Improving public health amidst crises. Introduction

Esteban Rodríguez-Ocaña (*) and Patrick Zylberman (**)

(*) Universidad de Granada. erodrig@ugr.es
(**) CERMES, Centre de recherche Médecine, Science, Santé et Société, CNRS, Paris. zylberma@vjf.cnrs.fr

This dossier springs from a meeting of the network "Health in the Interwar years" held in Granada in April 2007. This international network, which it is loosely organised around the electronic list of distribution maintained by the spiritful dedication of Iris Borowy, from Rostock University in Northern Germany, had a first presentation meeting in 2003, which produced a book on Facing Illness in Troubled Times. Health in Europe in the Interwar Years, 1918-1939 ¹. There we tried to grasp the actual health experiences beyond political shifts and organizational changes of the time, taking a view on the forming of health statistics that remained as main quantitative sources for the period. This allowed for a nuanced approach to the European past and contributed to the better understanding of the several case-studies (on Yugoslavia, Spain, Macedonia, Germany or Palestine, among others) presented. The book produced a nitid view of health as becoming a first-class political problem in the interwar years, full of questionings, rich in promises and burgeoning professional administrations, a space worth of further analysis. At a next informal gathering in Paris, at the occasion of the 2005 Conference of the European Association for the History of Medicine and Health, we decided that time was ripe for a second scientific meeting dealing with "Crises as opportunities for health?". We aimed to discuss aspects and initiatives of future developments that revealed themselves through the diverse critical situations lived during the interwar years in Europe, and their interconnecting links, by means of a plurality of singular, nation -or institution- centred studies. A selection of papers presented at the Granada meeting have been collected here, including a further one prepared independently that has been added because of its closeness to our subject. Thus, we present papers on Britain, Norway, Greece and Spain (two), as well as one on a Jewish organization in Russia and/or Poland and a further one on the activities of the main institutional international actor in public health of the time, the League of Nations Health Organisation.

All these papers have in common an enquiry into the impact in society of the social and scientific developments that earmarked the broad domain of health and how challenges and public health risks, old and new, were perceived and answered in different locals contexts. At the same time, case studies show a common context of shared assumptions and beliefs on public health issues, shaped by a growing consensus on public health doctrines sustained on networks of experts and the circulation of knowledge.

The interwar years were a critical period of European history. An epoch ended with the 1919 peace treaty and a new one was painfully born that harboured the appearance of a number of features that are still important traits in the European culture of today.

One of those is the rise of the health of the nation as a central concern, brought about as an immediate result of the casualties during the First World War and the impact of the influenza pandemic of 1918-19, and as an outcome of an older tradition, strengthened since the last third of the nineteenth century, that turned medicine and public health into a political issue ². The epidemiological transition, the diminishing size of the families and the increasing involvement of the state administration on health were experienced everywhere, although the particular implementation of each was dependent on national and personal contexts. Flowering social medicine increased attention to particular groups of population to which new schemes of expert intervention were directed, or refined, introducing health education as a foremost goal. This included an active search of clients among the targeted population by means of new networks of public health centres (under different names in each country). To the classic grouping of population (children, women workers, miners), peasants were added for the first time as a paramount target of health intervention ³. Standardization as a means of achieving scientific objectivity found its way through statistics and new international agreements. New types of health workers emerged. State health insurances spread out as they dawned in most European countries, increased its obligatory membership and upgraded the quality of provisions available, embodied in "the mixed economy of welfare" ⁴. And the international scene bred new expertise and produced new forms of legitimisation, while allowing for two-way paths of influence between the international and the national and local scenes that were exemplified by Rockefeller Foundation's campaigns and the League of Nations Health Organization endeavours ⁵.

The League of Nations has become in the last decade a topic of choice for the field of transnational history due to the new political conditions following the collapse of the Soviet Union and the wave of ethnic conflicts appeared in Europe ⁶. As Susan Pedersen writes in a recent review essay on the subject, greater attention is being paid to the less-studied areas of state-building and international cooperation, where archival research has been greatly enhanced, to show the profound innovation brought about by the League ⁷. At least three the articles in this Dossier, by Borowy, Menéndez and Theodorou/Karakatsani, are included in this description.

