes improving the population’s health a governmental responsibility. (This was the same government that had abolished most social benefits.) The National Health Care Council, an inter-ministerial, inter-sectorial body, was called into being for consensus-building. The efforts of the council were far from farreaching. There were meetings of experts but these did not really influence policymaking. The structure of healthcare provision is also set down in this law. This is the first healthcare law since 1972 so it is an important achievement. There were attempts that spanned all three governmental cycles of the nineties. One such reform effort was the World Bank-financed Health Services and Management Project. The project, initiated in 1993, was, in the words of a World Bank document designed to support the Hungarian government in restructuring the health system to focus more on cost-effective, strategic investments in public health, selected clinical services, and reforms in health services management. The Close the Gap Programme and other public health interventions have been designed to keep the health of Hungarians at the forefront of national and local debates until behavior and lifestyles change for the better. More than $30 million of the funding for the World Banksupported Health Services and Management Project is devoted to public health activities. Of this amount, $20 million has been earmarked, under the Close the Gap

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Programme, to support competitively selected projects intended to bring average longevity of life in Hungary into line with that in the rest of Europe.27

The Close the Gap programme had a number of sub-component programmes (among others school health promotion, regional health development, community development and provider-initiated screening). These programmes were “experiments”. Hungarian expert groups worked on these projects from 1993 until 1999, in most cases with foreign help and supervision. Some projects were feasible, others not. Only the School of Public Health and the secondary prevention program were adapted; the rest were thrown out by the Hungarian government. The provider-initiated mammographyscreening program is still on hold. Think of the lives just this programme could have saved if it had been put into operation in time.

Breaking with the past (again) (1998–2002) This most recent period is the hardest to evaluate. The period is too close in time for an objective judgement to be made. Most analysts are biased either in favour of or against it. In 1998 the major question was whether this government was capable of making the best of a relatively favorable economic situation and of concentrating on real reforms or whether it should continue with the crisis-management style of the previous administrations. For the first time there were resources at the disposal of the government for healthcare reform.28 The new government started energetically by cancelling a number of initiatives and acts of the previous government. The capacity law was cancelled, the regional modernization programme and most other World Bank programmes were forgotten. The modernization of X-rays that was in progress was suspended immediately. Health promotion initiatives were discontinued and started afresh just like four years before.

27

“Investing in People, the World Bank in Action”, 2001 at http://www. Worldbankorg (website of the World Bank Group).

28

http://www.konzilium.hu/szakpol/ is a site containing many of the primary documents of this era.

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As far as the health of the population is concerned, the reestablishing of social welfare benefits was a positive step. Families with children receive a considerable monthly benefit now and dental care is free.29 In order to freeze pharmaceutical prices the government used its power to intervene in the pricing policy. Using its right of intervention, the government acted in favor of consumers and against the multi-national pharmaceutical giants. Centralization and rigidity of control were strengthened. First, in 1998 the local level administration of the Health Insurance Fund was suspended. Then in 2001 the Fund, independent since 1992, was brought under direct ministerial control. The reason given was to better manage the huge deficit. Until 1998 contributions were collected by the Fund. Now the National Tax Authority collects them. Privatization was at the top of the political agenda in order to obtain the capital needed. (Although a large sum was also promised from the central budget to manage the crisis, this was never realized.) Private hospitals are still extremely rare. What is more common is so-called “endo-privatization”. Hospital departments and services are privatized, receiving a fixed proportion of the hospital’s budget. Quality improvement was the expected outcome. As yet it is very hard to evaluate this phenomenon. There are some scandals but reports of success, too. The need for capital influx was great. The answer was seen in privatization and the introduction of market forces. For this reason, somewhat persuasive financial incentives were given to family practitioners to privatize their practices. But it is already evident that the removal of centralized control over healthcare provision and unregulated competition has already led to significant market failure, resulting in a haphazard pattern in investment in some areas with much waste, while basic needs cannot be met in other areas. Privatization is not an adequate substitute for rational planning and decision-making. To sum up, no real reforms took place; there were numerous proposals regarding insurance structure and outpatient and hospital privatization As we have seen, the rhetoric of health policy in the nineties was strictly quality-oriented, while practice was all about restructuring the mode of financing. There was talk about having various

29

http://www.eum.hu/politika/eu_politika.html contains descriptions of this period.

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insurance companies compete with each other. The allocation of major resources was promised to satisfy the capital needs of health care. Nothing. Salaries in health care are still shamefully low. The medical infrastructure is just as far from being satisfactory as it was in 1987. As usual, the last year of the government’s life saw the publication of yet another comprehensive state-of-the-art public health programme, rushed through Parliament in order to be in tine for the election campaign. And, as had been the case four times previously, next to nothing came of it. The new government, in office since May 2002, has already started working on its own programme. In conclusion, we may say that despite all the tentative efforts of the last fifteen or so years the same problems still exist. The health status of the population is worse than ever. Improving the effectiveness and efficiency of the service is still a dream. The outcomes and costs remain uncalculated. The system is not responding to the needs of the population because they have not been adequately calculated either. The consequences of reforms are not really predictable. With so many unknowns, rational policymaking is impossible. Healthcare resources are possibly being misused and misallocated. The current system of performance-based financing is creating an incentive for institutions to report unreliable data. The system is rigid; politicians are only capable of crisis management. Maybe in the next four years?

Chronology of reform measures in health care 1987 1989 1990

1991 1992

Long-term Societal Program of Health Promotion is announced Reform secretariat is set up Legalization of private enterprises in health care Transfer of healthcare institutions run by the councils to local authorities The National Public Health Centre and Medical Officer Service established Ministry of Welfare and Health Renamed Ministry of Welfare Funding through compulsory insurance under the social insurance board National Renewal Programme announced Ministry of Welfare issues its Action Programme Resolution on future development of health insurance adopted by Parliament Separation of Health Insurance Fund and Pension Fund

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1993

1994

1995 1996 1997 1998

2000 2001 2002

Parliament eliminates universal eligibility to health care and introduces mandatory insurance Introduction of Family Doctor System with capitation-based financing Local administration of Health Insurance Fund The creation of Voluntary Mutual Health Insurance (supplementary private insurance) authorized. DRG financing in hospitals and fees for service in outpatient care remuneration Act of Hungarian Medical Chamber ethical norms and procedures and general rules of conduct between doctors and health insurance. The government adapts new National Health Promotion Strategy. New elections – a new government Governmental efforts to limit hospital capacity Economic Stabilization Package erases many welfare acts and benefits Capacity Law passed by Parliament Parliament accepts the new Health Care Law New election – a new government Abolition of the Capacity Law Re-establishment of most welfare services and expenditures Abolition of the local administration of the Health Insurance Fund New, more liberal law on practice privatization Centralization of Health Insurance Fund by bringing it under the direct control of the Minister New public health programme passed in Parliament New election

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The NHS Plan: A Healthy Rhetoric, But So Far an Unhealthy Reality Tony Warne (Manchester Metropolitan University, United Kingdom) David Skidmore (Manchester Metropolitan University, United Kingdom) Susan McAndrew (University of Leeds, United Kingdom)

Introduction Public sector services in the United Kingdom have been shaped by a series of policy shifts: • In the 1970s and early 1990s: the so-called era of Thatcherism and the adoption of free market approaches • In 1997, the New Labour government’s so-called Third Way and the current mixed economy of health care (Warne, 1999) Whilst the ideological underpinnings of these policies are different, it can be argued that there is a convergence of policy intent, reflected by the continued cannibalization of private sector approaches to public sector organizational management (Shifrin, 2002). This process of “policy shift and convergence” is not just a UK phenomenon. In the context of current UK health and social policy, this “policy shift and convergence” is illustrated by The NHS Plan, heralded as an overarching blueprint for the modernization of the UK health care system (DoH, 2000). The NHS Plan aims to close the gap between policy objectives and practice realities. This paper examines the impact of a number of overlaying policy initiatives, which, we argue, reveal that lessons from the past have not been learnt.

50 years of the NHS and the enactment of UK health policy In the UK, the fundamental principles underpinning the creation of the NHS have largely remained unchanged. However, since its creation in 1948 the organization,

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Tony Warne, David Skidmore, Susan McAndrew

management and manner of service delivery have been subject to much change. Many of these changes have been driven not by a desire to promote “health” as a “social good”, thus enabling the individual to function within society, but for economic reasons (Warne, 1999). For example: • The introduction of market approaches in the 1990s and the development of the Private Finance Initiative (PFI) • The New Labour Party launched a programme of modernization again changing the structure and organization of the NHS. One of the first policy statements published in response to this crisis was The New NHS: Modern, Dependable (DoH, 1997). This document set out an analysis of past failures, a possible future NHS and a number of structural changes intended to realize this future. It was also the first step in translating the emerging “Third Way” doctrine into practice and was largely concerned with setting in motion the modernization of public services in general and healthcare services in particular. Thus a brave new world was promised that would ensure that the founding principles of the NHS remained unchanged, but where a modern, patient-centred system would enhance these principles by quickening the drive to provide faster, fairer and more effective health and social care services. The emphasis on service delivery is underpinned by an apparent governmental desire to develop the concept of active citizens empowered and emboldened to make informed decisions about lifestyle choices, social duty and responsibilities and expectations of a new or restructured welfare state. Some three years later, these changes in policy aims were polarized and embodied in the publication of The NHS Plan (DoH, 2000) in order to illustrate the extent of the changes in the values, resources and culture of the NHS that had been achieved or were to be achieved. The need for such “ontological security” becomes apparent when these strategic documents are viewed from three interrelated perspectives. • A conspiracy theorist view • A myth and magic theorist view • A reality theorist view We argue that these perspectives begin to expand the somewhat reductionist view of the “shift and convergence” in the potential policy outcomes but also note that Labour’s third way does not transcend the Old Left and New Right, and that between these two ideological positions there might be room for more than one third way with varying values and policy aims. However, we also caution that there are a number of important

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The NHS Plan: A Healthy Rhetoric, But So Far an Unhealthy Reality

factors that underpin these changes but that are not readily evident. Equally, what is possibly not so transparent is the pernicious impact of how changes in DoH policy affect everybody, both at a personal and at a professional level, for example: • Since the publication of The New NHS: Modern, Dependable a plethora of publications in the form of White Papers as well as official guidance have served to illustrate the shift of responsibilities of professionals, patients and politicians and reinforce the “active citizen” policy strand. • There has been an explicit reaffirmation of the importance of “community” in realising these strategies (Skidmore 1998). • A Foucauldian concept of “governmentality” is used, which attempts to make individuals take responsibility for themselves but allows the government to “control at distance”. • There has been a continuous countervailing process of boundary setting, which has resulted in changes to the autonomy of professionals, leading to a continued refinement of what is understood, sociologically, by the processes of professionalism. • A National Institute for Clinical Excellence (NICE) has been established to ensure that all healthcare interventions are research and evidence based and rely less on individual clinical judgement (the cornerstone of medical practice, Freidson, 1970). • Higher numbers of overseas staff being employed have created tensions around the government’s ethical foreign policy objectives. • Longer term, the emergence of the proposed “generic health care worker” driven largely by economic factors (Whittaker et al. 2000) brings the spectre of a “core and periphery workforce” closer. • There is evidence that the whole culture of nursing has shifted from a hands-on approach, where senior nurses knew their patients, to a notice-board approach, where nurses refer to written information to account for the progress of their patients. • There is also a countervailing pressure to this, which comes from a recognition of the rise of consumerism in health care, aided by developments in and improved access to new technologies, where patients, carers and users are given greater opportunities to participate in all aspects of care – to become equal partners with professionals in determining what, how and where healthcare interventions are to be provided.

