Perspectives in Medical Humanities Health Citizenship Essays in Social Medicine and Biomedical Politics Dorothy Porter, PhD Page Intentionally Left Blank Health Citizenship Perspectives in Medical Humanities Perspectives in Medical Humanities publishes scholarship produced or reviewed under the auspices of the University of California Medical Humanities Consortium, a multi-campus collaborative of faculty, students and trainees in the humanities, medi- cine, and health sciences. Our series invites scholars from the humanities and health care professions to share narratives and analysis on health, healing, and the contexts of our beliefs and practices that impact biomedical inquiry. General Editor Brian Dolan, PhD, Professor of Social Medicine and Medical Humanities, University of California, San Francisco (ucsf) [email protected] Recent and Forthcoming Titles The Remarkables: Endocrine Abnormalities in Art By Carol Clark and Orlo Clark (Fall 2011) Clowns and Jokers Can Heal Us: Comedy and Medicine By Albert Howard Carter iii (Fall, 2011) Paths to Innovation: Discovering Recombinant DNA, Oncogenes and Prions, In One Medical School, Over One Decade By Henry Bourne (Fall 2011) Darwin and the Emotions: Mind, Medicine and the Arts Edited by Angelique Richardson and Brian Dolan (Summer, 2012) www.medicalhumanities.ucsf.edu This series is made possible by the generous support of the Dean of the School of Medicine at ucsf, the Center for Humanities and Health Sciences at ucsf, and a Multicampus Research Program grant from the University of California Office of the President. To all of the inspirational students it has been and continues to be my privilege and honor to teach Health Citizenship Essays in Social Medicine and Biomedical Politics Dorothy Porter First published in 2011 by University Of California Medical Humanities Press and distributed by UC Press. berkeley — los angeles — london © 2011 University of California Medical Humanities Consortium 3333 California Street, Suite 485 San Francisco, ca 94143-0850 Cover Art by Rajlich Design (1995) Image courtesy of Wellcome Trust Library, London Library of Congress Control Number: 2011936638 isbn 978-0-9834639-3-1 Printed in usa Contents Acknowledgments ix Preface 1 Public Health 1 Changing Definitions of the History of Public Health 9 2 Public Health and the Rise of the Bureaucratic State in Nineteenth-Century Britain 23 3 Physical Culture and Health Citizenship 65 Social Medicine 4 What Was Social Medicine? An Historiographic Essay 84 5 Social Medicine and the New Society: Medicine and Scientific Humanism in Mid-Twentieth-Century Britain 104 6 John Ryle and the Party of Humanity 132 7 Late Modernism, Social Medicine, Epidemiology and Class Culture in Britain after the Second World War 154 8 The Decline of Social Medicine in Britain in the 1960s 182 9 The Changing Social Contract of Health in the Twentieth and Twenty-First Centuries 204 viii Health Citizenship Biomedical Identity 10 Eugenics, Public Health, and Environmentalism in Fin de Siècle Britain 221 11 Eugenics and the Sterilization Debate in Sweden and Britain before the Second World War 247 12 Biological Determinism, Evolutionary Fundamentalism, and the Rise of the Genoist Society 270 Index 295 Acknowledgments he research for the essays collected here took place over two decades. There Tare so many colleagues, students, friends and family members to thank for their support it would exhaust the space of the entire book to mention them all in- dividually. Similarly, the number of archives and archivists, libraries and librarians are far too many to mention each of them. I would like, however, to at least attend to a few amongst the very many that have been critical. Firstly I want to thank John Alfred Ryle’s children and grandchildren for the enthusiastic support of my attempt to re-engage his vision of social medicine and its relationship to health reform. All of his children, John, Tony and Margaret, gave me unique insights into their father’s world and his critical comradery as much as dearly romantic relationship with his wife Miriam. Tony Ryle gave me access to their father’s personal papers that had been brilliantly archived by their mother. The papers were ready and waiting for an historian to review and analyze them. Margaret Ryle provided me with copies of John Ryle’s unpublished manuscripts that were utterly engrossing in the opportunity they offered not only to understand Ryle’s reasoning but the academic and political spirit of his epoch. I was only able to meet John Ryle’s family because, after I presented a paper on him at what was then the Wellcome Institute for the History of Medicine, a questioner stood up and said, “I was very interested in your paper. I am John Ryle.” This was the distinguished journalist John Ryle, the grandson of John Alfred Ryle. I am eternally grateful for his help in allowing me to meet Ryle’s family who gave me such a distinctive understanding of this inimitably significant figure in the history of social medicine. For an extensive period during which this work was undertaken I was a lectur- er