Borowy's article focuses on the activity of the LNHO around the six points research programme on the relationship between economic depression and health, which the Organization set itself on its agenda in October 1932. Borowy carefully explores the uneven development of the policies that framed the internationalist compromise that characterized the LNHO. A new type of international expertise, the LNHO went beyond the inter-governmental decision-making process to finally stand as a separate and seemingly superior space of decision and counselling. Guidelines on healthy diet, recommendations on improving education and income in order to enhance nutritional standards or the introduction of general principles to rationalize healthcare and public health national schemes, such as those issued between 1934 and 1937 by several LNHO sub-commissions sometimes including members of twin organizations like the International Labour Organization or the International Agriculture Institute, thus formed the basis for the holistic conception of health later recognised by the new World Health Organization in her own constitution (1948). One of the finest piece of this "third" League of Nations, little wonder that the LNHO survived and underwent a successful metamorphosis into WHO after the Second World War. For, in marked contrast to its most criticized security capacities, what the League's founders expected "to be minor adjuncts of its work" became in the end the main sources of its prestige.

However real was this international cooperation in the sphere of public health, contemporaries were often unable to know what were its laws or principles, exactly. One field of intervention for the LNHO was helping new European states to cope with the forming of their health administration, in a context of impairing epidemics and copious migration. A model case-study is provided by Greece, as studied by Vassiliki Theodorou and Despina Karakatsani. There LNHO and Rockefeller Foundation agreed and competed between themselves and with local agencies and officials. After a brief recall of the rise of a public health conscientious professional minority in Greece, the public health problems related to the bitter end of the long period of war, in one way or another, from 1913 to 1922, are shown. These were mostly linked to forced migration of hundred of thousands from Asia Minor, one of the catching focus of recent international scholarship ⁸. This case-study shows the difficult adaptation of international guidelines or norms into a particular national context, taking into account the political instability and the lack of a powerful professional minority compromised with the aims and methods of reform.

Among novelties of the interwar period a most lasting one was the medical and legal construction of a workers' disease linked to compensation schemes, silicosis. As Alfredo Menéndez explains in his article, it suited an international concern on the health of workers and on the political stability of nations that produced a international body of counselling, the ILO, and a growing national legislation on safety and health at work that gave rise to the new professional sector of the industrial physicians and the medical inspections of work. The process around pneumoconioses in Spain had not yet been studied, as accomplished here by Menéndez, who compares the endeavours of Republican and Francoist governments around this topic.

The comparison runs between two very different political regimes but also between these two regimes and an international body interacting with both of them. It thus provides a useful device to understand the complex framing of the scientific implication in the solution of social problems and, conversely, the uses of medicine and science as tools for political play. Even though the LNHO successfully built capillaries through its own organs and into national bureaucracies and corporate philanthropy, one can therefore ask to what extent did the growth of an international organization necessitate the growth of internationalism ⁹.

The multifaceted crises of the 1930s expose the shocking limits of such a growth. The 1920s had been a high point of international cooperation and state-building. The world had not been transformed, however. Nationalism remained as strong as ever, and the 1930s emerged in the midst of a renewed and still more violent struggle between democracy and dictatorship. It is against this backdrop that Josep L. Barona and Enrique Perdiguero scrutinize the health of the Spanish population in times of the civil war. They first set out to display the changes within the state health administration, highlighting the surprising feature of an Anarchist-held Ministry of Health (November 1936-August 1938) and the political quarrels with their Socialists counterpart. They describe the worsening conditions of life brought about by the war and its effects on the health of the population. Reports from international observers are used as main source, together with internal information from both sides of the conflict. International aid to the Republican side is followed, while the rebel's foreign support in health matters is still a blank in the copious historiography of the Spanish civil war. Democrats and leftists that helped the Spanish Republic against fascism published freely their advertisements, their meetings and their reports, while military secret seem to hamper the knowledge of details of the German intervention, duly praised by Spanish francoist authorities of the time. Admittedly, Barona/Perdiguero's study of civilian health conditions during the war will fill a gap in a historiography mostly devoted to the study of military health or the fate of particular institutions, disciplines or professional figures. This paper matches a recent thesis (PhD dissertation) read at the University of Pompeu Fabra (Barcelona) in 2005 which refers to 1931-1939 Catalonia ¹⁰. Recent epidemiological findings suggest that the consequences of the undernourishment in wartime extended beyond the actual acute, on the spot effects and resulted in a heavier toll of ischemic deaths in adult life for children born immediately after those episodes ¹¹.