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•

There has been the development of Clinical Governance, a new statuary responsibility for all healthcare organizations, which also includes greater involvement of service users in all aspects of the planning, delivery and evaluation of healthcare services (DoH, 1999).

Thus, a new tripartite relationship has been promulgated that is set against a range of structural and process changes. The emphasis on service development and delivery is built upon a strategic shift from secondary services (typically the acute hospitals) towards a more primary health care driven orientation (through the compulsory corralling of GP practices) first as Primary Care Groups (PCGs) (Warne, 1999) and currently as Primary Care Trusts (PCTs). These PCTs are the cornerstone of the modernization agenda. PCTs are able to bring together community services, social service and primary healthcare services into one organization. By 2004, these PCTs will be responsible for 75 percent of all commissioning of healthcare services. Despite this healthy rhetoric, Davies (2002) notes that two years into The NHS Plan implementation, the focus remains on secondary care, largely driven by the performance management of national targets such as waiting times. This creates two further tensions for PCTs: • Responding to secondary-care-based targets results in primary-care issues being sidelined. • Commissioning for health need rather than for traditional patterns of service provision has led to concerns that the current level of expertise at PCT level is unequal to the change agenda facing them (Walshe and Smith, 2001). Thus, whilst The New NHS promised a modernized NHS, achieving this is proving to be not without its difficulties. The consequence of these difficulties, we argue, is that the healthy rhetoric of The New NHS has been translated into an unhealthy reality for practitioners, patients and managers as they attempt to work towards achieving the policy aims and objectives.

Translation points All healthcare professionals and managers working in the NHS will be aware of The NHS Plan. Indeed, The NHS Plan was said to be backed by a national alliance of health and social care professional bodies and patient groups and was developed partly in response to a national public consultation exercise. Whilst some groups may have come to regret their earlier endorsement of the plan, Higgins (2002) notes that there is still

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widespread support for the principles underpinning the plan. Set out as a 10-year blueprint, The NHS Plan promised unprecedented investments, a shift in the balance of power to primary health care, comprehensive quality systems, a drive towards managed continuing professional development and improved opportunities for public involvement. The devil, however, is in the detail, and despite the healthy rhetoric of these aims, a series of overarching and centrally driven caveats were also described that have the potential for creating further tensions. For example: •

Chapter Four of Delivering the NHS Plan (DoH, 2002) describes a system of “payment by results” and “incentives for performance”, a mantra similar to Thatcher’s “the money follows the patient” (Shifrin, 2002). Whilst Delivering the NHS Plan does not actually say “the money follows the patient”, preferring “moving resources with patients”, this represents a very close interpretation.

The cyclical nature of these changes, as illustrated by the change in language, if not intent, seen in the example above, can also be found in the structural changes that both political parties have imposed upon a long-suffering NHS workforce. These changes appear to be based upon two erroneous assumptions • That it is possible to easily reduce the negative impacts of parochialism and that localities will be willing to share resources, even where this means the loss of a local district hospital. • That the structure of an organization defines its function and that by imposing yet another structure, improvements in terms of organizational management, higher quality and economic efficiency will naturally follow. These assumptions belie the human nature of interpersonal relationships, whether in small groups or across large organizations and communities. Partnership and more collaborative work practices cannot be imposed or legislated for (Marris, 1976; Warne, 1999). However, as Stark et al. (2000) note, it is human nature to seek security and certainty, particularly in times of uncertainty, mistrust and turbulence. Simply recreating organizations with clearly delineated structures is unlikely to promote a sense of security in the long term, leading to another tension, that of a powerful prevailing habitus. We argue that a reliance on target setting, national standards and league tables (part of the naming and shaming approach spawned by the insidious development of an audit culture) paradoxically increases perceptions of uncertainty and turbulence. The consequence is often an increase in “paper chase” activities as organizations strive to

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amass information for evidential and explanatory purposes (the vicious circle) rather than for proactive and creative purposes (the virtuous circle).

A healthy rhetoric, an unhealthy reality Market approaches, explicitly and implicitly utilized by both the “reformers” and the “modernizers”, have underpinned both policy and practice changes. However, this approach has been tempered through the countervailing processes of high levels of governmental intervention. It has been argued that the internal market failed because it was internal (Shifrin, 2002). However, the heavily disguised but nevertheless external market approach outlined in The NHS Plan is as likely to fail because its external and pricing mechanisms have not yet been adequately formulated. Added to this situation is the fact that both Conservative and New Labour policy shifts appear to have been built upon the cannibalization of private sector approaches to organizational management. Evidence-based health care is the new panacea not just in terms of clinical services per se, but also in organizational and economic terms. Such an approach is unlikely to result in the “blame free”, “empowering” and “enabling” culture aspired to in the policy documents. Clinicians and managers are reported to be feeling “overwhelmed” with the “top-down” approach, in which national initiatives distort local priorities (Lakhani (2001). We argue that the UK is witnessing the rise of “calibrated” organization, where the rhetoric sees individuals as empowered and enabled to constantly increase the quality of the care they are able to provide, and where organizations can acquire greater freedoms from governmental interventions. The reality, however, is that the 300 explicit targets contained in The New NHS and The NHS Plan alone serve more to constrain than promote freedoms for practitioners and managers. Thus outcome-driven organizations (where the empowered are able to re-engineer the future) are replaced by capacity-driven organizations (where the oppressed are asked to give an account or explanation of their failings). The response by many chief executives to the publication of Shifting the Balance of Power in the NHS: Securing Delivery (DoH, 2001b), which set out the timetable for PCG conversion to PCT, abolishing the NHS Executive’s Regional Offices and the replacement of the 95 Health Authorities with 28 larger Strategic Health Authorities, was very negative (Walshe and Smith, 2001), confirming that trying to achieve The NHS Plan targets in the midst of extreme structural and organizational change, combined with performance management pressures and the entire modernization agenda, may be too much for most healthcare organizations to cope with.

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The ability of individuals and organizations to cope with these competing demands gives rise to economy of performance – ecology of practice tensions (Stark et al, 2000). In this context the notion of an economy of performance refers to the sorts of mainly quantitative indices that determine effective or ineffective performance. They are the indices of accountability familiar in the wider contexts of markets, league tables and star-rating systems. This idea results in the reduction of professional work to that which can, but not necessarily that which should, be measured in an appeal for greater transparency and accountability. Tsoukas (1997) notes that such approaches create imbalance and separation in a self-balancing world. Ecology of practice, on the other hand, refers to those more voluntaristic aspects of practice that express the choices and affiliations that professionals make individually and collectively. Stark et al. (2000) argue that the boundaries between the economy of performance and the ecology of practice are relatively open. Tension arises as these two registers are called upon in embracing or resisting change, particularly where such changes are imposed from the outside in, rather than originating from the inside out. These tensions can be seen at the macro, meso and micro levels of policy and practice. The policy exhortations appear based upon the notion that it is possible to “create” a culture for change. Improvements in quality and economic efficiency and effectiveness are to be achieved using an “outside-in” approach based upon performance management and control, measuring and monitoring a plethora of targets, rather than the “inside-out” approach more typically seen in the development of professions. The major protagonists involved in implementing The NHS Plan, doctors and managers, often occupy different paradigms, reducing the chance of a shared culture emerging: the art of management does not always sit easily with the science of medicine.

Conclusions Public-sector services in the UK have and continue to be shaped by a convergence of policy intent that transcends political ideologies. In the context of current UK health and social policy, this policy “convergence” is illustrated by The NHS Plan, heralded as an overarching blueprint for the modernization of the UK health care system that aims at closing the gap between policy objectives and practice realties. However, exploring a number of overlaying policy initiatives reveals that lessons from the past have not been learnt. An analysis of the emerging brave new world shows a schism between policy aspirations and pragmatic practice responses where a healthy

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policy rhetoric is established but where the translations to practice have resulted in a largely failing, perverse and unhealthy reality being experienced by patients, managers, practitioners and policy makers alike. A new convergence is required that will bring together the policy makers and practitioners in an agreed set of intentions. We recommend that real partnerships be developed between those who are charged with delivering the policy and those who are responsible for making policy decisions. This would help to ensure that the healthy rhetoric is translated into a health reality where individuals are enabled and empowered to deliver a meaningful, quality service for all.

References Baker, M. Making Sense of the NHS White Papers (2nd ed. – 2000) Oxford: Radcliffe Medical Press. Barnett, N. (2002) “Including Ourselves: New Labour and Engagement with Public Service”. Management Decision 40:4, 310–317. Beecham L. (2000) “Tony Blair Launches Radical Plan for England”. British Medical Journal 321, 470. Davies, J. (2002) “No Quick Fixes”. Health Service Journal 112:5813, 25–29. Department of Health (1997) The New NHS: Modern, Dependable. London: The Stationery Office. ------- (1998) Working Together: Securing a Quality Workforce for the NHS. London: The Stationery Office. ------- (1999) Clinical Governance: Quality in the New NHS. London: The Stationery Office. ------- (2000) The NHS Plan. London: The Stationery Office. ------- (2001a) The Expert Patient: A New Approach to Chronic Disease Management in the 21st Century. London: The Stationery Office. ------- (2001b) Shifting the Balance of Power in the NHS: Securing Delivery. London: The Stationery Office. ------- (2002) Delivering the NHS Plan. London: The Stationery Office. Driver, S. and Martell L. (2000) “Left, Right and the Third Way”. Policy and Politics 28:2, 147–161. Freidson, E. (1970) The Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Mead and Co. Higgins, J. (2002) “A Cause for Celebration?” Health Service Journal 112:5813, 24–29 Illich, I. (1978) Deschooling Society. London: Pelican. Lakhani M. (2001) “Hamster Healthcare and Quality”, The Journal of Clinical Governance 9:3 1–2. Le Grand, J. (2002) “Further Tales from the British National Health Service”. Health Affairs 21:3, 116–129. Munro, J., Nicholl, J., O’Cathain, A. and Knowles, E. (2000) Evaluation of NHS Direct First Wave Sites: Second Interim Report to the Department of Health. Sheffield: Sheffield University. Pollard, M. (2001) “On the Side Walk”. Health Service Journal 111: 5783, 22–25. Price, D., Pollock, A. and Shaoul, J. (1999) “How the World Trade Organization is Shaping Domestic Policies in Health Care”. The Lancet 354, 1889–1891. Shamash, J. (2002) “What is on the Agenda?” Nursing Times 98:22, 10–11. Shifrin, T. (2002) “Living on Borrowed Ideas”. Health Service Journal 112:5803, 11.

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Stark, S., Stronach, I., Warne, T., Skidmore, D., Cotton, A. and Montgomery, M. (2000) Teamworking in Mental Health: Zones of Comfort and Challenge. English National Board for Nursing, Midwifery and Health Visiting Researching Professional Practice Report 17. London. Tsoukas, H. (1997) “The Tyranny of Light. The Temptations and Paradoxes of the Information Society”. Futures 29:9, 827–843. Walshe, K. and Smith, J. (2001). “Cause and Effect”. Health Service Journal 111: 5776, 20–24 Ward S. (2001). “Dial M for Medical Advice”. Health Service Journal 111:5756, 24–26. Warne, T. (1999). Contracting and Customs in the UK General Practitioner Fundholding Scheme. Unpublished PhD Thesis Manchester Metropolitan University. Whittaker, S., Carson, W. and Smolenski, M. (2000). “Assuring Continued Competence – Policy Questions and Approaches: How Should the Profession Respond?” Online Journal of Issues in Nursing 30 June.

