The Locus of Care

Families, Communities, Institutions, and the Provision of Welfare Since Antiquity

Peregrine Horden, Richard Smith, Peregrine Horden, Richard Smith

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9781138868205
• eBook ISBN:
  9781134831913
• Topic: History
• Subtopic: World History
• Index: History

The care of the needy and the sick is delivered by various groups including immediate family, the wider community, religious organisations and the State funded institutions. The Locus of Care provides an historical perspective on welfare detailing who carers were in the past, where care was provided, and how far the boundary between family and state or informal and organised institutions have changed over time.
Eleven international contributors provide a wide-ranging examination of themes, such as child care, mental health, and provision for the elderly and question the idea that there has been a recent evolutionary shift from informal provision to institutional care. Chapters on Europe and England use case studies and link evidence from ancient and medieval periods to contemporary problems and the recent past, whilst studies on China and South Africa look to the future of welfare throughout the world.
By placing welfare in its historical, social, cultural and demographic contexts, Locus of Care reassesses community and institutional care and the future expectations of welfare provision.

Part I Informal Care: From Ethnography to Ancient History

1 Household Care and Informal Networks

Comparisons and continuities from antiquity to the present

Peregrine Horden

DOI: 10.4324/9780203428047-2

To King Ptolemy greeting from Ctesicles. I am being wronged by Dionysius and my daughter Nike. For though I had nurtured her … when I was stricken with bodily infirmity and my eyesight became enfeebled she would not furnish me with the necessaries of life. And when I wished to obtain justice from her in Alexandria … she gave me a written oath by the king that she would pay me twenty drachmae every month … Now, however, corrupted by that bugger Dionysius, she is not keeping any of her engagements to me, in contempt of my old age and my present infirmity.¹

I

What can a student of antiquity or the early Middle Ages contribute to a volume such as this? Vignettes of broken promises will certainly not be enough. The chapters that follow weigh the relative significance of familial, extra-familial, and, within that larger category, institutional care of the sick and disadvantaged. They investigate the multiple connections between those different support sectors. They adduce case histories, generate statistics, date changes to within a decade. Where much earlier centuries are concerned, none of this is possible. Tentative suggestions must substitute for solidly buttressed arguments.

That is most acutely the case with informal care, which is the chief focus of this opening chapter. Part of its purpose is to sketch a broad historical and anthropological backdrop to the more localized concerns of subsequent contributions. The intention is also, however, to give some indication of how, under this heading of informal care, we might conceive the period preceding that covered in the next contribution (McIntosh's account of the later Middle Ages).

The present offering is thus prologue as well as scenery. It assembles and compares evidence of domiciliary care and informal networks of support in the longue durée, from antiquity to the recent purview of ethnographers, sociologists, and experts in social policy. It uses that evidence, by implication throughout and explicitly at the end, to lend plausibility to three linked suggestions. The first is that there is no ‘golden age’ of household care to be discerned in the European and Mediterranean worlds in antiquity or the Middle Ages, no period or area in which large supportive families have been efficiently responsible for the overwhelming bulk of welfare provision. The second is that networks of connections between households, not necessarily involving kin, have probably been of immense importance to the needy, but that such networks seem often to have been limited in strength and capacity. At this level of generality, it is argued, continuity in the history of households and networks is more evident than some fall from grace. Obviously enough, there have been enormous and multifarious changes in the history of welfare provision since antiquity; but they have not been of the kind that can be captured by theological analogies or simple evolutionary frameworks. The third suggestion elaborated in what follows, therefore, is that historians of the sick poor should envisage a broad spectrum of resources beyond the household and its immediate connections – patrons, formalized community organizations, institutions, and so on – as having been called upon for a very long time to supplement informal assistance. To that extent, there is nothing new or modern about the ‘mixed economy of care’.²

Those suggestions can be proffered only tentatively because of the state of the evidence available from pre-modern times. The ancient historian or early medievalist lacks the parish registers, the wills and nationwide censuses that make it possible to discern the family structure and local connections of those in need; lacks also, beyond a few scraps, the forensic and institutional archives, the case-books and correspondence that can reveal the circumstances under which the locus of care was determined. In a field rightly dominated by the equivalent of miniaturists, the ancient historian or medievalist cannot even aspire to the detail and finish of abstract expressionism.

