Health Care and Poor Relief in 18th and 19th Century Southern Europe

Ole Peter Grell, Andrew Cunningham

• Publisher: Routledge
• Year: 2017
• Topic: History
• eBook ISBN:
  9781351931366
• Subtopic: World History
• Index: History

The poor and the sick-poor have always presented a problem to the governments and churches of Europe. Whose responsibility are they? Are they a wilful burden on the honest working population, or are they a necessary presence for the true Christian to live the true Christian life? In the 18th and 19th centuries what happened to the poor and the sick-poor in the north and south of Europe was different. In the north there occurred first the Reformation in the 16th century, which changed attitudes to the poor, and then the advent of industrialisation, with its far-reaching effects of pauperisation of people both in town and countryside. In the Catholic south, where industrialisation did not appear so soon, the Catholic Church introduced a programme of reform at all levels but along traditional lines. This included the founding of new orders dedicated to the care of the poor and sick, of new institutions within which to house and care for them. At all times it was taken for granted that it was a necessary aspect of being a Christian that one should give for the care of the needy, and that this was not the duty of the state or of secular institutions. The secularising movement did however reach the southern countries by way both of the Enlightenment and - more drastically - in the form of the Napoleonic invasions. But after the defeat of Napoleon, the Church reasserted its right to administer and control the support of the poor and sick, and this situation continued until 1900 in most areas. Moreover the effects of industrialisation and the concomitant increase in population did make itself felt in the south in the course of the 19th century, which put great stress on the institutions for poor relief and health care for the poor. All this is still relevant today, since the situations that governments and the Catholic Church found themselves confronted with, and the stark choices they had to make, are being replayed to some extent today. Who is responsible for the poor, who is to blame for their being poor? How should their poverty be relieved, how should the health care of the many be funded? These are still live issues today. While complete in itself the present volume also forms the fourth and last of a four-volume survey of health care and poor relief in Europe between 1500 and 1900, edited by Ole Peter Grell and Andrew Cunningham

Chapter One
Some Closing and Opening Remarks

Andrew Cunningham

Today on my way to work I was accosted by a beggar, then another and another. This is the year 2003, in a wealthy town in a wealthy country with low unemployment. When I was growing up I never saw a beggar, just the occasional traveller or 'man of the road', and if they begged from people then they did so unobtrusively and non-aggressively. It appears in fact as though, over the last thousand years or more, western Europe has been free of beggars only for a few decades, from about 1950 to about 1980, maybe an even shorter period. Now they are everywhere again, in the towns and cities of rich countries as well as poor, though not in such great numbers as our predecessors knew. Our personal and social responses to beggars today are replaying some of the arguments and discussions of people in every early modern Christian society where beggary was a universal fact of life, though today we discuss the issues largely without the Christian dimension any longer.

What were Christian people supposed to think about beggars and the sick poor? Were they a blessing – representatives of Christ, opportunities to practise the Christian virtue of charity? Or were they a curse, an indication that proper Christian values were not observed throughout society? What was one supposed to do to and for them? Give them personal charity: from one Christian to another? Give them disciplined charity: from one church, city, state agency to each poor person, on condition? Dissuade the beggars from their way of life by training them in the joys of employment? Punish them for challenging the ethic of work? Whose responsibility were they? What was the cause of their beggary and poverty? Was it personal failing on their parts – a moral weakness – simply a refusal to work? Was the apparent solution – the giving of charity – actually the cause of continued poverty, by locking the poor into a vicious circle of dependency?

This is for myself arid Ole Peter Grell a moment of closure, since this is the fourth and last in a series of volumes dealing with health care and poor relief in early modern Europe that we have edited. When we started the series of conferences on which these volumes are based, our own central concern was with the medical care given to the poor in early modern Europe: what kind of medical care did they receive and under what conditions? Of course in early modern Europe there were no state schemes offering universal health care for the poor, or indeed for the rich. Such schemes were begun only at the very end of the 19th and the beginning of the 20^th centuries. Before that period the rich had had to cater for themselves by hiring the services of physicians or surgeons as they needed them. The poor, by contrast, certainly did receive certain kinds of provision in times of sickness, but the medical assistance that they received was always linked to their poverty: they received medical assistance by virtue of their poverty. So we knew that it would be necessary for us and our contributors to look at both poor relief and health care as intimately linked issues. And poor relief was itself also linked to a myriad of other issues, all of which have subsequently been unlinked in modern societies, issues such as bastardy, the care and education of orphans, dowries for poor girls, the care of the insane, workhouses, rescuing women from prostitution, and care of the old who had no relatives to support them.