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Community Medicine and Primary Health Care in Norway: Competitors or Parts of an Entity? Øivind Larsen (University of Oslo)

A shift that should cause concern? In the history of public health there are periods when the paternalistic advisory role and the social consciousness of the physician were as important as therapeutic skills in maintaining the health of the population both on the individual level and for the group as a whole. For a series of reasons the community medicine and primary health care aspects of the medical services have more or less split up in many countries in the course of time. As a result, the strong client- and patient-oriented approach in health care leaves a vacuum when preventive measures and group-oriented work are needed to handle health risks and health problems that extend beyond the healthcare setting. A review of the historical development in this field might produce some ideas on how to re-establish a more comprehensive medical view and pull the different strands together when confronted with modern health issues that are deeply dependent on such factors as social structures, the economy or lifestyle trends. Here Norway has been chosen as an example, but presumably the Norwegian experiences have parallels in other countries1.

1

For works in English covering the development of public health as a discipline, see e.g. the comprehensive reviews in: Porter, D. (ed.): The History of Public Health and the Modern State. Amsterdam/Atlanta GA: Rodolfi, 1994 and Porter, D.: Health, Civilization and the State. A History of Public Health from Ancient to Modern Times. London/New York: Routledge, 1999. Modern views on the outline and practice of public health is extensively covered in: Holland, W.W. and Stewart, S.: Public Health – The Vision and the Challenge. London: Nuffield Trust, 1998; Detels, R., McEwen, J., Beaglehole, R. and Tanaka, H.: The Oxford Textbook of Public Health 1–3. Oxford /New York: Oxford

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Community Medicine and Primary Health Care in Norway: Competitors or Parts of an Entity?

Norway between the individualism of the past and the individualism of today Situated geographically at the top of Europe, for decades now the state of Norway has also enjoyed the reputation of being one of the top welfare states of Europe. The build-up of a primary healthcare system covering curative needs as well as offering public health services was part of this.2 The development and implementation of a general welfare ideology based on the feeling of mutual responsibility as a virtue can be traced back to the second half of the nineteenth century, but it experienced its culmination after the Second World War with the introduction in 1967 of the universal social security and health insurance system named Folketrygden. With this system serving as a basic security net, the responsibility for the safety, health and well-being of individual Norwegians was in principle taken over by the society, that is, by the authorities. This notion of general and unquestioned public support still exists, but owing to developments in a series of fields, ranging from politics in general through prevalent attitudes to health and the economy, the ideas have been challenged since the 1970s. From the mid-sixties general practice was upgraded in Norway and stimulated as a medical field to attract young doctors and recruit them to primary health care. However, over the years the curative treatment aspects of first-line medical work gradually came to dominate, leaving group- and environment-oriented medicine in a less favoured situation. The public responsibility that was gradually built up in the liberal and individualistic Norway of the 1800s has in a way met up with a new liberalism and a new individualism some one hundred years later.

University Press, 2002 and Pencheon, D., Guest, C., Melzer, D. and Muir Gray, J.A.: Oxford Handbook of Public Health Practice. Oxford/New York: Oxford University Press, 2001. The special conditions in Norway are discussed in: Larsen, Ø. (ed.) The Shaping of a Profession. Canton MA: Science History Publications/USA, 1996. 2

The royal appointment of Villads Nielsen Adamsen (c. 1564–1616) to the position of a doctor in Bergen on 3 July 1603 has been arbitrarily chosen as the birth date of the Norwegian health services. Part of the 400 year celebration in 2003 was the publication of a comprehensive two-volume medical historical review with an ample supply of further references: Schiøtz, A. (ed.): Det offentlige helsevesen i Norge 1603–2003 1–2. Oslo: Universitetsforlaget, 2003 (in Norwegian). Vol 1: Moseng, O.G.: Ansvaret for undersåttenes helse 1603-1850. Vol. 2: Schiøtz, A. and Skaset, M.: Folkets helse – landets styrke 1850–2003.

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Now when society is facing new medical problems related to lifestyle, work and the environment, new demographic and social relations in society and the re-emergence of old problems such as tuberculosis, food-borne infections and other hazards connected with individual and public hygiene, a sort of limbo has emerged that hampers preventive and group-oriented efforts. The possible explanations for this shift should be discussed, kinds of research that could give more precise indications as to the mechanisms involved should be indicated, and feasible countermeasures should be suggested.

The case of Norway: a brief historical overview Norway gained independence from Denmark in 1814 and entered a political union with Sweden; this was followed throughout the rest of the nineteenth century by the development of a society with a national identity. The population increased from approximately one million at the beginning of the century to about two million at the end, despite substantial emigration – more than 800,000 Norwegians left the country, mainly to the United States, especially in the years between the American Civil War and 1930. The great majority of the changes in society took place in the second half of the nineteenth century. At the outset the mainly rural population was living scattered on separate farms and in small townships all over the country, but after urbanization and industrialization began, large-scale internal migration led to the rapid growth of central cities, in particular the capital, Christiania (now Oslo), and its environs. Health conditions in Norway before the Napoleonic wars were similar to those in other rural countries of the ancien régime. Mortality was high and fluctuated around the three percent level for yearly deaths, only slightly lower than the similarly high birth rate. Infant mortality showed the traditional pattern: between every third and every fourth newborn did not survive until its first birthday. However, soon after 1814 the mortality rates started to decline. The reasons for this remarkable development are subject to long-standing and still ongoing historical discussions. Should it be attributed to the separation from Denmark, or did Norway catch up with a development that had been proceeding more gradually in continental Denmark thanks to the relief from the naval blockade and other hardships that had hurt Norway during wartime? Were the bad health statistics of Norway an indication that a

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major part of the population had been living just above the minimum level of existence, so that when an even slight amelioration in living conditions took place immediate reactions could be read from vital statistics?3 If we exclude smallpox vaccination, compulsory from 1810–1976, and scrutinize the medical history of Norway in the early nineteenth century, no clues can be found indicating that the medical services made any substantial contribution to the decline of mortality, nor were there any new medical achievements that could explain any medical success. In 1814 there were around 100 doctors with various professional backgrounds in Norway. Obviously, their efforts could not cope with the demands, at least with medical requirements as we see them today in an historical perspective. One hundred years later, at the beginning of the twentieth century, Norway had approximately 1200 doctors, all of them almost exclusively trained at the medical school of the new national university, founded in Christiania in 1811. Around the middle of the nineteenth century the capital city of Christiania still exhibited the traits of a small and provincial town. Fifty years later the city and its surroundings housed the impressive number of around 240,000 inhabitants, a considerable population even in European terms. Its new Berlin-inspired architecture left no doubt that Norway had become a modern society with European ambitions. However, this process took its toll, in the field of health as elsewhere. Infection rates closely followed the figures for migration and urbanization, which called for medical efforts on the public health level.4 A special challenge was a typical Norwegian phenomenon: the extensive seasonal fisheries along the western and northern coast. Between their trips to sea to catch fish, thousands of fishermen came together and sought shelter in primitive dwellings in fishing villages with low or no hygienic standards, exposing themselves to epidemics and other infections that they afterwards brought back with them to their homes. In the leading medical circles in Christiania, combating epidemic diseases was a central issue throughout the nineteenth century, a discussion that of course gained more in substance after the discovery of microbes in the latter half of the period.

3

Comparative figures regarding the demographic transition the Nordic countries are found in: Larsen, Ø., Berg, O. and Hodne, F.: Legene og samfunnet. Oslo: Den norske lægeforening, 1986 (In Norwegian).

4

See: Larsen, Ø. Epidemic Diseases. Norway in a Period of Change. An Atlas of Some Selected Infectious Diseases and the Attitudes towards Them 1868–1900. Oslo: Unipub forlag, 2000.

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However, effective hygienic measures to curb and prevent epidemics could be difficult to combine with the demands from a rapidly growing economy. These conflicts of values were brilliantly pointed out in the 1882 play En Folkefiende (An Enemy of the People), by the Norwegian author Henrik Ibsen (1828–1906). In it, a physician warns of bacterial pollution in the drinking water of a city prospering from its spa. The city’s reputation and its income depend on the water supply, but the city fathers refuse to deal with the situation. The doctor, energetically fighting against the health risks, is belittled and regarded as a fool by the community because of his potentially dangerous ideas. Although some hospitals existed, medical services in Norway in the nineteenth and early twentieth centuries were based on primary health care offered by general practitioners. Up to World War II the typical general practitioner ran a private practice, obtaining her or his income from patients, from some sort of sickness insurance, from poor relief funds, from an employer, from the city or municipality or – in most cases – from combinations of such sources. At the heart of the system for health service provision were the district physicians – publicly paid health officers who also had responsibility for the sick care of the inhabitants. The Norwegian Sanitation Act of 1860, in force until 1984, entitled the district physicians to implement even rather harsh measures when their medical judgment told them it was necessary, e.g. in the case of an epidemic. As chair of the local sanitary board, the district physician could sometimes play a somewhat absolutist role in medical matters. Of course, it is debatable to what extent any significant number of district physicians really achieved substantial results in the field of public health in a country where the population was often very conservative – and above all was reluctant when faced with anything that might imply expenditures. On the other hand, no one would deny that the image of the district physician and the combination of curative and public health practice had a strong impact on the image of medicine as such long into the twentieth century.5

5

See Larsen 1996 and Schiøtz, A. Doktoren. Oslo: Pax, 2003 (in Norwegian).

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Prevention of disease: a national virtue Acceptance of preventive medical measures requires an understanding that the absence of disease has a value in itself, comparable to other values. Especially in the years between the First and Second World Wars, Norway experienced a period when sanitation and health had a high standing. There were several reasons for this. One was political. In Norway, as elsewhere, the connection between poverty and disease was obvious. And poverty was a problem. This meant that health measures were in fact political tools, and they were promoted in different spheres. Occupational medicine and work-safety regulations were introduced in the 1890s on the initiative of workers. On the other hand, extensive health schemes for employees were also launched by paternalistic industrialists. Thus the modern industrial health services in Norway originated from a system developed at the Freia Chocolate Plant in Christiania/Oslo from 1917, headed by Carl Schiøtz (1877–1938), later professor of hygiene at the University of Oslo. Professor Schiøtz also was head of the school health services in Oslo. Here systematic health examinations were introduced and the large amounts of data from the schoolchildren, who were monitored, were used for scientific and practical purposes. The so-called Oslo Breakfast was introduced by Schiøtz for the school children of Oslo in order to safeguard their nutritional status, and was highly appreciated. The breakfast was offered to children from all social classes as a general measure. Nutrition held a special position in early twentieth-century Norway. Arctic explorers such as Fridthjof Nansen (1861–1930) and Roald Amundsen (1872–1928) were national heroes. Vitamin and other nutritional research had a high standing in Norwegian medicine, and it was widely known that the scientific composition of the diet, following recommendations by the medical professors, had contributed to the success of the polar expeditions. Why should the children not benefit from this progress in nutritional knowledge as well? And in fact the curves for schoolchildren’s body height and body weight showed a steady increase which, though there was a setback during the war years from 1940 to 1945, only flattened out in the 1950s, indicating that an optimal level had probably been reached. Tuberculosis ravaged Norway as it did other countries, and the social profile of the disease was clear-cut, at least when it came to the outcome of the infection, where patients in bad physical and nutritional shape had higher odds against them than the more well-off. The fight against tuberculosis in Norway in the first half of the twentieth

