Disease prevention in the collective
George Rosen, author of the classic A History of Public Health,1 argues that from the seventeenth century onwards, a mercantilist approach perceived the population as a resource, which helped to legitimise health on a collective level as an economic necessity.2 It should be noted, however, that mercantilism was a markedly different political system centred on the (absolute) ruler. The economy or the health of the population did not, in other words, serve a larger collective or entity like the nation state, but the political elite. In contrast, in the postlude to the French Revolution, individual and population health was elevated to a universal human right. These two perspectives create an interesting tension that seems to reappear time and again in the conceptual history of public health.
Existing research on the history of public health has identified a medical, scientific and social reform movement in the nineteenth century which had the aim of eliminating the pathogenic conditions identified in poor housing, inadequate sanitation, dangerous workplaces and poverty.3 Industrialisation has been identified as the driving force of the process that, on the one hand, contributed to urbanisation with a concentration of sources of infection and, on the other hand, required a large and healthy workforce.4 Efforts to reach these aims included a focus on social structures, social activism and a determination to improve the living conditions of the population in general.
Whereas nineteenth-century public health focused on the environment as a source of illness, in the early twentieth century it was complemented by a prophylactic approach. It placed the focus on the individual, in order to prevent disease in the collective as well as in the individual. Political opposition (in the US) to the progressive ambitions of older public health, new insurance statistics with a focus on lifestyle factors and an actual reduction of contagious diseases in the industrialised urban communities around the turn of the century contributed to a shift in perspective.5
The first half of the twentieth century was also in other ways a turning point in Western public health discourse. Many Western former imperial states, particularly in Europe, embraced democracy, communism, authoritarianism or fascism. This was not only a big political change, but resulted in social transformations as well. As nations struggled for hegemony in a spirit of rising nationalism, they intensified their focus on the national and social body, i.e., the population. The First World War was a peak of this development, when a war dominated by technology and modern forces of destruction hit the Western world, and left not only the national body but also the physical body of the individual with deep wounds. Eric Hobsbawm calls this time the âAge of Catastropheâ.6 This stimulated an increasing interest in health, the individual and the health of the entire population, as well as the development of new medical knowledge about the human body.
Technological and scientific progress was manifested in new ways of detecting disease and new treatments. Albert Calmette and Camille GuĂ©rin first created a vaccine against widespread tuberculosis (TB) in 1906. From the 1920s onwards, medical scientists started developing vaccines further (the first successful vaccine, against smallpox, had been introduced in the late eighteenth century). The development of penicillin by Sir Alexander Fleming in 1928 and its first use in the Second World War on soldiers constituted a turning point in health care. After the Second World War, both treatments â vaccination and penicillin â became widely available to the public in the Western world.
In our effort to understand how conceptualisations of public health and medicine have changed through history, in this book, we have sought to identify characterising developments. Clear-cut periodisations are often anachronistic in that, firstly, they mask how change in ideas, concepts and practices is gradual and even slow â and not necessarily even recognised by contemporaries. Secondly, they overlook how concepts and notions are built on past concepts and notions; i.e., how new ideas and concepts carry their history with them. In this book, we study how public health, health policy and medicine have been conceptualised at different times, and how these conceptualisations have evolved. Furthermore, we see them as interrelated, each creating their own layer on which later actors build new concepts. Therefore, rather than seeking to identify or label breaking points or distinct periods, we look at transition periods during which ideas, concepts and practices gradually take on new forms.
Since we are, in a sense, chasing a moving target, we need to focus on selected aspects of public health in order to make sense of conceptual change. In the early twentieth century, conceptualisations and notions included the concept of hygiene in its various forms7 and eugenics (or âracial hygieneâ, as it was called in German and the Nordic languages), as well as a focus on the individual as part of the collective (population, people, race, etc.).
Eugenics was one of many ways to conceptualise public health in the early twentieth century. Eugenicists drew upon Darwinian ideas of natural selection and their applications, such as those of Darwinâs cousin, Francis Galton. The idea was to shape and improve the quality of the population (or âraceâ). Galton saw eugenics as a means to manipulate natural selection in humankind.8 In his book Memories of My Life (1908), Galton described eugenics as follows:
Its first object is to check the birth-rate of the Unfit, instead of allowing them to come into being, though doomed in large numbers to perish prematurely. The second object is the improvement of the race by furthering the productivity of the Fit by early marriages and healthful rearing of their children. Natural selection rests upon excessive production and wholesale destruction; Eugenics on bringing no more individuals into the world than can be properly cared for, and those only of the best stock.9
Galton spoke as if from a position above the rest of the society. From this perspective, Galton and his followers were able to divide people into âFitâ and âUnfitâ groups. The âFitâ were those whose offspring were thought to be beneficial for the future of the âraceâ.
Positive eugenics (i.e., encouraging the reproduction of individuals with desired qualities...