Our second concern throughout this series has been to try to produce a comparative view of the state of, and developments in, health care and poor relief across the whole of western Europe. Our own experience had shown us that if one takes only one country as one's focus for such questions, then one can end up trying to find local, particular, explanations for phenomena which in fact were common across many of the states of early modern Europe at the same time. Looking in this comparative way, it soon became clear to us that local, national, experiences of changes in health care and poor relief were actually only local variants on cross-European experiences. To limit oneself to giving an explanation in local, national, terms, meant ignoring the larger pressures and causes of change which were affecting states across great areas of Europe at a time. With the current tendency amongst historians to work within nationalistic boundaries, it is no surprise that there has not hitherto been any volume which synthesizes the health care and poor relief history of western Europe as a whole. But it is most unlikely that one would find a historian with the necessary skills to make such an overview out of all the separate national stories. So it was obvious to us that we would have to try and find historians within each modern west European state who could produce the appropriate local story for us. It would then be possible for the reader to contrast and compare the separate accounts and create a unified account for him or herself. We hope these volumes have made a start at least in this direction, by getting experts on each particular region or country to face the same set of questions as each other. Our success in finding historians to give coverage to every state in early modern Europe was good, but not always as great as we had hoped, since it seems that health care and poor relief are simply not topics that have yet found their historians in Ireland, Wales or Switzerland (for example) or in most of the regions of modern Spain. However, we believe that the range of case-studies that we have been able to gather in these volumes certainly makes it possible to make Europe-wide generalizations well-supported on a wide range of evidence from different countries.

Our third concern in creating this series was our conviction that from the early 16^th century the ways in which health care provisions and poor relief have been conceived and have been changed, owed a great deal to the great confessional change brought about by the Protestant Reformation and by its mirror-image movement (as it were) the Catholic Counter Reformation. In other words we took it as axiomatic that the kind of health care and poor relief offered by the rich for the poor depended on the ideology of the givers, and that Protestant givers would have created for themselves a different view of provision for the poor than Catholic givers had traditionally held. Both of us thought that the largely statistical approach to social history that had been the norm since the 1960s, whatever its other virtues may have been, had omitted the ideology of provision for the poor and the intentionality of the historical actors involved. The prevalent view among historians had thus been that the care that had been offered to the poor in different times and places was a simple response to perceived need. We, by contrast, felt that the perception of need is itself a product of ideological positions. We held out our own 'ideological' view to our contributors as a possible route for them to take in their accounts. Some of them did, while others did not, preferring to downplay if not dismiss altogether the role of religious ideology in health care and poor relief. However, we believe our own starting point to have been vindicated if one looks at the contributions in all four volumes as a whole. For there is a most striking north/south difference, running precisely along the fissure between Protestantism in the north and renewed Catholicism in the south. In the north from the Reformation onwards, provision of health care and poor relief, in all its changing ways, came to be seen as the responsibility of the community as a whole, not something to be left to the vagaries of individual charity. In the south, by contrast, from before and still after the Counter Reformation, personal charitable giving was deemed to be in itself a Christian duty, which was an essential part of true Christian living.

Turning now from my closing remarks to my opening remarks brings us to the themes of the present volume. In addition to the common experience of a renewed and refreshed Catholicity in the wake of Catholic Reform, the southern, Catholic, countries of Europe can all be seen to have been confronted with the same series of large events in this period, which in turn affected the situation of health care and poor relief in each country. First there was the intellectual movement known as the 'Enlightenment' in the course of the 18th century, according to which reason was to be preferred to religion, rationality to superstition, and the true nature of man was to be the basis of all measures to reform and improve society. The effect of the Enlightenment was considerably less in the south of Europe than in the north, but its impact was still significant in changing attitudes and strategies. No sooner had measures been taken to meet (or reject) these new values, than each and every one of these southern countries was invaded by Napoleon, bringing his particular French version of Enlightenment values. Napoleon and his agents sought to remodel all of these states along bureaucratic, centralized, lines. With respect to health care and poor relief this meant in practice removing the Catholic Church from any role in health care and poor relief, 'rationalising' institutions by consolidating small hospitals or confraternities into one, and locking up the poor in Depots de mendicité or workhouses. After Napoleon's defeat, the restoration of the status quo ante everywhere meant that the agents of the Catholic Church returned to take charge of the institutions, to fragment them again after their Napoleonic interlude, and to put a renewed stress on the indispensability of individual charitable giving, under state oversight. Then in 1848 the liberal revolution was experienced throughout southern Europe (except in Turin), and while it was a failure in itself, in its wake were introduced more liberal values – which for health care and poor relief meant a greater stress on the duties and failings of the individual, and the view that poverty was itself a moral failing which required punishment to be rectified.