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century became a broad public movement, especially among women. There are indications that the national solidarity around the turn of the century, when an armed confrontation with Sweden seemed a likely possibility, was transformed into a movement against another enemy, tuberculosis, after the union with Sweden had been dissolved in a peaceful way in 1905. Sanatoria and cottage hospitals for tubercular patients were erected by private means all over the country. However, the preventive side of this committed struggle against tuberculosis was a growing general interest in hygiene and cleanliness. Despite the despair caused by tuberculosis for those affected, the positive effect of the disease for the general health education of the population should not be underestimated. Personal and public hygiene, housing, an end to unpleasant habits like the widespread practice of spitting in public – much changed for the better, with the fear of tuberculosis as the driving force. After World War II the tuberculosis problem seemed to have been solved; at least that was the general view in those years. Then another disease attracted public attention, even though it was certainly not a new disease: poliomyelitis repeated the medical history of tuberculosis. In the years around 1950 a severe poliomyelitis epidemic struck Norway. Even though the contagious principle was not yet known, the connection with hygiene was understood. Poliomyelitis had no social profile and struck all social strata. Again a broad engagement took place in society. Historically, there is no doubt that poliomyelitis and the new need to care for people with physical impairments changed the public’s perception of handicapped persons and its feeling of responsibility for them. In the years that followed, health problems that are markers of the affluent society appeared – obesity, diabetes type II, heart disease, smoking-related lung disease. But now history went in its own direction: Even though public interest was clear and sustained, no general movements came up. It was hard to settle on generally accepted strategies against the new disease pattern. Why was this?

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Towards a personal touch For 34 years health policy in modern Norway in a peculiar way lay in the hands of one single man, the medical doctor Karl Evang (1902–1981), who was appointed Director General of Health in 1938 and held this position until his retirement in 1972.6 Politically Evang belonged to the left wing. In the 1930s he carried out studies that shed further light on the inequalities in living conditions and health, and he launched radical ideas on then sensitive issues like birth control and sexual behaviour. His career has to be understood in the light of the prewar political situation. Two generations of urbanization and industrialization had induced social and political changes and also created what was perceived as social inequities. The Norwegian Labour Party was founded in 1887 and grew to be a powerful force that more or less dominated Norwegian politics from 1935 until the 1970s without any challenges that seriously disturbed its clear social-democratic ideology. There were, however, conflicts. In the interwar years, the labour movement showed tendencies to split and a faction actually separated, embarking on a Stalinist line and later forming the Communist Party. On the other hand, radical younger intellectuals, many of them from the traditional upper class, gathered in a movement called Mot Dag (“Dawn”), where a social-democratic ideology was the guiding force. Karl Evang belonged to this group, which in the years to come gradually achieved an informal but important position.

6

The understanding of the impact exerted by Karl Evang is crucial for the interpretation of Norwegian health politics in the long period he was in charge. There are two authoritative biographies available (in Norwegian): Nordby, T. Karl Evang: en biografi. Oslo: Aschehoug, 1989; Berg, S.F. Den unge Karl Evang og utvidelsen av helsebegrepet: en idehistorisk fortelling om sosialmedisinens fremvekst i norsk mellomkrigstid. Oslo: Solum, 2002. See also the festschrift on his sixtieth birthday (in Norwegian): Bruusgaard, A. and Gjestland, T. and Evang, K. Festskrift til Karl Evang på 60 årsdagen. Oslo: Gyldendal, 1962. Evang carried through studies on social conditions: Evang, K. and Hansen, O.G. Norsk kosthold i små hjem: virkelighet og fremtidsmål. Oslo: Tiden, 1937 (in Norwegian) and Evang, K. and Hansen O.G. An Inquiry into the Diet of 301 Poorly Situated Families in Norway. Acta medica Scandinavica. Suppl.103: Helsingfors, 1939. After his retirement, Evang published a textbook on social medicine, in a way summing up his views (in Norwegian): Evang, K. Helse og samfunn: sosialmedisinsk almenkunnskap. Oslo: Gyldendal, 1974. Of his international publications there may especially be mentioned a book based on a series of lectures given in London in 1958: Evang, K. Health Service, Society, and Medicine. London: Oxford University Press, 1960. See also Evang, K., Murray D.S. and Lear, W.J. Medical Care and Family Security. Englewood Cliffs, N.J.: Prentice-Hall, 1963 and Evang, K. Health Services in Norway. 4th ed. Oslo: Universitetsforlaget, 1976.

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The interwar economic recession was also felt in Norway. The urban working-class population was hurt by unemployment and suffered difficult living conditions, a development that strengthened leftist politics. Their traditional counterparts were the mostly conservative country people and the bourgeois-minded city dwellers. As time passed, the demarcations ceased to be so clear. Of course shipowners and post-WorldWar-I speculators showing off their wealth in champagne and caviar were an appropriate political target group, but it was small. Combating them would have no political effect. And the rich industrialists of course could be politically annoying, but nevertheless they represented the highly needed employers. The civic-minded middle class was ambiguous. Stagnating salaries caused worries among employees in the public sector and those in the service occupations. In addition, doctors and other health personnel experienced at first hand through their work how living conditions and health suffered from the lack of more comprehensive and farsighted guiding principles. Rural areas also fostered radical currents. The agriculture and forestry sectors, still old-fashioned and labour-intensive, struggled to meet payrolls when market prices for products were low. When mortgages had to be paid off in times when incomes were low, the land-owning farmers themselves also suffered from the market forces. Thus the quest for a new policy had a broad but by no means uniform basis. Rightof-centre politicians cleverly played on negative experiences from the East that followed in the wake of the Communist takeover in Russia. And when the National Socialist ideology spread from Germany, the Bolshevik threat was made a prime issue, accompanied by a celebration of conservatism and traditional Nordic values. This might be part of the explanation for why the Norwegian National Socialist Party enjoyed limited but nevertheless astonishingly significant support for a period before and during World War II. The intellectual elements in the social-democratic movement, which included Dr. Evang and his medical colleagues, faced a series of difficulties in order to set up and implement broadly based planning for a new society, grounded in the ideas of equality and equity. However, visible results of large-scale planning had already appeared. For example in the capital city, Oslo, cooperative-based housing projects were designed by the best architects, and city planners of the time paved the road for further progress.

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On 9 April 1940 Norway was attacked by German forces. Within a few weeks the whole country was occupied and a puppet government took over. A substantial number of Norwegians, Parliamentary and government officials and many leading figures from different parts of the society and also from the social-democratic leadership, fled to neutral Sweden and to Allied countries, mainly England and the United States. In exile, plans were made for building up the Norwegian society after the expected Allied victory. Among the exiles was Karl Evang. When World War II came to an end in 1945, there existed at least on the surface in Norway a broad political consensus on the need for a concentration of efforts to build up and restructure the society. However, this positive spirit could not conceal conflicts between those who returned from exile and those who had endured life at home, and the old political skirmishes revived. Above all, this period was marked by the condemnation and legal prosecution of the large number of Norwegians who had shown pro-German sympathies (active or passive) during the years of German occupation. A comprehensive historical interpretation of what happened in the first postwar years still remains to be written, as the topic still evokes strong emotions even half a century later. However, it is also true that many old disagreements and conflicts were no longer and sharp and divisive, and the basis was laid for the strongly regulated and centrally planned social-democratic state that it was felt was needed in order to restore the country. Over several Parliamentary elections, whose outcomes reflected major confidence in the system, this basic situated existed more or less unchanged for three decades.

The Evang model The fact that Karl Evang was among the civil servants that went into exile during the war was important for the Norwegian health services in the years to follow. His position as Director General of Health was already strong when he entered it in 1938, and later it became even stronger. But his wartime experiences with foreign health services and his engagement in what would become the World Health Organization (WHO) in 1946 were crucial for the architecture he chose when he returned to the postwar health services in Norway.

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One other thing must be stressed when dealing with the situation within medicine and attitudes towards health during the war, and this is that antibiotics had become available. Yet infections were still a scourge in Norway. Many of them were strongly feared and often a fatal outcome was regarded as inevitable. Children were taken away by meningitis, and pneumonia could be a deadly threat at all ages. But mow drugs could save lives and relieve suffering. There were other important issues too: the concept of disease had expanded, now documented through the WHO definition of health, which opened up new fields of the health domain, not least on the social side, and defined them as spheres for medical concern. Doctors’ work took on new dimensions, both quantitatively and qualitatively. And in hospitals, surgery was no longer so complicated or dangerous, when the risk of infection risk had diminished. Medical science had developed, and so had medical equipment. Naturally enough, all this had consequences for the shape of the health service system. To put it briefly, in his mind’s eye Evang saw a system of universally available central hospitals, distributed all over the country and providing advanced medical treatment in their wards. Specialists would also be available in the adjacent policlinics with access to all the technical services of the hospital. Preventive medical services, health counselling and the like would also be offered by the hospitals, which would then be the natural medical centres of the regions. The core of the out-patient primary health services at the local level would be the publicly appointed district physicians with their combination of sick-care and preventive tasks. A supportive hierarchy had been established: Entering the career path of a district physician might imply starting up in a remote district, and then later advancing to more central parts of Norway. Above the district physician was the county medical officer, who in turn reported to the Directorate of Health, headed by Evang himself. Evang was very interested in people who showed a sense of commitment to public health, and therefore an aspiring district physician might be sent abroad to take a public health degree at some school of public health, and later perhaps be promoted to county physician or receive the offer or a leading position in the Directorate. Evang also was in favour of developing the district nurse system, creating a personnel category that would serve in the first line of the public health services of the municipalities.

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In the 1950s and the 1960s hospitals were built all over Norway and the district health system was strengthened. On the political side the financial backing was gradually settled, but this took time. Medicine and health services moved into a new position in the eyes of the public: medical success became a daily experience and it was universally available, independent of social position or economic situation. And the rapidly growing health services provided work where work opportunities had been scarce. Parts of the female population in particular had new opportunities for pursuing professional careers or for earning money as employees. Medical optimism and the broad range of achievements and consequences for the society that gave rise to it became a hallmark for the new era. In retrospect, it becomes clear that at this stage in Norwegian medical history the construction of a comprehensive health system had objectives far beyond the safeguarding of health. This may be one important reason why the leading social-democratic politicians, with only a few exceptions, delegated the medical leadership to Karl Evang, a situation that more or less lasted until his retirement at the age of seventy in 1972. However, to understand the relationship between public health – understood as group- and environmentally-oriented medicine – and curative medicine services in the years to come, it is also important to look at what fields Evang did not favour, and what parts of the health services he did not look upon with sympathy or his habitual enthusiasm. First-line occupational medicine in Norway had mainly been taken care of by the employers, and since 1943 through an agreement between the employers’ organization, the central trade union and the Norwegian Medical Association. For workplace sanitation, health counselling, screening projects and other work-environment and group-directed activities, this quite comprehensive preventive medical system was of considerable importance.7 Personally, Evang was not so interested in this. A proof of his attitudes in this respect may be found in the history of the seamen’s health services. During World War II Evang was instrumental in building up a healthcare system in international ports for Norwegian seamen sailing on the seven seas on Norwegian ships

7

See Natvig, H. Thiis-Evensen sen. Arbeidsmiljø og helse. Yrkeshygienens og bedriftshelsetjenestens frembrudd og utvikling i Norge. Norsk Bedriftshelsetjeneste 1983; 4:1–333 (in Norwegian).

