Health, Civilization and the State Changes in attitudes towards the provision of health care and the revolution in the structure of the bodies supplying it have been as frequent as changes in medical practice. Health, Civilization and the State examines the problems of public health provision in a historical perspective. It outlines the development of public health in a global context, from the ancient world through the medieval and early- modern periods to the modern state. It combines a clear account of the history of health service provision with a discussion of the social, economic and political issues at stake including: • pestilence, public order and morality in pre-modern times • the Enlightenment and its effects • public health and centralization in Victorian Britain • localization of health care in the United States • population issues and family welfare • the rise of the classic welfare state and its health care policies • attitudes towards public health into the twenty-first century. Health, Civilization and the State draws on the proliferation of works written in the last forty years on the social and historical approaches to the history of public health. Dorothy Porter is Wellcome Reader in the History of Medicine at Birkbeck College, University of London. I dedicate this book to my mother and late father Health, Civilization and the State A history of public health from ancient to modern times Dorothy Porter London and New York First published 1999 by Routledge 11 New Fetter Lane, London EC4P 4EE This edition published in the Taylor & Francis e-Library, 2005. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Simultaneously published in the USA and Canada by Routledge 29 West 35th Street, New York, NY 10001 © 1999 Dorothy Porter All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Porter, Dorothy. Health, Civilization and the State: a history of public health from ancient to modern times/Dorothy Porter. p. cm. Includes bibliographical references and index. 1. Public health—Social aspects—Europe—History. 2. Public health—Social aspects—North America—History. 3. Public health—Political aspects—Europe—History. 4. Public health—Political aspects—North America—History. 5. Social medicine—Europe—History. 6. Social medicine—North America—History. I.Title. RA424.P678 1999 362.1’09dc21 98–21836 ISBN 0-203-98057-3 Master e-book ISBN 0-415-12244-9 (hbk) 0-415-20036-9 (pbk) Contents Acknowledgements vii Introduction: Changing definitions of the history of public 1 health PART 1 Population, health and pre-modern states 9 1 Health and morality in the ancient world 10 2 Pestilence and public order in medieval Europe 23 3 Enlightenment discourse and health 45 PART 2 The right to health and the modern state 61 4 Social science and the quantitative analysis of health 63 5 Epidemics and social dislocation in the nineteenth century 77 6 Public health and the modern state: France, Sweden and 96 Germany 7 Public health and centralization: the Victorian British state110 8 The enforcement of health and resistance128 9 Localization and health salvation in the United States147 PART 3 The obligations of health in the twentieth century 163 10 The quality of population and family welfare: human 164 reproduction, eugenics and social policy 11 Health and the rise of the classic welfare state195 12 Conditional citizenship: the new political economy of health231 PART 4 Preparing for the twenty-first century 279 13 Being fit to live in the twenty-first century: healthy bodies and 280 somatic maps vi Epilogue 314 Bibliography 320 Index 367 Acknowledgements While writing this book I have accumulated many debts of friendship and support. First I should like to thank my large family for all the affection and support that they have always given to me. Among my closest friends the Abichou family have become almost like extended kin to me. A group of especially dear friends supported me in my worst travails and finest hours: Joanna Bourke, Sam and Jen Guttenplan, Vanessa Harding, Michael Imlach and Camilla, Hilary Sapire and Stella Tillyard and her family. All my colleagues and friends at Birkbeck College have made it a complete joy to work there. No one could ask for a more intellectually stimulating or profoundly gratifying environment than Birkbeck’s history department and no teacher could find finer students anywhere. The achievements of my research students, in particular, have given me some of my proudest moments. My appointment at Birkbeck was made possible through funding from the Wellcome Trust for which I am deeply grateful. Furthermore, the Wellcome Institute and Library provide myself and so many colleagues within the discipline of the history of medicine with fantastic research resources. Many colleagues and friends from within the communities of the history of medicine and science and the history