Health and Citizenship

Political Cultures of Health in Modern Europe

Frank Huisman, Harry Oosterhuis

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9781848934320
• eBook ISBN: 9781317319023
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

This collection of essays looks at issues of health and citizenship in Europe across two centuries. Contributors examine the extent to which the state can interfere with the private lives of its citizens, the role of individual responsibility and if any boundary occurs in terms of what the state can realistically provide.

Part I: Liberal Citizenship and Public Health

After the French Revolution had proclaimed the principles of liberty, equality and fraternity, it was up to post-revolutionary generations to take a stance towards them. This section is concerned with the dilemmas of liberal citizenship, in relation to developments in (public) health care during the nineteenth and early twentieth century. All four chapters are about the relationship between citizens and the state in a period in which Europe was going through profound social (industrialization) and political (democratization) changes. Over the course of the nineteenth century, liberal democracy gradually took shape and the first contours of public health in industrial society appeared. Inherent tensions between liberal-democratic principles troubled the relation between health and citizenship. Each of the chapters discusses the contradictions within liberalism with respect to state intervention, the role of medicine in society and the protection of individual rights. Their common focus is the problem of reconciling freedom and distributive justice.

Matthew Ramsey outlines the tension between the promises of the French Revolution with respect to public health care and the liberal aversion to direct intervention by the state in society. Among other things, the constitution of 1791 had promised a broad system of public assistance, but the liberal respect for individual autonomy, private property and free enterprise hampered the enactment of compulsory legislation. Two major projects – one on poor relief and the other on medicine – sought to make medical assistance available to the poor. The authors of both projects, however, expressed distrust of a state apparatus exercising uniform control over poor relief and the provision of health care. As the project for poor relief evolved, it increasingly diminished the role of the state, emphasizing the contributions of voluntary philanthropy. In fact neither project was ever implemented. Indeed, again and again, arrangements for medical assistance to the poor reaffirmed liberal misgivings about state-intervention. In public assistance, commonly seen as a duty of society rather than as a right of the citizen, the state merely advanced private philanthropy and mutual aid – a policy that continued to dominate until the 1930s. To a large extent, public health measures depended on the good will and resources of local authorities. Over the course of the nineteenth century, a series of piecemeal measures extended the reach of medical assistance programmes at the level of the municipality and the département. In 1893, a medical assistance act made the provision of health care for the indigent an obligation for the municipality, the département and the state. The programme was highly decentralized, and many individuals who were too poor to pay for private insurance or membership in a mutual aid society, were not poor enough to qualify for government assistance. In the end, the French Revolution fell short of its high expectations. It had dismantled the network of local charitable institutions of the Ancien Régime, but it did not succeed in putting a new national system of public assistance in its place. Ramsey concludes that despite the high flown ideals of the Revolution, French citizens have never shared a common right to health care, and do not fully do so today.

The implementation of public health policies never went uncontested, especially when commercial interests were involved, especially in a liberal political context. By exploring the case of the British shellfish trade – an economically important yet unregulated industry – Anne Hardy shows that the state could not simply impose civic responsibility on society on the basis of unequivocal scientific evidence on the risks of the shellfish trade. In a way, entrepreneurship implied a one-sided interpretation of liberal citizenship in terms of freedom at the cost of the public interest. The suggestion that typhoid and gastro-enteritis might be transmitted to humans by eating sewage-contaminated shellfish caused a major food scare in Great Britain around 1900. After the connection was suggested by epidemiologists, the different interest groups quickly co-opted bacteriology in an attempt to either confirm or refute the claim made by epidemiologists. Since bacteriology was still in its infancy, its claims were contested. Its uncertainties were exploited by the liberal interests of free enterprise, which sought to reject moves by the state to impose hygienic controls on the shellfish industry. Thus, the decade around 1900 witnessed a collision between economic group interests and collective health interests. The issue raised questions of scientific authority, of the pros and cons of state intervention, and of the social responsibility of the food trade towards consumers. Hardy explores the clash of interests over shellfish borne typhoid, and the ways in which scientific knowledge was used by the different parties to argue their case. Initially, the fish trade had been determined not to give in to the regulatory demands made by science and the state. It had sought to destabilize bacteriological knowledge and ignored political calls to take responsibility for its products. However, under the pressure of loss of public trust (and hence market share), the trade had to give in and move towards self-regulation. One could argue that this is a case of citizenship and civic responsibility forced on entrepreneurs by the market – rather than by science or the state. Negotiated in the years between 1895 and 1905, the outcome of this crisis is suggestive of a preference for self-regulation and minimalist state intervention that may still be observed in British attitudes towards food safety.