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in Allied service. This system focused on health care and had few public health and occupational health elements, even though there would have been excellent opportunities to introduce such aspects. One aspect that might be part of the explanation of why occupational medicine existed only on the fringe of the other public health activities may be its administrative position. Workers’ diseases and workplace safety issues were in the domain of the Norwegian Labour Inspection Authority and were not headed by the Director General of Health. In the 1970s the occupational health services were more or less taken over by the Ministry of Internal Affairs and definitively separated from the rest of the medical services, which were organized under the Ministry of Health and Social Affairs. This process was also accompanied by a series of conflicts at the political, medical and personal levels. When the economy and the structure of industry changed, problems emerged in maintaining the old employer-based system. Therefore, since then Norwegian occupational medicine, as part of public health, has probably suffered from its separation from the rest of medicine.8 In the 1960s and 1970s public interest in nature conservation and environment preservation grew. Powerful movements rallied to stop the devastation of unspoilt nature, for example when plans arose to construct hydroelectric power plants in some distant wilderness or even when roads had to be built in the forests. And air and water pollution from industry became a common concern. Here the shift in attitudes occurred rather swiftly. As late as the 1950s power plants, power lines and new roads were regarded as signs of success and of man’s conquest of nature. The smoke from foundry chimneys was the smoke of prosperity. This new wave of interest in a clean and untouched environment could easily have been linked to the objectives of hygiene in general, to public hygiene and to occupational medicine, but this never happened. A joint commitment to the care of nature, whether of the environment or the human organism, could have been staged, but it was not.

8

An outline is given in Larsen, Ø. “Origins of the Norwegian Occupational Health Services and its Association of Physicians” in Grieco, A. et al. (eds.): Origins of Occupational Health Associations in the World. Amsterdam etc. Elsevier, 2003, pp. 147–156.

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On the other hand, Evang was concerned with the hazards to the society that might be induced by capitalists and loss of public, national autonomy. Privately he was a longstanding and strong opponent of the Norwegian application for membership in the European Union. This application was never submitted, owing to the referendum of 1972, when the population voted strongly against the government’s proposal. This stance was confirmed in a second referendum in 1994, and today the question is still hanging in the air. Evang was deeply sceptical of private health services, including private practitioners. As private practice had traditionally dominated the first-line services, this of course led to conflicts with the doctors and their strong professional organization, the Norwegian Medical Association. There was a contradiction here. The demand for doctors was huge and the district physician system was not able to meet it, especially not in the cities. So private practitioners in the first line and as specialists had to be accepted, but their activities could be regulated through payment systems and in other ways. What really came to hamper private practice, in spite of such positive factors as the rather favourable financial prospects in the 1950s and 1960s, was the fact that hospital medicine grew so quickly. The new hospitals attracted the young and aspiring among the doctors. It was obvious that it was in hospital medicine that the interesting developments would take place. At the same time it was there that regulated working hours, good pension schemes and other benefits could be offered. For these and other reasons, recruitment to private practice, as well as to the position of district physician, dropped. One of Evang’s ideas was never put into practice – the preventive medicine activities that he wanted to take place in the hospitals. One of the key factors might be that the dominant financing system for health care, universal sick insurance, almost exclusively focused on medical treatment, not on prevention. Such was the situation when Evang retired in 1972, by then one of the last absolutists in a democratic state. For a while his successor Torbjørn Mork (1928–1992) tried to continue along the lines from the past, but he met with severe opposition and did not achieve the same degree of success. A period was over.

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Who is the modern enemy of the people? The playwright Henrik Ibsen was clear: The perceived public enemy of the 1880s was the physician with his ideas about public health and disease prevention. Although the doctor obviously represented the medical establishment of the time, his weird talk about dangerous but hardly visible animals in the drinking water was only seen as destructive to the flourishing economy. One hundred years later, the situation had not changed that much. Regulations based on medical concerns were still looked upon with scepticism, but there was an inherent paradox: in cases of failure, lack of proper regulations and control were loudly criticized. There are different reasons for this. One is the fact that the perception of risk and danger had changed. In the 1880s the risk of infection was everywhere and the prospects of an untimely death were ever present. One hundred years later health risks seemed more remote and did not have the same impact. Besides this, many hygienic measures had already been seen to. Water pollution, air pollution, accident prevention and so on had become integrated parts of modern society, and no longer presented themselves primarily as medical issues. And even personal hygiene, in earlier periods marketed and implemented with arguments concerning the risk of infection – for example, the threat of contracting tuberculosis – suffered from the fact that should infection set in, effective antibacterial treatment was normally ready at hand. Precautions no longer seemed so important. Besides all this, given the present level of morbidity in the population, what ranking has health as compared to other values in life? Community medicine and preventive medicine of the past cannot escape accusations of having been authoritarian and normative, or at least of having been perceived that way. Therefore the general anti-authoritarian attitudes of the 1970s of course inevitably had a negative effect on attempts to implement restrictions or give advice for medical reasons. In the years after the Second World War, several screening programmes for disease were launched in Norway. This community approach was also met with interest and acceptance beyond its personal side because of its potential to elicit and combat important diseases in society. Politically, publicly-run screening programmes also signalled down-to-earth public concern for the well-being of the individuals. However,

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as time went on, second thoughts about such aspects as violation of personal integrity took on more weight in the public and hampered the projects. The public enemy of the late twentieth century, understood as the enemy of the health, well-being and prosperity of the population as a whole, was probably more the population itself than any representative of the medical profession.

The part played by the doctors In the first part of the twentieth century community medicine knowledge and public health attitudes were integrated parts of the image of Norwegian doctors. On the university level, which then meant at the only medical school in Norway, at the University of Oslo, hygiene was a comprehensive discipline, touching on a wide range of medical methods and techniques from epidemiology to bacteriology and dealing with problems from nutritional hygiene to sexual education. The students were prepared for the public health officer part of a job as a district physician. The body of knowledge in the field and its complexity increased substantially over the years. It became obvious that the academic basis for public health had to be split up, a development in line with the general scientific reductionism of the time. In the technical parts of public health, for example, new personnel groups more or less took over. Engineers and natural scientists came to have a more central position than doctors in such spheres as air pollution, drinking water preparation and waste disposal, and the veterinarians took over the responsibility for nutritional hygiene. Separate scientific institutions were established outside of the university for these fields, and many tasks became the responsibility of the National Institute of Health. In spite of this, formal responsibility for public health still lay with the district physician, and up to the early 1970s a comprehensive and mandatory course in community medicine was given to all medical students in Oslo. In 1951 the Institute for Hygiene at the University of Oslo hived off a new department for what was called “social medicine”, including such fields as demography, insurance medicine, and the health impact of social conditions. In the course of time, this new institute concentrated more and more on the problems of less favoured population groups and persons with special vulnerability. The remaining institute took care of the traditional hygiene and kept the word hygiene in its name, but after some years changed this to the not quite synonymous “preventive medicine”. From around 1975, interests shifted to epidemiology as the main field of research. In 1990, following

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a major reorganization of the medical faculty at Oslo, a quite large new institute was established; by 2003 it was called the Institute of General Practice and Community Medicine. This institute covers the previous disciplines of hygiene and social medicine as well as some other fields related to public health, and includes general practice as a major section. However, it can be claimed that the well-meant basic idea of integration has failed in a way during the years that have elapsed since then, because the profile of the community medicine part has become somewhat blurred when mixed up with so many other topics. At the medical school in Bergen in western Norway (established 1946) and in what is boasted to be the northernmost university of the world, the University of Tromsø (established 1968), epidemiology has also been the main public health interest. New computer techniques have made large-scale epidemiological studies more feasible than before. For example, both the birth registry in Bergen and the population studies carried out by the epidemiologists at Tromsø have gained wide recognition. To sum up, academic public health and community medicine in Norway developed in two directions: One was client-oriented social medicine, the other theoretical epidemiology. Neither of them put the emphasis on the community medicine overview promoted by the old hygiene, the technical parts of public health and the practical sides of working with the society as the “patient”. Given the present academic structure in Norway, at least in Oslo, students undoubtedly perceive the individual human being as the most important “patient”.9 In the 1960s general practice suffered from low recruitment and declining prestige. Enthusiasts saw that this development only could be changed if general practice was turned into an academic discipline of its own, with the primary encounter with the unselected patient as its core feature. The first university institute for general practice was established in Oslo in 1968, but it had a specialist in internal medicine, not a general practitioner, as its head. Over the years, general practice has become one of the main disciplines at all four medical faculties in Norway, forming a significant part of the curriculum and making

9

About medical teaching in Oslo, see Larsen, Ø. Mangfoldig medisin. Oslo: Universitetet i Oslo, 1989 and Larsen, Ø. Legestudent i hovedstaden. Oslo: Gyldendal akademisk, 2002 (both in Norwegian).

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the image of the family doctor a strong element in the overall image of the modern physician. General practice also has been recognized as a medical speciality. What role have doctors played in this development through the medium of their organizations? In Norway, the Norwegian Medical Association has traditionally included almost all doctors in Norway on its membership list. Over time, its interest in and impact on community medicine and public health issues have shifted somewhat, depending on the representatives that have been elected to its General Assembly (landsstyre) and Executive Board (sentralstyre) as well as on the issues that were felt to be the most important. For an understanding of the balance between the curative medicine and community medicine approaches it is crucial to recognize that much of the new general practice during the last few decades has developed into a marked patient-oriented discipline. The community aspects have mostly been concerned with guiding patients through the labyrinths of specialists, hospitals, social security and legal regulations. Group-oriented responsibility has more or less vanished. This is also true of the role of the practising physician, where the new list patient system has been introduced (2002), a system where every Norwegian citizen has to sign up on a general practitioner’s patient list. In the wake of this reform, a new wave of privatization in general practice has occurred. Shifts in the medical problems presented to most first-line doctors have also given the patient-centred approach priority. One other factor adds to this: following new legislation in force from 1984, the role of the district physician as a state-appointed public health officer no longer exists. The latter has been replaced a doctor employed by the municipality who has no more than advisory functions: the final decisions are in the hands of the municipality leaders. This change must probably be regarded as one of the most serious blows to the standing of public health in modern Norway.

Neither competition nor cooperation – a low tide for Norwegian public health thinking The problems in Norwegian community medicine are in no way specific to this country. But as group-oriented medical problems and the relationship between health and an increasingly complicated society persist, there is a challenge to do something – to create a modern form of community medicine for a modern society. This is a process that will probably need a long time.

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Paradoxically, the increase in biomedical and sociological insights has undermined the comprehensive approach to how human health interacts with society and the physical environment. In the medical setting, patient-oriented thinking has mostly taken over, so that it is rare nowadays to find community medicine and primary health care as real competitors – but on the other hand, they are seldom parts of the same entity. Therefore the long-term objective obviously must be to link the two parts together again. More knowledge will be needed about how attitudes change in the population, and then about how attitudes change in the professional worlds of medicine. And on the larger scale, the role of professionals as policy-makers in general seems to have been weakened, and this is also true in medicine. If a more general view on health in society is to be strengthened or recreated, and if it agreed that a public health and community medicine approach is necessary to cope with health risks and problems of today and of the future, appropriate steps to implement this have to be taken at the political, educational and administrative levels.