Together with these experiences affecting health care and poor relief, the southern countries also all experienced repeated extreme famines. These, linked with the effect of early agricultural reform, drove many more poor starving people from the countryside to the towns, putting the institutions which provided for the poor under great strain. As in northern Europe, the initial stages of agricultural reform and industrialization, which in the long term were to provide much improved food supply and wealth, in the short term both brought with them greater poverty, and affected a wider range of people than hitherto, reducing capable workers to beggars.

Taken all together, these events led to a gradual differentiation of functions of the institutions of poor relief during the course of the 19th century, though with different rates of change in this respect in the different states, in effect laying down the bases for the collectivist state of the early 20^th century. But till the end of the 19th century, and in some cases even beyond this date, poverty and its alleviation did not become a purely secular affair in the southern states of Europe. The Catholic Church still jealously guarded charitable institutions from state takeover for as long as it could.

In all that follows, we need to remember that there were literally thousands of institutions dealing with different aspects of poverty in southern Europe in this period, most of them small and concentrating on one issue in one very limited locality, some of them very large indeed and with many purposes, such as the great hospitals for the poor and sick in the great cities which could accommodate hundreds of inmates and patients. Most but not all such institutions were in the towns. They were supported by legacies and donations, and run by a wide variety of organizations, among which the church orders were particularly visible, especially the new nursing orders and orders dedicated to the relief of the poor and sick, whose founding was a special feature of reformed Catholicism.

Although putting the poor to work – and thus making them self-supporting – always seemed like an excellent answer to indigence and begging, nowhere in Europe did it ever succeed in the long term, partly because it was at times of economic depression that indigence was at its height, partly because it was not acceptable to undercut other manufactories. So the workhouse scheme never worked as its proponents repeatedly hoped it would. It was a great dream which always turned out to be a nightmare.

I shall now draw attention to some salient points from the chapters which follow, and which indicate some of the local responses to the common challenges with respect to the poor and the sick which faced the rulers of the south European states in this period. Our volume opens with two general surveys of the economic and ideological state of southern Europe through these two centuries. In Chapter 2 John A. Davis shows the coincidence of agricultural and industrial changes in the 18th century with worries about population decrease, and a general flight of population to the towns, especially as a result of the frequent famines. Traditional (church and voluntary) forms of giving were put under stress leading, in the case of absolutist Hapsburg rule, to state intervention such as the building of great institutions by the state. Davis calls it a 'discourse of power rather than a functional response to the needs of the poor and the sick'.Nicholas Davidson in Chapter 3 explores the 18th century literature discussing the causes of poverty and potential solutions to it. The issue of individual Christian charity versus central government arises repeatedly in these discussions, though many economic arguments were also raised, both for and against a free market.

Austria was a centre of 'enlightened' thinking, and in Chapter 4 Martin Scheutz shows how, under the stress of an enlarged impoverished population, the Josephist reform of poor relief – the 'poor institutes'– though an attempt at centralization, was still parish-based, with the religious co-opted to collect and distribute voluntary contributions to finance it. This sort of compromise between state and church roles in disciplining and caring for the poor and the sick poor, was reflected in many other states of the time. Scheutz calls this period one of 'working poverty'. The treatment of the poor and the sick poor varied between relief and discipline, but increasingly poverty came to be conceptualised negatively.

In central Spain Pedro Carasa in Chapter 5 points to repeated battles between the Catholic Church and more secular attitudes over poverty and the provision of health care. A period of secularisation in the Renaissance had been followed by a clerical reaction, and the Counter-Roformation had produced a renewal of private Christian charity and new clerical institutions. In the 18th century the 'enlightened' again argued for a secular approach, and promoted the view that the cause of poverty was idleness, and its cure was work. A campaign to 'disentail' charitable institutions from their aristocratic and church followed, with the promotion of centralized, secular, charity institutions. Finally the 19th century liberals in Spain, with a class-oriented and capitalistic approach, came to see poverty as a necessary part of capitalist society. Carasa has much to say on the different liberal values as they were applied to poverty and health care of the poor in the 19th century. The general directions of change charted by Carasa for central Spain are to be found also in a more localized region, Catalonia and in particular in the growing industrial city of Barcelona. In Chapter 6 Alfons Zarzoso shows that here, too, the liberals of the early 19th century progressively demolished the church-controlled forms of assistance and transferred them to the control of civic authorities. He demonstrates the importance of the great institutions of Barcelona for the poor – the hospitals – and how they were affected by liberal attitudes. The 19th century liberal attitudes here, as elsewhere, led in general to a harder life for the poor and the sick-poor.