Frank Huisman moves the focus from the domain of public health to individual health care. By looking at the debate on Dutch medical legislation that was current in the 1910s, he explores the strained relations between patient autonomy and professional medical authority. The debate is a perfect illustration of the democratic paradox. Liberal democracy was based on the principle that the state guarantees civil liberties. To liberals, social policies should not be based on direct state intervention but rather be delegated to professionals outside the realm of the state. By delegating policies to putatively neutral outsiders, their intervention was separated from political controversy. Over the course of the nineteenth century, this method of depoliticizing social issues had come to be accepted for the domain of public health. In individual health care, however, classical liberal principles were still very much alive. This became clear when in 1913, three Dutch lawyers submitted a petition to the Dutch parliament requesting the abolition of the monopoly of treatment for physicians. Because of all the inherent tensions mentioned above, the petition was taken very seriously. The social liberal ministers of the Dutch government were challenged by classical liberals to ‘repair’ earlier legislation. The three lawyers questioned the expertise of the medical profession and disputed the exclusive right of physicians to give medical treatment. Medicine should be in the service of the patient instead of the physician, they argued, and patients – being free citizens – should have the right to consult the healer of their choice. The petition caused much social and political commotion. As many as 7,700 people expressed their approval by signing it. While the petition was under consideration, many articles, brochures and pamphlets – pro and contra – were published. At stake was the authority of medicine vis-à-vis the rights of patients as free citizens. Huisman’s chapter addresses the fundamental question also raised by the petition: how should the paradoxical relationship between patient autonomy and professional expertise be organized? He discusses this debate against the background of tensions between classical liberal principles and social liberal ideals. After a landslide victory in the general elections of 1917, however, the new government of Christian-democrats decided to leave things as they were.

In their chapter on Lebensreform movements in Belgium, Evert Peeters and Kaat Wils also look at disputes over the exclusive right of professional physicians to give medical treatment. Although Belgium is reputed to have been the most liberal country in nineteenth-century continental Europe, liberal physicians were in favour of state intervention in the field of health care in order to secure public health on the basis of scientific insights and their own professional interests. Nonetheless, although Belgium developed rather progressive initiatives in health care during the 1840s, the momentum of reform had been lost by the late nineteenth century. The liberal hygienist movement was hampered by the strong Catholic hold on government as well as by divisions within the Belgian medical profession. In the 1890s, a ‘political counterculture of health’ took shape, claiming the right of citizens to withdraw from professional regimes. They doubted the liberal belief in progress through science, and they resisted state-supported professionalism. For them, health was a personal affair in which the state had no right to intrude. Inspired by the anti-modernist German Lebensreform movement, they embraced alternative cultures of health. Peeters and Wils observe that the communitarian utopia of naturopaths and the social engineering of hygienists were alternative expressions of the same ambition. Both similarly diagnosed society, considering it as an organism on the verge of degeneration. However, naturopaths did not believe in the need for state-supported collective action. The cures which they proposed were neither collective nor disciplinary in nature. Contrary to the proposals of hygienists, the movement of natural healers advocated a strictly individual reform of lifestyle which the modern autonomous and self-responsible citizen had to perform on his own initiative, without external pressure. Alternative healers in Belgium contrived a project of health care in which citizens and their individual experience of illness and health played a central role. Opposing the dominant hygienist discourse with its patriotic and even nationalistic emphasis on the health of the nation, natural healers construed an alternative, more or less politicized ideal of a self-sufficient community.

As Ramsey remarks, the French Revolution had opened a new space for innovation and contestation in many fields, including health care. A debate on liberties and benefits should always begin with a debate on the nature and limits of liberty itself. As the chapters of this first part abundantly make clear, the outcome of these debates was by no means self-evident or straightforward; rather, it was highly dependent on national contexts, the interpretation of political principles and the financial possibilities of the moment.