More daunting even than these deficiencies is the realization that, for all the relative abundance and articulacy of their documents, a number of contributors, even those involved with the apparently voluble nineteenth century, still have to confront the fact that they can study informal domestic care only through its failures (cf. Suzuki, Wright). It is the breakdown of domestic support that so often produces the written record (such as the papyrus from Hellenistic Egypt quoted on page 21). In this volume we are mostly looking at health care within the context of the wider history of poor relief, and hence at families or individuals of at best very modest means. We can therefore scarcely expect to find letters or diaries that relay in any quantity or vividness the successful routines of visiting, nursing, medication, confinement, or attending to a sick person's other ‘necessaries of life’. Oral history will take us a little way back into the past but, as Wright cautions below, its witness may be coloured by nostalgia and has to be tested against what written evidence is available. In any century earlier than our own, then, family care that was adequate to its task leaves few traces.

Yet the effort to gain at least some impression of both its successes and its failures must surely be made – by students of later periods as much as by the medievalist. For self-help and domestic care constitute the great submerged ice sheets of the history of health, as also of the history of poverty in general. We perforce devote most of our attention to the visible peaks and ridges of documented medical practice and institutional support. Yet we also have to find ways of reminding ourselves how small a proportion of the whole subject is actually in view.³ If that applies to modernists, on so many other occasions dispirited by the profusion rather than the scarcity of their sources, how much more so must it apply to historians of antiquity or the Middle Ages.

Proceeding by analogy is one remedy; a modest and partial remedy, but to be seized on none the less. And that is why the bulk of this chapter is devoted to mustering comparative material from which analogies may be drawn. The immediate comparisons aré those supplied by other contributions to this collection. I shall look to them first; then cast the net more widely, to exemplary studies of informal care and household interaction; then turn, in the eighth and last section, to the period preceding that covered in later chapters, the ancient and earlier medieval worlds.

II

The following points relevant to antiquity and the Middle Ages seem to me to emerge from the papers in this collection. Each point of course has a broad bearing on the whole history of health care in modern times; but each should additionally give pause to historians involved with the less well-documented epochs. These points can be summed up, banally but accurately, under the related headings of variety or complexity.