of social policy have also helped me to develop this work. My special thanks go to those who read the manuscript at various stages, including two anonymous referees. I should also like to thank Heather McCallum for her patience, faith and excellent advice as an editor. The responsibility for the limitations of this work is, of course, entirely my own. Finally, I wish to thank Brian Dolan for allowing me to experience the happiest period of my life. Introduction Changing definitions of the history of public health For many students the idea of studying the history of public health provokes a very big yawn since it conjures up an image of investigating toilets, drains and political statutes through the ages. This caricature of public health history was fostered, in part, by administrative histories of public health written in the 1950s and early 1960s which documented parliamentary reforms and technological developments that helped to create healthier environments, which in turn reduced the spread of infectious disease. Historians of public health such as the political biographers Samuel Finer, R.A.Lewis and Royston Lambert (Finer, 1952; Lewis, 1952; Lambert, 1963) and the English public health officers who wrote outstanding administrative histories of public health, William Frazer and Colin Fraser Brockington (Frazer, 1950; Fraser Brockington, 1956) all used a definition of the subject which closely reflected the ideals of nineteenth-century public health reform. They and earlier public health practitioners, such as George Newman and Arthur Newsholme (Newsholme, 1927; Newman, 1932) equated public health with ‘the sanitary idea’ and methods of preventive medicine, such as vaccination. The limitation of infectious diseases through environmental and preventive reform was represented in this historiographical tradition as the triumphant culmination of a long tradition stretching back to biblical times. In 1952 René Sand, professor of social medicine at Brussels University, wrote an impressive account of what he called The Advance to Social Medicine from ancient to modern times (Sand, 1952). Similar themes were subsequently explored by George Rosen in 1958 when he wrote what became the definitive textbook on the history of public health (Rosen, 1958). Both Sand’s and Rosen’s works were imposing erudite surveys of health regulations from pre-Socratic times to the early years following the Second World War. Both accounts were written at a time when public health appeared to be victorious in achieving massive reductions in mortality rates in the Western world, when scientific medicine seemed to have almost eliminated the menace of pestilence. As a result Sand and Rosen both wrote grand narratives of progress, arising from the technological advance of science and medicine and its capacities to combat endemic and epidemic disease. This heroic vision was reinforced in 1976 by the conclusions of a professor of social medicine, Thomas McKeown, that clinical medicine had played no part in The Modern Rise of Population, which had, 2 INTRODUCTION he claimed, largely resulted from improved nutrition. McKeown also argued that environmental reforms such as the creation of clean water supplies had played a role in population growth (McKeown, 1976a; McKeown, 1976b). When the parameters of public health history were confined largely to sanitary reforms and the control of infectious diseases, then it was possible to argue that although public health was invented in the nineteenth century it had been preconfigured in technological developments stretching back through time, such as the Mosaic Code and Roman baths and aqueducts (Newman, 1932). In the three decades following the 1960s, social historians of health, illness and disease began to challenge such a view. In 1961 the eminent social historian of nineteenth-century Britain, Asa Briggs, suggested that the story of cholera had been overlooked as a major factor in historical change in Victorian society (Briggs, 1961). Subsequently, historians began to explore not only cholera but the impact of epidemic and infectious disease on historical transformations in early modern and modern European and North American societies. Historians such as Margaret Pelling, William Coleman, Charles Rosenberg, Charles Cippola, Paul Slack, James Riley, Richard Morris and Richard Evans (Pelling, 1978; Coleman, 1982; Coleman, 1987; Rosenberg, 1962; Cipolla, 1979; Slack, 1985; Riley, 1989; Morris, 1976; Evans, 1987) used the economic, social, political and ideological responses to disease to explore the complex ways in which change both caused and was determined by the impact of epidemics. This new historiography investigated the differential experience of epidemics by social classes, professionals, scientific and religious communities and political states and oligarchies (Kiple, 1993).