Although Nadav Davidovitch and Rakefet Zalashik's article concentrates on the aftermath of the First World War in Eastern Europe, the period as well as the region were still full of sound and fury. Refugees, orphans and sick people wandered, often in appalling conditions. Charities and philanthropies, national and international, mobilized. Among them, the Society for the Preservation of the Health of the Jewish Population -or OZE, the acronym formed from its Russian name- addressed the health and hygiene questions among Eastern Jewish communities. Interactions with European and American philanthropic organizations (such as the Joint Distribution Committee of American Funds for the Relief of Jewish War Sufferers) and two public health campaigns conducted again "Jewish diseases", namely typhus and favus, are the main interests here of Davidovitch and Zalashik ¹². According to the authors, OZE served as a bridge between the local context and reform ideas originating from Western Europe and America. But, founded by Jewish physicians in St. Petersburg in 1912, and forced to move to Berlin in 1922, OZE was a transnational organization in its own right. It shed some light on the way Americans saw health issues in the aftermath of the war in Eastern Europe, and how they thought to remedy to these wounds, especially if one compares it with other philanthropies like the Rockefeller Foundation or the Milbank Memorial Fund. But more than that, it provides the opportunity to rise the question of an internal comparison between two cultures of health and race across Europe. As the article concludes, American philanthropies (or Western European, for that matter) offered money and knowledge, but organizations such as OZE offered "situated knowledge", without which relief and reform could never have been implemented.

The LNHO identified itself completely with the primary objective of the League of Nations, namely the development of this weak and shapeless area in the center of Europe that the First World War had just restored to political existence. It was some kind of a premonition of that "post-modern Empire", pluralistic and dedicated to a diplomacy of transparency and cooperation, based on the value of the individual, about which Robert Cooper speaks ¹³. Today, it takes the form of the European Union, which considers the State not as the instrument of a policy based on power but as a normative apparatus whose goal is to extend the application of law and solidarity to increasingly vast areas of the planet. Such an ideal is fraught with ambiguities. Ironically, much of these ambiguities are visible in the history of Western Europe during the interwar years. Scandinavia is a case in point.

Ida Blom's article about the politics of the birth-rate in Norway reflects on maternity, although by the indirect way of looking at the number and the health of infants. Within a common European tendency sprung from old mercantilism and aggravated by the consequences of the imperialist division of the world, the fast diminishing birth rate and a rising, mostly male migration to America, generated feelings of weakness in Norway at the beginnings of the twentieth century ¹⁴. Legal interventions started first in 1892, when protection was decided on working mothers, and increased particularly after 1915. In 1906 the first maternal dispensary was created to educate mothers and to control healthy children, a movement that was spread through private charities organizations after 1914. In 1924 a first counselling centre on contraception was opened that lead to a parallel, mostly municipally funded, network of clinics that had to fight strong moral opposition from the conservatives until the 1930s. In connection with this last move, legislation on forcible sterilization was implemented in 1934. In Blom's study, legal provisions and organizational implementation are related to common women's representations, using women's journals and collections of letters addressed to some of those centres. She discusses the health effect of these measures to conclude that the crisis of natality gave way to the opportunity of enhancing infant health as shown by deep sink of mortality and reduction in most specific causes of death.