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Fathers in the Swedish Family from the 1940s to the 21st Century Ann-Sofie Ohlander (University of Örebro, Sweden)

The analysis focuses on Swedish welfare measures concerning children in the family – to take two instances: paid maternity leave in 1955 and the same right to parental leave for fathers as for mothers in 1974. Particular attention is paid to fathers and the emergence and codification of a new parental role for men.

Changes from 1850 onwards In Swedish history, from 1850 and onwards, a tangible increase in women’s independence was followed by an equally tangible increase in children’s prominence. This change was in its turn followed by a change in the role of the father, one that is still ongoing. Men began to become fathers in the same sense as women had always been mothers (Ohlander 1994). Sweden has undergone a comprehensive transformation over the past 150 years. The change could roughly be described as the transition from a developing country to an industrialized one. From having been a relatively poor, mainly agricultural country, Sweden was transformed into a rich industrial state with a high standard of living. There has also been a shift from a traditional, hierarchical society to a modern, parliamentary democracy. During the first phase, from the mid-1800s to around 1930, women obtained increased control over their lives. First unmarried, then married women achieved a majority; women obtained new opportunities to study, new professions and jobs opened up for them and they got the vote in 1921. The birth rate fell in conjunction with this phase.

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During the second phase, children’s living conditions and security improved. This came about at the same time as Swedish society began to accept responsibility for reproduction and children. It was primarily female politicians who pursued questions relating to children and parenthood. The entry of women into political life was thus a significant factor in Sweden, as was the case in other countries (Ohlander 2002, Wennemo 1994). In the third phase, from the 1950s onwards, there was an expansion of men’s parental role. Swedish fathers begin to play an ever-increasing part in the care of and responsibility for their young children. It became, for instance, increasingly common during the 1940s and 50s to see men pushing prams. From the 1960s onwards, it became normal for men to be present when their wives gave birth. These days, as a rule, both the prospective father and mother attend antenatal classes (Bygdeman and Lindahl 1994). The expansion of men’s parenthood is codified and supported in statutes and in social policy. It is to this last phase that I will pay particular attention here.

The father’s historical role Fathers’ increased parental responsibility was, from an historical perspective, something completely new. It was, by all accounts, associated with children’s increasing prominence as individuals with rights of their own, which in turn is likely to have resulted from an increase in their mothers’ rights (Ohlander 1994, Ohlander 1995). The increase in women’s independence, both in society at large and within the family, also revealed the imbalance between men’s and women’s responsibilities. All down the centuries, women had always played both roles in Swedish society – productive worker and carer for children. Now that women had gained political, legal and financial independence this fact became, in all conscience, more difficult to ignore. Women’s double load of responsibility in a visible way contrasted with the single burden shouldered by men. Is it possible that this is one of the explanations for the everincreasing participation by men in the basic care of their children? In the past in Sweden – as elsewhere in Europe – infant mortality was high. Around 20 percent of the infants died before the age of one in 1800; 10 percent suffered the same fate a hundred years later. Several investigations show that a child under the age of five who lost its mother also ran a great risk of dying. The physician Ulf Högberg, who has made an investigation of women’s mortality in childbirth from 1750 onwards, also looked into the mortality of their children under five (Högberg 1985). He found

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that that during the eighteenth and nineteenth centuries the most significant factor determining a child’s chances of survival was whether its mother was alive or not. The historian Marja Taussi Sjöberg has made a longitudinal study of 225 prisoners, both male and female, from the county of Västernorrland in the north of Sweden during the nineteenth century (Sjöberg 1986). She followed them from birth to death, a procedure made possible by the meticulous way Swedish population registers were kept in the past (Kälvemark/Ohlander 1977). Most of the prisoners came from very poor families – theft was a common reason for punishment. They were also deprived in other respects. Approximately 40 percent of the men and 60 percent of the women had lost one or both parents during childhood. There is a distinct difference between those families who lost their father and those who lost their mother. If the father died the usually very poor mother somehow succeeded in keeping the family together and providing for it. If the mother died the family instantly dissolved: the father disappeared, the small children ran the risk of dying and the older ones had to turn to poor relief. The disappearance of the father in these cases seems to be due to the fact that historically the paternal social role did not include taking practical care of children. Another historical investigation from Linköping, a relatively large town in the south of Sweden, in the nineteenth century yielded similar results (Bengtsson 1996). Three generations of family patterns in the town were analyzed. The death of the father in a family made no difference in terms of the small children’s chances of survival. But regardless of the social and economic status of the family, the risk of a young child dying increased by 30 percent at its mother’s death. The child’s chances of survival increased significantly if the father married again, thus introducing a stepmother into the family. But if no other woman was available among the relatives, the rule seems to have been that the family broke up if the mother died. If the man died or disappeared, on the other hand, the mother, as a rule less well equipped financially and legally, managed both to look after the children and to support them. The historical gender role of men excluded them from typical women’s working tasks, among them childcare. Men who tried to break through their gender role in this respect tended to encounter problems. In Solna, a Stockholm suburb, it happened more than once at the beginning of the twentieth century that a working-class father whose wife had died wanted to take care of his own children. The local Child Welfare Bureau took the position that men were not able take care of children, and the children were accordingly taken from the father and placed in foster homes (Weiner 1995).

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These days, a Swedish child who loses its mother runs no risk – to put it dramatically – of dying or being given away because its father is incapable of taking care of it. In the light of the historical perspective presented above, this amounts to a major change.

Increased parental responsibility: children born outside wedlock One hundred years ago financial and legal power within the family was vested in men as fathers, but in reality their practical responsibility for children seems to have been minimal. This was even more apparent from the circumstances of children born outside of marriage. Under these circumstances the mother was forced to go to court in order to obtain maintenance from the father, but the court procedures were such that it was easy for men to deny liability. The 1920s, however, saw the introduction of such positions as that of the child welfare officer, whose task was to uphold the rights of single mothers and their children, including those with regard to the father. This constituted, in principle, a reinforcement of the way in which the father’s parental responsibility was viewed. The early child welfare officers spent a large part of their time in often fruitless efforts to make fathers pay up. The state subsequently (1938) moved into this area and paid what were known as advance benefits to single mothers so that the children did not suffer when the fathers failed to meet their financial obligation.

Family policy – a new phenomenon In 1949 Swedish legislation concerning children and parents was collected within a new Children’s and Parents’ Code or – the exact translation of the Swedish term – a “Family Code” (familjebalk). At the same time a new term, “family policy”, was introduced in Swedish social policy concerning parents and children. Formerly this had been labelled “motherhood policies” (moderskapspolitik) and then “population policies”. The change in terminology seems in both cases to indicate that children were a responsibility for both parents, not only for mothers. This does not hold true for the whole area, however. Fathers could thus still be regarded with the suspicion shown by the aforementioned Child Welfare Bureau in Solna. When maternity relief was introduced at the end of the 1930s it was paid directly to the mothers, not to the fathers. This was a new phenomenon; usually men handled financial matters, particularly in the countryside (Kälvemark/Ohlander 1980). When

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general child allowances were introduced in Sweden in 1948, they were also paid only to mothers. In an opinion poll carried out within the Federation of Social Democratic women in 1954, “the social and psychological value of paying the allowance directly to the mother” was emphasized (Ohlander 1992). Fathers were seen as not directly involved in the care of their children and could therefore obviously be suspected of using the allowance for other purposes than the benefit of their children. Children’s allowances are still paid to mothers, and this fact is the subject of an ongoing discussion.

Parental insurance in 1974 At the end of the 1950s, young, female politicians began to discuss the lack of equality between the sexes in Swedish society. A feminist movement developed with party and extra-party political support. An article submitted to a newspaper by Eva Moberg, a young, female, liberal politician, played a crucially influential part (Moberg 1961). The article was entitled “Women’s Conditional Discharge” and it’s author demanded liberation, not only for women but for men too. Husbands and wives should share the burden of housework and that of responsibility for their children. The father should also take advantage of the maternity leave when he became a father. He, too, should be able to take care of his young child. Gender equality would thereby be achieved and family solidarity saved (Moberg 1961). The eventual consequence of these demands, after a long drawn-out political debate, was the introduction of parental insurance in 1974. Maternity insurance, introduced in 1955, had been successively extended from 1955 onwards. However, it still applied to mothers only. In 1974, the insurance was renamed parental insurance and fathers were granted the same rights to be at home and take care of their young child as mothers (Ohlander 1994, 1995). From 1974 onwards benefits amounting to 90 percent of the wage were paid for 180 days, which had to be used up before the child was eight years old. Also temporary allowances were introduced, to be used, for instance, when a child became ill. These amounted to ten days per family per year for children under twelve years of age. In 1978, 1980 and 1989 the parental insurance allowance was gradually increased to 450 days, ninety of which were at the minimum rate only. Also temporary allowance increased to the level of 120 days per child per year in 1990 (Statistics Sweden 2002, The National Social Insurance Board 2002).

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A quota allocation of parental insurance has also been carried through in Sweden. Parents get prolonged leave if they share it, a reform nicknamed “Dad’s months”. In 1995 this “mummy/daddy month” was introduced, with the provision that thirty days had to be used by the mother and thirty by the father. Either parent could use the remainder. For the main part or three hundred days the allowance was diminished to 80 percent but during the mummy/daddy month the compensation was 90 percent. During the economic recession in the 1990s the level of compensation was lowered to 75 percent of the wage at its lowest but in 1998 it was increased again to 80 percent. To date, fathers have taken less parental leave than mothers. The share of fathers who took any parental leave at all was very low at the beginning but has risen during recent years. In 1977, 23 percent of the fathers took parental leave, whereas the corresponding figure for 2001 was 40 percent (cf. Diagram 1). Diagram 1: Sweden: Insured persons claiming parental allowance 1985–2001 Allowance – numbers in 1000’s and breakdown by sex (%)

500

28%

450 400

26%

32% 36% 38%

40%

Men Women

23%

350

72%

300 250

77%

74%

68% 64% 62% 60%

200 150 100 50 0

1985 1990 1995 1998 1999 2000 2001

Source: På tal om kvinnor och män. Lathund om jämställdhet 2002. Stockholm: Statistiska centralbyrån. Programmet för jämställdhetsanalys. 2002, s. 38. (Women and Men in Sweden: Facts and Figures. Stockholm: Statistics Sweden. Gender Statistics Unit)

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But parental leave measured in number of days is considerably over-weighted for women. In 1989, 92 percent of the total leave was taken by mothers and hence only 8 percent by fathers. In June 2001 the corresponding shares had changed to 86 for mothers and 14 for men (cf. Diagram 2). The figures for the year 2003 show the same increase in the parental leave taken by fathers: 43 percent of them took some parental leave and by then their share of total days taken had risen to 17 percent. Diagram 2: Sweden: Days for which parental allowance is paid 1974–2001 Allowance. Number of days in 1000s and proportion (%) drawn by women and men

55000 7%

50000 45000

93% 91%

40000 6%

35000 30000

5%

25000 20000 15000

9%

0%

Men Women

11% 10% 12% 12% 14% 89% 90% 88% 88% 86%

94%

95%

100%

10000 5000 0 1974 1980 1985 1990 1995 1996 1998 1999 2000 2001

Source: På tal om kvinnor och män. Lathund om jämställdhet 2002. Stockholm: Statistiska centralbyrån. Programmet för jämställdhetsanalys. 2002, s. 38. (Women and Men in Sweden: Facts and Figures. Stockholm: Statistics Sweden. Gender Statistics Unit.)

