The protagonists of the articles in this special issue form a colourful bunch: an American Protestant missionary doctor who performed surgery in the Belgian Congo in the 1910s and 1920s; an architect who drew up the building plans for a new, ‘progressive’ psychiatric hospital, including the designs for new windows, in Brussels in the 1930s; a Dutch advertiser who launched a commercial campaign to promote slimming remedies in the interwar years; a Leuven professor-turned-hospital director who got caught up in the linguistic struggles between the Dutch- and French-speaking communities in post-war Belgium; a veterinarian who lobbied the Dutch government – with little success – for stricter regulations on food safety to prevent outbreaks of salmonella in the 1960s; a former hard drug addict who reflected on the popularity and rebellious nature of heroin use in Amsterdam during the 1970s and finally, a Minister of Health who mediated between physicians and politicians to push ambitious reform plans in Dutch health care, putting it on rational, evidence-based grounds, in the 1990s.
Such a variety of actors and themes has not always been present in the work of medical historians. This variety testifies to the remarkable growth and vitality of medical history as a scholarly field over the past three decades, primarily in the English-speaking world.1 The range of topics treated by medical historians has expanded far beyond the scope of the social history of medicine of the 1980s. Three decades ago, social historians of medicine problematized traditional internalist narratives on the continuous progress of medicine and focused instead on the history of medicine as a profession and its relation to the (welfare) state. Since then, attention to new topics such as medicine and gender, alternative medicine, patient care, religion, and the practice of science – to name only a few – have deepened our understanding of the medical field. These new studies have ‘decentred’ medical history, in the sense that they put the central position of doctors, medical institutions and the state into perspective. As these new studies have shown, medical practices and discourses were not confined to hospital wards; authority on medical matters was in no way a monopoly of physicians, and much health care was realised with little to no state support – for example through (religiously inspired) traditions of philanthropy and care. Medical historiography has thus not only moved beyond the old narrative of progress, it has also expanded beyond the narratives of the social history of medicine by introducing new topics and concepts.
The variety of the group of protagonists in this special issue leads to a second observation about medical history, which is its strong intertwinement with socio-political shifts. The architects, (missionary) doctors, advertisers, patients, consumers and politicians that have shaped the medical field brought their own convictions with them, firmly embedding medicine within the social fabric of their times. This holds particularly true for the twentieth century, the century of the welfare state, which turned medicine into an important domain of public policy. As the medical field expanded since the late nineteenth century, medical care became a social right for the citizens of the welfare state and many social issues – ranging from the deviance of individuals to the sexual behaviour of the nation as a whole – were recast in medical terms. In this process the field became thoroughly politicised to a far greater degree than in previous centuries. This meant that social and ideological conflicts were often transported into the medical domain and that, conversely, medical arguments were used to support a variety of political opinions.
Because of this intertwinement, we argue, the history of medicine is not only relevant to specialists, but to general historians as well. This special issue intends to show the potential of medical history to contribute to major historical debates (e.g. on the rise of the welfare state or on the – contested – function of institutions). Together, the articles in this issue make clear that medical history, for the twentieth century even more so than for earlier time periods, is strongly embedded in social, cultural and political history. The second goal of the special issue is methodological. It aims to highlight the conceptual work being done by medical historians. The recent successes of the field are in no small measure due to the introduction of new concepts, which allowed the scope of medical history to expand beyond the traditional axis of physicians, medical institutions and the state. Current medical historiography comprises a wealth of methodologies and subjects, revealing the creative ways in which the ‘objects’ and ‘categories’ of medical history are being questioned and redefined. Such methodological innovation is not only of interest to an audience of specialists, but may also inspire historiographical reassessment in other historical subfields.