What in the end was the balance sheet of the European public health of the period in-between the wars? Martin Gorsky offers here a carefully crafted contribution to the debate about the relative success or lack of success of English public health in the interwar years. This debate is a very live one at the moment. In the 1980s, Jane Lewis and Charles Webster stressed the weakness of the public health in England and Wales. A more positive view was recently proposed by A. Levene, M. Powell and J. Stewart as well as John Welshman, who set out to criticize the pessimistic assessment of Lewis and Webster ¹⁵. Gorsky chose to examine the policies and performances of public health services in the South-West of England as a means to re-evaluate interwar public health, along with the contribution of medical officers of health. "Failure", as he views it, seems in some respects unwarranted. Admittedly, responses to TB and learning disabilities showed serious lack of effectiveness, and maternal mortality remained appallingly high. All the same, regional disparities regarding maternal and child welfare narrowed, despite the economic depression. As for the MOsH, their positive influence demonstrably weighed upon new forms of services and advances in equity.

As Gorsky himself underscores, this rereading of the interwar years invites a fresh look at a later time. This goes not only for Britain. Did the causes of the decline of social medicine in the 1970s lie in the previous period? Were the consequences of the 1930's crisis long lasting? Shall we surmise long-term after-effects of the interwar crises upon the new social and administrative environment of the 1950s and 1960s? In the cases of Spain or Greece, for instance, but also Norway, evidences would counte-nance a positive answer.

References

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Webster, Charles. Medicine and the welfare state 1930-1970. In: Cooter; Pickstone, n. 2, p. 125-140;        [ Links ]

Cuesta Bustillo, Josefina; Samaniego Boneu, Mercedes. Los seguros sociales en la España del Siglo XX. Vol. 2 and vol. 3, Madrid: Ministerio del Trabajo y Seguridad Social; 1988.        [ Links ]

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11. González Zapata, Laura Inés et al. El hambre en la Guerra Civil española y la mortalidad por cardiopatía isquémica: una perspectiva desde la hipótesis de Barrer. Gaceta Sanitaria. 2006; 20 (5): 360-367        [ Links ]

12. The so-called "Jewish diseases" have attracted a good deal of historical works, among which: Gilman, Sander L. Jewish frontiers. Essays in bodies, histories, and identities. London: Palgrave; 2003, p. 149-168;        [ Links ]

Kraut, Alan M. Silent travelers: Germs, genes, and the "immigrant menace". Baltimore: Johns Hopkins University Press; 1995;        [ Links ]

Efron, John. Defenders of the race. Jewish doctors and race science in fin-de-siècle Europe. New Haven: Yale University Press 1994;        [ Links ]

Dwork, Deborah. Health conditions of immigrant Jews on the lower east side of New York: 1880-1914. Medical History. 1981; 25: 1-40.        [ Links ]

13. Cooper, Robert. The breaking of nations. Order and chaos in the twenty-first century. London: Atlantic Books; 2003, p. 61-78.        [ Links ]

14. A seminal gender approach to this subject was Thane, Pat; Bock, Gisela, eds. Maternity and gender politics. Women and the rise of the European welfare states 1880s-1950s. London: Routledge;1991.        [ Links ]

Of the vast industry on health policies regarding infant and children see for instance Gijswijt-Hofstra, Marijke; Marland, Hilary, eds. Cultures of child health in Britain and the Netherlands in the twentieth century. Amsterdam and New York: Rodopi; 2003;        [ Links ]

Masuy-Stroobant, Godelieve; Humblet, Perrine C., dirs. Meres et nourrissons. De la bienfaisance à la protection médico-sociale (1830-1945). Bruxelles: Éditions Labor; 2004;        [ Links ]

Stern, Alexandra Minna; Markel, Howard, eds. Formative years: children's health in the United States, 18802000. Ann Arbor: University of Michigan Press; 2004.        [ Links ]

15. See the bibliography in Gorsky's article.