and later Professor of History at Birkbeck College in the University of London. No one could find a more stimulating and challenging academic environment than the School of History, Classics and Archeology at BBK. The mission of the college x Health Citizenship and the collegiality of the faculty and staff are as exceptional as each other. I could never have become an historian of any stripe without my extraordinary colleagues at Birkbeck. I must mention in particular my dearest friend and brilliant scholar Jo- anna Bourke and my singularly distinguished colleague and friend Michael Hunter. I can never thank them enough for all they have given to me in friendship and enlightenment. For part of this period in my career I was married to and continued to col- laborate with Roy Porter. It is not possible for me to express the deep influence he had upon my understanding of historical change. His grossly untimely death was a tragedy for the world of historical scholarship and the public understanding of medicine and science. In the last decade, my career emigrated across continents to the gorgeous West Coast of the United States where I took up a position as Professor in the History of Health Sciences at the University of California San Francisco. The opportunities for historical analysis of the transformations taking place in biomedical science, bioengineering, clinical medicine and global public health practice are flabbergast- ing at this world center of discovery and innovation. The small Department of Anthropology, History and Social Medicine occupies a tiny corner of this astonish- ing enterprise but one from which I and my colleagues gain a piercing view of a scientific revolution that has implications for transforming the world of health and medicine on a global scale. My colleagues here are intensely engaging and stimu- lating and I cannot thank them enough for the intellectual challenges they have provided me with. The publication of this collection is made possible by the brilliant vision and endeavor of the University of California Medical Humanities Consortium under the Directorship of Brian Dolan who created this book series and is its chief editor. He allowed this manuscript to go forward for peer review for consideration in this series and scrupulously attended to the recommendations from that process. I am eternally grateful to him and the University of California Press for their decision to publish this volume. This volume is dedicated to all the students I have taught and will teach in my career. I cannot say enough about the honor it has been, and is, to be able to help expand their understanding of historical change and the dialectics of knowledge. Preface his book is dedicated to all the talented and inspirational students it has Tbeen my great privilege to teach during my hugely rewarding career. It collects together a group of essays that have been scattered in a wide range of publications to provide a learning aid for current and future students eager to understand the history of public health, the rise of the modern state, the role of the social sciences in population health promotion, and the changing social contract of health citizenship in industrial and post-industrial societies. The rights and responsibilities of health citizenship are increasingly at the forefront of public policy debates concerning disease prevention and health management in dramatically changing demographic, economic, po- litical and ecological environments. Political discourses on the relationship between the health of populations and the wealth of nations have been pro- foundly influential in the history of the modern state since eighteenth and nineteenth-century philosophies explored the rights and responsibilities of democratic citizenship. In 1792 French revolutionaries declared health an obligation of the so- cial contract between the democratic state and its citizens and invented the idea of health citizenship.1 When the Constituent Assembly’s Committee on Salubrity and the National Convention added health to the democratic state’s obligations to its citizens they believed this could be achieved by establishing a network of rural health officers who, while trained in clinical medicine, would also become responsible for reporting on the health of communities and monitoring epidemics among humans and farm animals. The citizen’s charter of health, however, was double-sided. The idéologue Constantin- François de Chasseboeuf, comte de Volney, raised the issue of citizens’ re- sponsibility to maintain their own health for the benefit of the state. In the new social order the individual was a political and economic unit of a collec- tive whole.2 It was a citizen’s duty to keep healthy through temperance, both in the consumption of pleasure and the exercise of passions, and through cleanliness. 2 Health Citizenship The dialectical relationship of health citizenship, entitlements, and re- sponsibilities was subsequently expressed in the political and social develop- ment of public health systems and practices up to the twenty-first century.