The ambition to make medical history visible within the historical community is not new. In the 1980s, during the heyday of the social history of medicine, several special issues were published in Low Countries historical journals. The focus of the 1982 volume of the Tijdschrift voor Sociale Geschiedenis [Journal of Social History] was on the relationship between social conditions and morbidity and mortality patterns, with a focus on the disciplining role of the medical profession in the ‘therapeutic state’ of the nineteenth century.2 A year later, the editors of the Tijdschrift voor Geschiedenis [Journal of History] were keen on giving a broader temporal overview of medical history, with articles ranging from Antiquity to the twentieth century. What connected them was the notion of professionalisation, which was derived from the social sciences. All of the articles dealt with the social status of physicians in their respective eras.3 Together, the special issues contained the early work of the Rotterdam scholars Mart van Lieburg, Willem Frijhoff and Hans Binneveld, who were the pioneers of the ‘new’ medical history in The Netherlands.4 In 1985, the special issue of the Belgisch Tijdschrift voor Nieuwste Geschiedenis [Journal of Belgian History] had a very similar focus on professionalisation, especially looking at nineteenth-century developments in the medical profession and medical statistics.5 The issue assembled the early work of Karel Velle, Rita Schepers and Carl Havelange, who together have opened up the field of medical history in Belgium in the second half of the 1980s.6
During the 1990s, professionalisation and medicalisation theories – the frameworks that underpinned the social history of medicine – were felt to be too schematic and too ahistorical to have real explanatory value. Inspired by British colleagues working on the early modern era, Dutch medical historians embraced the concept of the medical marketplace, to which special issues of two journals were devoted.7 The medical marketplace soon came to be defined as ‘the interactive whole of ideas, practices and relationships leading groups in society to a collective understanding of health and healing’.8 Articles dealt with a range of topics, moving from negotiations going on in the doctor-patient relationship to advertisements of itinerant medical practitioners and the transformation of the pharmaceutical industry. Such research was also discussed during the meetings of several networks and working groups on medical history, which testify to the growing vitality of the field in the Netherlands.9 The center of gravity of research done in the 1990s was a network chaired by the Amsterdam scholar Marijke Gijswijt-Hofstra. It had originated as a group of researchers looking at witchcraft and sorcery in the early modern era, moved on to the social history of medicine – also including fringe practitioners and patient history – and finally engaged with psychiatry in the nineteenth and twentieth century.10 Today, there are several groups and individuals scattered across the country, working on a wide range of topics. A group called WEMAL (chaired by Orlanda Lie) is working on medieval artes literature, with medicine, natural history and astrology as important topics.11 The history of the body and the history of emotions have become important sites to explore the ways in which meaning was created with regard to the human body over the course of time. When looking at representations of the human body from a cultural perspective rather than from a medical one, boundaries between lay people and (medical) experts are blurring.12 The study of colonial health recently received new impetus from a comparative research project looking at dealings with Hansen’s disease in Suriname and the Dutch East Indies.13 Finally, research on the ways in which the health care system was structured and financed developed particularly strong in The Netherlands, and the same goes for historical demography.14
In Belgium, the idea of the medical marketplace proved a far less fruitful historiographical concept.15 A special issue of Sextant in 1995 directed attention to the position of women in the medical field, scrutinizing for instance the debates over the laicisation of nursing since the late nineteenth century.16 Attention to gendered roles and ideas in the Belgian medical field was continued in studies on the history of the body, and more recently on the medical discipline of gynaecology.17 The question of ‘medicalisation’ was revisited in several edited volumes which brought the perspective of cultural history to the fore. These studies paid particular attention to the role of medical discourses in the humanities and the social sciences and in the construction of collective norms and identities.18 The history of medical education at the Belgian universities was equally explored, including in several recent studies.19 At the same time, the history of psychiatry has attracted recent attention.20 The diverging pathways of medical history in Belgium and the Netherlands may be partly explained by pointing to differences in their institutional grounding. Unlike in the Netherlands, medical history was never strongly developed at the Belgian medical faculties. It was (and still is) practiced in history departments and was therefore less developed as an autonomous subfield and more closely connected to existing research traditions in social and cultural history.21
Today, both Dutch and Belgian medical historians are revisiting some of these older themes (e.g. the rise of the welfare state, the medicalisation of society) with fresh enthusiasm, focusing increasingly on twentieth-century developments. Such renewed attention occurs against the background of continuous political debate over the sustainability of our health care systems.22 Together with the growing historical distance from the twentieth century, such debates have stripped modern health politics of its previously perceived ‘naturalness’, inspiring critical attention among historians. Two challenges mark this historiographical shift in particular: first, the desire to give a voice to a greater variety of actors and – related to this – to find the right methodological strategies and conceptual tools to do so. Second, the ambition to situate health politics within twentieth-century politics and culture. Since both challenges are of interest to a wider audience of historians, we invited members of a new generation of medical historians in the Low Countries to make the relevance of their topic to general historians explicit, either by showing the potential of new approaches or by showing the intertwinement between medical and wider socio-political or cultural trends.