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Major differences are also evident between different groups. Fathers take more parental leave if they are less well-educated than the mothers are. The same thing applies when both parents are well-educated. Men working in workplaces where women form the majority take more parental leave than average. Male nursery school teachers, youth leaders, physiotherapists and librarians head the list. Fathers in male-dominated professions take least parental leave. Farmers and forestry workers, as professional groups, take least parental leave of all. Even in such heavily male-dominated professions as construction workers, bricklayers and painters, however, more than half of the fathers take at least some parental leave. The educational and income pattern is about the same for men who take “daddy’s months”. Fathers with higher education and higher incomes take advantage of the possibility of “daddy’s months” to a higher extent. The education and income of the mother seem to play corresponding roles: when the mother is well educated and has a high income the father in the family is more likely to take “daddy’s months”. But the level of compensation also plays a role. A recent report from the Swedish National Social Insurance Board shows that the percentage of fathers taking “daddy’s months” decreased when the level of compensation sank from 85 to 75 percent of the wage in 1996. The differences can be attributed to various factors. It seems evident that differences in salaries play a major part. If the mother earns more than the father does, it will, by and large, be he who takes paternity leave, and vice versa. This is one instance where the lack of gender equality in the labour market also has an impact in the home. Colleagues’ and, above all, employers’ attitudes also play a part. It is probable that men are more subjected to discontent on the part of their colleagues when they take parental leave than women. Are women then not subjected to a corresponding degree of discontent? In this context it is perhaps worth considering whether sanctions against men’s and women’s parental leave, respectively, take different forms. It may be that employers who are hostile to parental leave simply do not employ women. Either way, it is not unknown for women seeking employment to be asked whether they plan to have children within the immediate future or to be required to promise not to. Sanctions against women thus appear when they try to get employed. Sanctions against men, on the other hand, are applied after they have been employed.

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Custody of children after a divorce has, as a rule, been awarded to the parents jointly since the 1980s. In practice, this means that whilst the mutual marriage is dissolved, the mutual parental responsibility continues. This is an important change historically. It strengthens the father’s position. Custody formerly tended to go to the mother alone.

An international comparison A comparison between Sweden and Germany during the postwar period shows interesting differences (Kolbe 2002). The high participation of Swedish women on the labour market and the corresponding high participation among Swedish fathers in the care of their children turn out to have had no counterpart in Germany. There is also a significant difference in the birth rates: Sweden had one of the highest birth rates in Europe up to the mid 1990s. In 1992 the total fertility rate was as high as 2.1 (total fertility rate: number of children born per woman of one generation of women). During the same period German birth rates sank to the lowest in Europe, matched only by Spain and the northern parts of Italy. In these countries the general expectation was that only fathers should be gainfully employed whereas mothers were expected to be responsible for housework and the care of children. The rapid and extensive building of day-care centres in Sweden during the beginning of the 1970s had no counterpart in Germany. The combination of work and children is difficult and this might be one of the most important explanations for low birth rates in Germany and other European countries with similar family policies. Can the differences between birth rates and perhaps also the attitudes towards children be explained by the Swedish policies regarding the family? Or are they in themselves typical of Swedish tradition and mentality? Are Swedes a particularly childloving people? Or were the higher birth rates perhaps due to the Swedish fathers’ increasing interest and participation in the care of their children? These questions are difficult to answer. During the last decade German family policy has somewhat approached the Swedish model, whereas Swedish family allowances were reduced during the recession in the mid 1990s, with an accompanying fall in the birth rate. The birth rate in Germany is still lower than that in Sweden, and the Swedish birth rate has, as mentioned above, started to rise again.

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Conclusion For the children, major benefits could reasonably be deemed to accrue from having two parents with equal responsibility. The imbalance between the responsibility borne by women and men for their children nonetheless remains, as evinced by the fact that a low percentage of Swedish men take out their share of parental insurance. The historical Swedish trend and international comparisons may present at least two solutions to this problem. One is increased social responsibility for children – for example, by increasing the number of day-care centres. The other solution, which at least in principle does not entail any financial burden on society, would be an equal division between women and men in the assumption of responsibility not only for children but also for the social costs inherent in so doing. The Swedish birth rate was high compared to most other European countries at the beginning of the 1990s. It then fell, but has recently started to rise again. In Sweden it seems that the level of compensation in parental allowance may have played a role. However, the impact of social legislation and gender roles on the birth rates still largely remains to be investigated.

References Bengtsson, Magdalena (1996) Det hotade barnet. Tre generationers spädbarns- och barnadödlighet i 1800talets Linköping. [The Child at Risk – Infant and Child Mortality in Three Generations in Nineteenth Century Linköping]. Linköping Studies in Arts and Science 125, Linköping. Bygdeman, Marc and Lindahl, Katarina (1994) Sex Education and Reproductive Health in Sweden in the Twentieth Century. Report for The International Conference on Population and Development in Cairo 1994. Swedish Government Official Reports 1994:37. Ministry for Foreign Affairs. Högberg, Ulf (1985) Maternal Mortality in Sweden. Umeå: Umeå University Medical Dissertations. Kolbe, Wiebke (2002) Elternschaft im Wohlfahrtsstaat. Schweden und die Bundesrepublik im Vergleich 1945–2000. Campus Verlag, Frankfurt/New York. Reihe: Geschichte und Geschlechter 38. Hrsg. Ute Daniel, Karen Hausen and Heide Wunder Kälvemark (Ohlander), Ann-Sofie (1980) More Children of Better Quality? Aspects on Swedish Population Policy in the 1930s. Studia Historica Upsaliensia 115. Uppsala, Almqvist & Wiksell International. Kälvemark (Ohlander), Ann-Sofie (1977) “The Country that Kept Track of its Population. Methodological Aspects of Swedish Population Records”. The Scandinavian Journal of History. Stockholm 1977:2. Moberg, Eva (1961) “Kvinnans villkorliga frigivning” [“Women’s Conditional discharge”]. In Hederberg, Hans (ed), Unga liberaler [Young Liberals]. Stockholm: Bonniers. Ohlander, Ann-Sofie (1995) “La vuelta del padre? Una visión historica de la paternidad en Suecia.” In La figura del padre en las familias de las sociedades desarrolladas. Actas del simposium Internacional (Las

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Palmas de Gran Canaria, octubre 1994). Gobierno de Canarias, Departamento de Psicología y Sociología de la Universidad de Las Palmas de Gran Canaria, Fundación Centro de Orientación Familiar de Canarias. Ohlander, Ann-Sofie (2002) “‘Mina herrar!’ Mansrepresentationen i Sveriges riksdag” [“‘Gentlemen!’ On Men’s Representation in the Swedish Parliament”]. In Rösträtten 80 år.(Universal Suffrage 80 years). Stockholm: Justititedepartementet (Ministry of Justice). Ohlander, Ann-Sofie (1992) “The Invisible Child? The Struggle over Social Democratic Family Policy”. In Creating Social Democracy. A Century of the Social Democratic Labour Party in Sweden. Misgeld, Klaus, Molin Karl and Åmark, Klas (eds.). University Park, Pennsylvania, The Pennsylvania State University Press. Ohlander, Ann-Sofie (1994) Women, Work and Children in Sweden 1850–1993. Report for the International Conference on Population and Development in Cairo 1994. Swedish Government Official Reports 1994:38. Ministry for Foreign Affairs. – Also available in French: Les femmes, les enfants et le travail en Suède 1850. 1993. Rapport pour la Conférence Internationale sur la Population et le Développement Le Caire 1994. Rapports de commissions d’enquête officielles 1994:38. Ministère des Affaires Étrangères. Statistics Sweden 2004. På tal om kvinnor och män. Lathund om jämställdhet 2002. Stockholm: Statistiska centralbyrån. Programmet för jämställdhetsanalys. 2002, s. 38. (Women and Men in Sweden: Facts and Figures. Stockholm: Statistics Sweden. Gender Statistics Unit). Sjöberg, Marja Taussi (1986) Dufvans fångar. Brottet, straffet och människan i 1800- talets Sverige [The Prisoners of the “Dove” Prison. Crime, Punishment and People in Nineteenth-Century Sweden]. Stockholm: Författarförlaget. The National Social Insurance Board 2002. Riksförsäkringsverket analyserar 2002:14. Spelade pappamånaden någon roll? Pappornas uttag av föräldrapenning [Did ”daddy’s months" Play Any Role? Parental Allowance Paid to Fathers]. Stockholm: Riksförsäkringsverket. The Swedish National Social Insurance Board. Internet Home Page: www.rfv.se. August 2002. Weiner, Gena 1995) De räddade barnen. Om fattiga barn, mödrar och fäder och deras möte med filantropin i Hagalund 1900–1940 [The Saved Children. On Poor Children, Mothers and Fathers and their Meeting with the Philanthropy of Hagalund 1900–1940]. Södertälje, Hjelms förlag. Wennemo, Irene (1994) Sharing the Costs of Children. Studies on the Development of Family Support in the OECD Countries. Stockholm: Swedish Institute for Social Research 25.

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Epilogue The Politics and Policy of Population Health: A Comparative Perspective Presented by Daniel M. Fox (Milbank Memorial Fund, New York, USA)

This article raises analytical questions that can explain how policymakers in any country formulate problems for which health policy is the solution, array feasible alternative policies, enact policy (or fail to do so), implement it when they are successful, and then evaluate what they have done. These analytical questions are a framework for understanding the politics of health policy in any country. The questions are important because the politics of health policy – starting from what it is practical to define as health policy – are the principal factor that determines for particular countries why some policy alternatives become law and regulation while others do not. Put another way, the purpose of this article is to advocate that persons who study policy for population health both in particular countries and comparatively should begin with questions about politics and political culture, broadly defined, rather than with questions about mortality, morbidity and the determinants of health. The examples here are drawn from the United States. I do that for two reasons. One reason is that these are the examples I know best. The other is to offer evidence so that

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readers in the European Union and elsewhere can draw comparisons between the United States and other countries. Please note, however, that a fundamental premise of this paper is that it is important to know how countries differ before analyzing how, if at all, they are similar. The six questions that I will put distil what I have observed policymakers in health and social policy doing, and what I have done myself, for almost four decades. Although literature in political science, policy analysis and public management has enriched my understanding over many years, I have increasingly found my academic colleagues to be most persuasive when their findings validate my experience. I privilege experience because I learned as a young public official that most persons in senior positions in government employ more rigorous intellectual standards than most academics. They do so because they are constantly at risk of failure and disgrace and, as a result, of exile from positions of power. Moreover, in contrast to people who choose careers in research, policymakers are evaluated by voters, leaders of interest groups, journalists, as well as peers. People who can be undone in hours as a result of intellectual sloppiness for which they are accountable value accurate data and precise language. I learned more about how to write precise and concise prose in my first week in government than I had as a student at Harvard University. Politics is both inseparable from and preliminary to policy. During a public career of almost four decades, I have never worked with or heard about a successful policymaker who asked, abstractly, what should be done to solve a particular health or social problem. Policymakers invariably try to understand a problem at the same time that they assess what it is feasible to do about it. They understand that politics determines whether it is feasible to solve a problem at a particular time and which policy alternatives do and do not have any chance of being adopted. Formulating problems that can be solved by policy is difficult. Here is an example of that difficulty. In many of the countries of the European Union and other industrial democracies, policymakers have agreed that reducing disparities in income and health status between socioeconomic or ethnoracial groups is a problem that can be addressed. In other countries, for instance the United States, it is not currently possible to use evidence of such disparities as the basis for policy. This does not mean that the United States does not make policy to address the problems of health status that result from people in some groups not having enough