1 Before L'État-Providence: Health and Liberal Citizenship in Revolutionary and Post-Revolutionary France

Matthew Ramsey

DOI: 10.4324/9781315654423-2

In France, all citizens and, indeed, all regular residents are now guaranteed access to health care through the law on la Couverture Maladie Universelle, or CMU, passed in 1999 and implemented in 2000. The CMU, however, is not simply an act enforcing a fundamental right of the sort enunciated in 1948 in the Universal Declaration of Human Rights. The declaration proclaimed that

everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.¹

The language of the French text is less robust:

A couverture maladie universelle is created for residents of metropolitan France and the overseas départements which guarantees to everyone health care coverage through a medical insurance policy [une prise en charge des soins par un régime d’assurance maladie] and, to those persons with the lowest incomes, the right to supplementary insurance protection and exemption from the requirement to pay charges up front [and then apply for reimbursement].²

Although la prise en charge des soins might suggest that the state assumes broad responsibility for health care, the expression here has the narrower technical sense of coverage by an insurance policy. Everyone is guaranteed health insurance, but the terms of the coverage remain undefined.

In 2000, shortly after adoption of the CMU, the European Union promulgated a Charter of Fundamental Rights. One article recognized an ‘entitlement to social security benefits and social services providing protection in cases such as maternity, illness, industrial accidents, dependency or old age’. Another proclaimed a ‘right’ of access to health care, but stopped short of imposing new standards on member states and to some commentators seemed more the statement of a general principle than a basic right:

Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities.³

France remained committed to its own model for linking citizenship, rights and health.⁴

Health Insurance and the French Welfare State

The CMU, like all the components of the French welfare system that emerged in the aftermath of the Second World War, was the culmination of a long historical process. In the case of health care, the first national insurance law, passed in 1928 and modified in 1930, applied to wage-earning workers with incomes below a certain level and covered about 25 per cent of the population.⁵ The post-war social security system initially provided compulsory health insurance for industrial and commercial wage earners, with the exception of some already covered by a special scheme. Over time, new plans and occupational groups were added. By the time the CMU was enacted, less than 1 per cent of the population remained uncovered. The end result is a remarkably complex system run by quasi-public insurance funds supported by payroll and income taxes and supplemented by private insurance. Patients have free choice of physician; most obtain coverage through their employers.⁶

The French welfare state is often called l’État-providence, an expression that gained currency in the 1860s, primarily among critics, who warned of a dangerous tendency of the state to substitute itself for individuals. The term had roughly the same force as ‘nanny state’ in English a century later, though over time it came to be used in a more neutral sense. L’État-providence is arguably a misnomer, in the absence of uniform state-run programmes funded entirely by tax revenues. The substance is very similar, however, to what is usually understood as a welfare state and the basic framework is established in constitutional law. The underlying principles were stated in the preamble to the constitution of the Fourth Republic (1946), which started with the rights enunciated in the Declaration of the Rights of Man and the Citizen of 1789 but added a set of social and economic rights.⁷ A long-standing critique from the Left had held that the formal individual rights proclaimed in the Declaration meant nothing to the dispossessed. The sociologist Dominique Schnapper argues that these new rights made it possible ‘to pass from formal citizenship to real citizenship, to assure that individual citizens really exercise their rights’, as the French revolutionary tradition of the sovereignty of the citizen required.⁸ According to the preamble, ‘The Nation assures the individual and the family the necessary conditions for their development’ and also ‘guarantees to everyone, notably the child, the mother and old workers, the protection of health, material security, rest and leisure’. All those unable to work because of ‘age, physical or mental condition, [or] economic situation’ enjoy the ‘right to obtain appropriate means of existence...

Table of contents

• Cover Page
• Half-title Page
• Series Page
• Title Page
• Copyright Page
• Table Of Contents
• Acknowledgements
• List of Contributors
• The Politics of Health and Citizenship: Historical and Contemporary Perspectives –
• Part I: Liberal Citizenship and Public Health
• Part II: Social Citizenship: Health in the Welfare State
• Part III: Neo-Republican Citizenship: Health in the Risk Society
• Notes
• Index