1. The sheer variety of what must be understood by ‘care’: from the arrangement of retirement facilities in a long-stay institution to the restraint of imbeciles within one room in the house; from hiring a public physician at the most medical end of the spectrum to the provision of reassuringly ordinary living or employment conditions through boarding out or apprenticeship at the other extreme – from money to company in short; from maternal and infant welfare clinics to free burial. When students of darker ages write of care, it is tempting for them to think that they can readily imagine what was involved in it. Recalling that multiplicity is a necessary corrective.
2. The extent to which those various forms of care could be described as ‘outdoor’ or domiciliary relief. That the home should be a principal locus of care is to be expected in the chapters concerned with early modern England. It is somewhat more of a surprise in the contributions dealing with the mentally ill or handicapped in England during the eighteenth and nineteenth centuries. But in the historiography of that era the domination of the asylum has been ended. What is very striking, however, is the extent of outdoor relief to be found at both parochial and civic levels in Europe. In the light of Cavallo's and Dinges's chapters, and some other like-minded work, historians will have to reconsider the contrast habitually drawn between the outdoor relief sustained under the English Poor Law and the indoor relief supposedly favoured in continental welfare systems. Just as the history of the asylum is no longer taken as the whole story of the English insane in the Victorian age, but figures as one among several equally accessible resources, so the big European hospital, with its supporting policy of renfermement, is having to yield its centrality in historians’ agreed narrative. The great hospital may have been the focus of comprehensive poor relief measures, but it can function quite as much as the source of ‘care in the community’ as of campaigns to segregate.⁴
3. The role of ideology in general, but especially religious ideology, is harder to specify than might have been expected. Types of care cannot be predicated on religious affiliation. So far as antiquity is concerned, the differences so frequently stressed in the older scholarly literature between pagan and Judaeo-Christian philanthropy may well have been overdrawn.⁵ Or to take the most familiar example, no obvious and sustained divergences have emerged between Catholic and Protestant poor relief policies in the early modern period. The contrasts between two welfare communities of the same affiliation may be as significant as the similarities. It is local inflexions that count for most. Compare the ideals discernible at parochial level in Tudor Essex (McIntosh) with those in near-contemporaneous Bordeaux (Dinges). The latter shows how it was the hostility of the Catholic majority that strengthened informal care as a reaction to Catholic institutional provision. In Hadleigh, the animating idea behind outdoor relief had more to do with the creation of a ‘godly community on earth’. In Turin, by contrast, religious notions were less important than civic patriotism in generating welfare schemes (Cavallo). Even in the utterly different context of South Africa, differences in attitude to adoption between Islam, indigenous religion, and the Dutch Reformed Church are cast emphatically into the shade by the vastly greater gulf between, on one hand, their shared ambitions for supposedly unwanted children and those underlying the government's relocation schemes on the other (Burman and van der Spuy). To judge by the present collection of essays, then, a stronger determinant of the locus of care than religion is local or regional ideology and the definitions that it brings with it: a perverted notion of community in the case of South Africa under apartheid; an ideal of motherhood variously refracted through the political cultures of four London boroughs; the personal allegiances and perceptions of the governors of voluntary hospitals; the variously engendered local initiatives of the middle-range cities of late medieval England or early modern France and Piedmont.
4. It emerges forcefully that the different resources of care for the sick would have been conceptualized very differently in the past from the ways in which we may now distinguish them. Even in modern times, the terminology under which policies may be enacted can change quite rapidly: as Marks and Thomson demonstrate, the practice of ‘community care’ in Britain antedates by decades its emergence as a prominent government policy. More important than changes of label is the way in which, as McIntosh is the first to point out, the ‘personnel’ of the various sources of care confound all analytical distinctions we might care to draw. Most obviously, it follows from the extent of outdoor relief, under both the English Poor Law and continental systems of the kind described by Cavallo, that formal and informal arrangements blur and overlap. Neighbours or relatives of the needy are paid to offer board and lodging to those whom, in other circumstances, they might have supported from their own pockets. Such formalized boarding out moreover creates, as McIntosh and Dinges note, the opportunity for the boarder to join a new informal network. Employers are encouraged by subsidies to keep on sick labourers or servants. Neighbours contribute to, or manage, local charitable institutions. Hospitals or friendly societies are patronized by leaders of the community from whom the poor might also have expected informal ‘doorstep’ subventions: support for the institution is an extension of private charity, not its antithesis. Parishes – publicly funded by local taxes – hire the services of private establishments to reduce their medical costs and hence the burden on tax-paying parishioners. Outdoor relief assumes the guise of its indoor variety: those boarded out together in an inn, with the landlord paid to meet their domestic needs, are virtually hospitalized. The converse also applies. A row of Tudor almshouses is modelled on, and thence becomes, a neighbourhood. More deliberately, and in a later age, homes for the mentally handicapped imitate the architecture and ethos of the village. Public and private, formal and informal, paid and voluntary – however we describe them, the sectors cannot be kept analytically distinct. They are constantly smudging any boundaries we impose on them. As Thomson suggests, modern historians come to the discussion of the past, even a past as recent as the twentieth century's inter-war period, with misleading preconceptions shaped by the categories of modern welfare states – states in which hospitals are starkly separate from other social services.
5. The way in which the different agencies of care interact will be accordingly complex, hard to encapsulate with any simple formula. Certainly we should not speak of any automatic opposition between familial, communal and institutional care. In the chapters that follow, formal support from beyond the family, however that term is glossed, is usually intended to supplement or provide a temporary replacement for domestic sup...

Table of contents

• Cover Page
• Half-title page
• Series Page
• Title Page
• Copyright Page
• Table Of Contents
• List of figures and tables
• Notes on the contributors
• Acknowledgements
• INTRODUCTION
• Part I Informal care: from ethnography to ancient history
• Part II Networks and institutions in western Europe c. 1500–c. 1800
• Part III Beyond the asylum: mental health in Britain c. 1700–1939
• Part IV Children and the elderly in the twentieth century
• Index