Surprisingly, the Catholic Church had relatively little influence on health care and poor relief in Portugal, according to Maria Antónia Lopes, in Chapter 7. Again absolutist rule was leavened by the relatively liberal Enlightenment values brought to the administration by the marquess of Pombal, with his General Police Administration, and his belief that Portugal should be 'a police state governed by the light of reason'. During his administration (1750–77) the poor were policed and documented by a system of internal passports. However, Pombal did not go so far as to take the institutions of poor relief into state control. In the 19th century here as elsewhere the relatively generous Enlightenment liberalism was to be replaced by a hard, individualistic bourgeois liberalism hostile to the relief of the poor.

As we turn to Rome and the other Italian states, we turn to the world of the confraternity: the mutual self-help groups established round trades, occupations and localities, which provided so much of the medical and food care for the poor, and other forms of social welfare. As Martin Papenheim shows in Chapter 8, Rome was necessarily the charity capital of Europe. Not only was it a great pilgrimage destination, requiring hostels and hospitals for so many of the nations of the earth, but it was also 'the capital of beggars'. Workhouses were repeatedly used to lock them up and set them to work. But all to no avail. The papacy had direct and indirect influence in the running of the great hospitals of the city, in particular the great Santo Spirito. Hospitals continued to be founded throughout the 19^th century in this great charitable town.

Parma, discussed by David Gentilcore in Chapter 9, had its Enlightenment moment under the secretary of State Dr Tillot. The 'protomedicato' system, imported into several Italian states from Spain, was employed to put all the policing of medical qualification and public health issues under one man, himself responsible directly to the sovereign. The main institution of care in Parma (again as elsewhere) was the Misericordia hospital, where medical teaching was introduced. Here in Parma, the Napoleonic period meant that it was the doctors who were in charge of the hospital and of admissions, rather than the religious.

Naples, the third largest city of Europe in the 18th century, had probably the greatest problem with respect to beggars, and their numbers and persistence were frequently remarked on by visitors to the town, who sometimes estimated the begging population at 10 per cent of all the residents. It could be expected that there would be an extensive 18th century debate on the problems of poverty. As Brigitte Marin shows in Chapter 10, 'enlightened' men recommended that the poor be set to work. But this was no solution in practice, and many of the poor ended up imprisoned in the Albergo di Poveri, founded in 1751 by Charles of Bourbon, a public institution which could hold 800 poor people in the 1780s and three and a half thousand in the 1840s. Many other destitute people were also in the enormous Incurables hospital.

In Bologna the confraternity scene was somewhat different from elsewhere since, as Gianna Pomata shows in Chapter 11, in the 17th and 18th centuries they came to be founded by aristocrats. The protomedicato system of the 18th century was replaced at the Napoleonic invasion by a system of rationalization of hospitals, the exclusion of religious control from the hospital system, and the creation of a Commissione di Sanità.

The territory of Piedmont was ahead of most Italian states in terms of administrative centralization. Victor Amadeus II invited some Jesuits in 1716 to assist with the reform of hospices and charity, and they encouraged rich donors to give not to individuals or institutions but only to the official collectors, who would disperse the money wisely to the poor in institutions or in their own homes, and in a strongly religious context. The Jesuit's aim, Giovanna Farrell-Vinay writes in Chapter 12, was 'that rich and poor alike would benefit from the establishment of efficient networks of hospices and congregations of charity. The rich would be freed from continuous harassment and have the opportunity to contribute to the spiritual redemption of the poor'. This turn towards confinement and spiritual reform of the poor was not totally successful, but presents an interesting interaction of state, church and personal giving in a local context.

With the final chapter (Chapter 13) we come full circl...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Contributors
• Acknowledgements
• 1. Some Closing and Opening Remarks
• 2. Health Care and Poor Relief in Southern Europe in the 18th and 19th Centuries
• 3. Poor Relief and Health Care in Southern Europe, 1700—1900: The Ideological Context
• 4. Demand and Charitable Supply: Poverty and Poor Relief in Austria in the 18th and 19th Centuries
• 5. Welfare Provision in Castile and Madrid
• 6. Poor Relief and Health Care in 18th and 19th Century Catalonia and Barcelona
• 7. Poor Relief, Social Control and Health Care in 18th and 19th Century Portugal
• 8. The Pope, the Beggar, the Sick, and the Brotherhoods: Health Care and Poor Relief in 18th and 19th Century Rome
• 9. Poor Relief, Enlightenment Medicine and the Protomedicato of Parma, 1748—1820
• 10. Poverty, Relief and Hospitals in Naples in the 18th and 19th Centuries
• 11. Medicine for the Poor in 18th and 19th Century Bologna
• 12. Welfare Provision in Piedmont
• 13. A Journey of Body and Soul: The Significance of the Hospitals in Southern, Catholic Europe for John Howard’s Views of Health Care and the Creation of the Utopian Hospital
• Index