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Epilogue – The Politics and Policy of Population Health: A Comparative Perspective

money. American states and the federal government frequently enact policy to ensure that retirees and children have access to income and services that sustain their health. Adequacy is a more effective political issue than disparity in the United States because most of its citizens believe that liberty and opportunity reduce inequality. The difference between adequacy and disparity as the basis for policy can be further demonstrated by comparing how countries of the European Union and the United States define poverty. In Europe, poverty is a relative concept: it is defined as a percentage of the median income. That is, the European definition of poverty is the result of the concept of disparity – some having more and some less – having political legitimacy. The United States defines poverty as income below a minimum, according to family size. The “poverty line” is determined by the cost of a minimum amount of goods and services. That its, the American definition of poverty prioritizes adequacy over disparity. It is no accident that the Canadians, who have been using a poverty line, are currently debating adopting the relative European definition. I do not judge either the European or the United States definition of poverty. My point is to use the different definitions to show that all health and social policy is grounded in politics and political culture. The first of my six questions for analyzing the politics of policy is about how people in different countries formulate problems. More specifically, how do leaders in the politics of policymaking in any country at any time characterize the health and social problems that they will address? By leaders, I mean both public officials and influential persons in the private sector, including leaders of business, interest groups and the media. The second question addresses the process by which policy makers decide which alternative policies could remedy problems they have chosen to address: How do policy makers decide which potential policies are worth their taking political risks to achieve? The third question is about the results of taking political risks. How do alternatives that are potentially achievable become policy, and how do the politics of policymaking affect the alternative that is successful? Fourth, how and by whom are particular policies implemented and how does implementation modify those policies?

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Fifth, how and by whom are the criteria and methods for evaluating the effects of a policy devised and how (and by whom) is evaluation conducted? Finally, how and by whom are the results of evaluating the effects of policy judged and what happens as a result of such judgment? To illustrate how answering the six questions can lead to a story that is both coherent and informative, I offer some recent history of the United States variant of an international phenomenon. That phenomenon is the promotion of concepts and language to inform policy to improve and maintain the health of populations. I chose this illustration because many persons in Europe and elsewhere who will read this paper are familiar with the international concepts and language of population health. In the paragraphs that follow, I am building on – but not describing – what I know from reading and conversation about population health thought and policy in other countries than mine, and particularly in Canada, China, Sweden and the United Kingdom. Research on rates and causes of mortality and morbidity and debate about policy to improve health status have a long history. Beginning in the 1930s researchers, especially in the United Kingdom, introduced new theories and methods for studying the health status of populations. By the 1970s, perhaps even earlier in some places, a small number of researchers had begun to call this discourse “population health” in order to distinguish it from “public health”, which they criticized for defining too narrowly the determinants of health status and methods to improve it; for example, focusing on surveillance, regulation and health services rather than taking full account of, for example, the health effects of nutrition, behaviour, income and social class. The language of the new discourse of population health began to appear in documents published by the Canadian federal government, the OECD and the World Health Organization in the 1970s. By the 1990s both the World Bank and its antagonists among researchers and policy advocates routinely used this language to discuss economic growth and stagnation in developing countries. Several key phrases in this language are familiar to everyone who has done research on health policy and social change. These phrases include identifying the determinants of health status and measuring their relative impact; measuring how disparities in access to care affect health status and the outcomes of care; identifying and promoting crosssectoral approaches to multiple determinants of health, and summary measures of health status. I am personally sympathetic to the concepts that underlie these phrases and

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eagerly read evidence about whether and how the discourse of population health informs policymakers in various countries. However, the international discourse of population health has scant appeal to policymakers in the United States. In population health as, recently, in some matters of international security, the United States insists on going its own way. I have attended or chaired meetings in which researchers from the United States and Canada tried to persuade American decision-makers from government and business that they should apply the concepts and language of population health. Decision makers have been perplexed at each of these meetings. Here are some representative comments: • “I am not particularly interested in summary measures of health status because I must have numbers that can be disaggregated so that I can manage more effectively.” • “It might be nice to know how much each determinant contributes to health status but I can only address determinants that are within my authority.” • “Income disparities may be unfortunate but income redistribution is a nonstarter in American politics most of the time.” These quotations exemplify the politics of policymaking in the United States. They are some of the evidence from which I could, on another, more didactic occasion, answer in detail each of my six general questions. However, many colleagues in the United States who are passionately committed to the international discourse of population health believe that they should be missionaries. They try to persuade policymakers that the statements I have quoted are wrong; they insist that American policymakers learn from their peers in European countries. Alas, their efforts at persuasion are counter-productive, reinforcing disconnectedness between researchers and policymakers. Here is a story in point. A group of policymakers are now supervising the completion of the most detailed accounting of government spending for population health in the fifty states that comprise the United States. Colleagues at the World Health Organization and in other countries say that accounting that employs such a broad definition of population health has not been attempted elsewhere. Nevertheless, a respected American population health intellectual disparaged this project. She told me “You cannot categorize population health because the entire budget of any state determines the health of the population.”

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This statement achieves the paradoxical effect of making it impossible for policymakers and interest groups to engage in the normal politics of budgeting. Battles over public budgets in the United States are fought line by line, behind closed doors and in public. In order to have a health budget to defend against enormous competition for resources, policymakers must define some budget lines as more important than others for maintaining the health of particular populations. They find it essential to specify that disease surveillance, health education, environmental quality, food, road and air safety, protection against toxins in the environment, income adequacy, health care, and responses to disasters are critically important for population health. Government response to the terrible events of September 11 yields additional evidence about the politics of policymaking in the United States. By mid-October 2001, four cases of anthrax had been diagnosed. To my knowledge, nobody (neither policymakers, journalists nor any ordinary citizen) inquired about the extent to which anthrax is a determinant of the health status of a population of 260 million people in order to justify activities to counter bio-terrorism. Instead there was consensus that we should spend as much as seemed necessary to protect the public even though nobody could predict whether at the end of October there would be five, 50,000, or as in fact happened, 22 cases of anthrax. Some eminent population health intellectuals, and not just in the United States, are disappointed that the politics of policy, in many and perhaps most industrial countries, frequently ignores denominators and calculations of cost-effectiveness. Several have said, privately, during the past year that the amount the United States is spending in response to terrorism would produce more quality-adjusted life years if it was allocated to improving diet and behaviour in order to prevent heart disease or to reducing ethnoracial disparities in access to care. Others merely wish that other determinants of health than disease and disaster caused by terrorists could attract the same amount of funding; that the public and policymakers who are required to be attuned to what the public wants and can be persuaded to accept have other priorities than health. These examples illustrate how one political culture works; the one in which I live. Each of you participates in a political culture that is equally distinctive and equally confusing to people who live elsewhere. I will conclude by suggesting that this distinctiveness could be useful for research, including research on social change. This, then, is a comparative paper that invites readers to do the comparing.

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I will summarize the argument I have just made in two hypotheses, each of which I submit has importance far beyond the boundaries of the United States. The first hypothesis offers an approach to research on health and social policy and its consequences; the second applies the general hypothesis to recent events in the United States (again, in order to invite comparison, not to describe American exceptionalism). The general hypothesis is that understanding of the politics of policy for population health will be improved if researchers examine the scope and discourse of such policy empirically within any country and its sub-units. Many notable researchers are studying this hypothesis, including persons in France, Russia and Sweden as well as the United States. The hypothesis that is specific to the United States, but which may also be true for countries of the European Union and elsewhere, is that policymakers have been expanding the boundaries of population health policy in recent years. A decade or so ago most American policymakers agreed that policy for health encompassed accessible personal health services, the surveillance, prevention and protection responsibilities of public health agencies, monitoring environmental quality and removing hazards, protecting the safety of the food supply and, though vaguely, aspects of formal education. The scope of health policy expanded in the 1990s, and there is evidence that this expansion is accelerating. Policymakers are, for example: • Using the findings of population-based research on health care interventions and especially the findings of the new science of research synthesis to inform public policy for regulating and financing health services, and within several large, multi-national corporations, policy to protect and improve the health of employees and their dependents; • Revising legal and administrative arrangements for population health, especially for responses to emergencies caused by disease and disaster that require coordination among diverse units of government that are responsible for public health, health care, criminal justice, emergency preparedness and environmental quality; • Devising new policies to encourage more savings for retirement and reforming the organization and financing of long term care services in order to address mounting evidence that diminished income and quality of life await many persons born between 1946 and 1964;

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Crafting policies for urban and suburban planning and land use that simultaneously stimulate economic growth and reduce ill-health that results from constraints on physical activity and polluted air; Translating the methods of science-based regulatory policy that has reduced the incidence of food-borne illness to health care in order to enhance the safety of patients; Redefining foreign, national security and trade policy to take account of evidence that improving and maintaining the health status of populations in developing countries is increasingly in the national interest of the United States.

The people who are making these policies do so because of their answers to the six questions about the politics of policy. I now return to these questions in order to describe somewhat more systematically, but still in summary, the politics of health policy in the United States. Policy for population health is what policymakers believe that significant numbers of voters, health professionals and interest groups will approve of their doing, even encourage them to do, about health at a particular time. In the United States these policymakers include: • officials of the legislative and executive branches of government responsible for public health, environmental affairs and decisions about health care access, cost and quality; • executives in the private and public sectors who decide what services and drugs will and will not be paid for with corporate and government funds; • leaders of professions, especially medicine and public health but also nurses, managers and the lawyers who craft the rules that specify and implement policy. Policy for population health evolves constantly. Those who are charged with making it and their staff calculate what the people to whom they are accountable want (in comparison with other wants). They also assess what the groups (including researchers) trying to persuade them that their interests are the same as those of the public want (and what they are willing to do to promote their interests). Policymakers also know that many, perhaps most, people are not eager to pay for what they say they want. In order to emphasize that this paper is about Europe and other countries, despite adducing evidence mainly from the United States, I remind you of a shrewd European insight by a great European social scientist, Max Weber. Eight decades ago Weber wrote that “Politics is the slow boring of hard boards.” It still is.

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I have considerable evidence from political experience and research that this summary, and the answers to the six general questions on which I base it, explain how policymakers make choices in the United States. But are the questions useful for studying choices in other countries? Research that I conducted in Britain and ongoing reading and conversation with colleagues there suggest that the questions help to explain policy choices in that country. Collaboration with policymakers in several Canadian provinces offers similar evidence. Three English-speaking countries is, of course, a very limited sample. I invite comments on my recommendations for assessing how policymakers make choices and survive in order to make more choices in the future. If an approach similar to what I have suggested produces thick and persuasive descriptions of the politics of policymaking in different political cultures and subcultures we will all know much more than we do now.

Endnote The oral version of this paper, which I presented at the PhoenixTN meeting in Évora, concluded with the invitation and challenge in the previous paragraph. Several months later, one of the participants in Évora, Dr. Mickey Chapra of the University of Western Cape in South Africa, sent me a message that confirmed my suggestion that my theme has resonance far beyond the borders of the United States. Dr. Chapra wrote, “Reflecting upon what is going on in Southern Africa at the moment, I do not think it is an exaggeration to state that it is politics that is the major determinant of health.” Indeed.

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