Together, the articles in this special issue shed new light on the particularities of twentieth-century health care. The role of mass media and public opinion in the medical field is touched upon in nearly all articles. Floor Haalboom, for example, discusses how public health and agricultural experts competed for attention on issues of food safety – the failure to mobilize the public proved an essential element in the former’s ‘defeat’ by the latter. Likewise, all contributions engage with the changing position of the patient in the twentieth-century medical field, whose agency – as a consumer of medical products or as a citizen entitled to health care – has to be acknowledged. Hieke Huistra tellingly reveals how ‘lay users’ represented a more powerful source of authority than medical doctors in advertisements for slimming remedies. Another connecting thread is the growing intertwinement between medical experts and politics in the twentieth-century welfare state. Nele Beyens and Timo Bolt reveal these interconnections perhaps most clearly as they retrace the career of the Dutch Health Minister Els Borst, who deftly moved back and forth between the medical and the political domain. And finally, several contributions stress the international dimension of medical care, highlighting the growing influence of pharmaceutical multinationals and international health organisations. Such internationalism, moreover, was not limited to the European mainland. Medicine in the Belgian Congo, as Sokhieng Au makes clear, cannot be understood without acknowledging the (competing) presence and influence of American Protestant missions in the region.
The contributions to this special issue share a second feature: they all question the established categories used in traditional medical histories. There is indeed a growing awareness that neither medicine nor medical history are monoliths, that concepts such as ‘medicine’, ‘profession’, ‘patient’ or ‘hospital’ have no fixed, ontological status, and that they therefore have to be analysed and ‘unpacked’ – to borrow a phrase from Science and Technology Studies.23 Put differently, the object of medical history is no longer easily defined. As Benoît Majerus argues for the history of psychiatry, the former categories of the social history of psychiatry are increasingly unfit to write the (twentieth-century) history of the field. What Majerus sketches for the history of psychiatry may hold true for medical history more generally. Other articles in this special issue display a critical stance towards categorisation as well. Rather than framing them as ‘patients’, Gemma Blok searches for new ways of giving a voice to drug users. Joris Vandendriessche and Liesbet Nys reveal the diverse ideological opinions and political views of the physicians at the University of Leuven – a clearly identifiable ‘medical profession’ was just as hard to pin down as a homogeneous group of ‘politicians’.
All articles in this special issue share the search for new conceptual and methodological frameworks and the ambition to bring out some of the particularities of twentieth-century medicine and health care in their relation to contemporary socio-political and cultural trends – the two challenges we identified for a developing historiography of the twentieth-century medical field. The first four articles offer a new take on the socio-political history of the Low Countries, grounded in medical history. They each reveal the intertwinement of twentieth-century health policies with different social, cultural and political issues. The second group consists of three articles which each develop a particular methodology: oral history, digital history and the study of material culture. These methodologies allow them to expand the range of actors in the medical field: architects, designers, ‘laypersons’, advertisers and drug users all extend the medical field beyond the established categories of ‘doctors’ and ‘patients’.
Western health care systems are facing spiraling health care costs which need to be kept within reasonable limits without losing the principle of distributive justice in the welfare state. The Netherlands – as the first of four articles on the relation between medicine and politics shows – are no exception to this rule. Since at least the 1970s, there have been many attempts to solve the problem. These were to little avail however, mainly because policy plans tended to take the shape of blueprints imposed on society, causing a lot of resistance. With their biographical approach, Nele Beyens and Timo Bolt contribute to the well-known problem of structure versus agency. To be sure, biography is nothing new as a genre, but the specific way in which Els Borst created her own ‘persona’ deserves our attention. In 1994 Borst became Health Minister; being a medical doctor and having been a hospital administrator, she was fully aware of the obstructive power of the medical profession when facing unwelcome measures from the state. In an attempt to counter the problem of excessive health care expenditure, Borst decided not to impose but rather to try to win the hearts and minds of physicians. Beyens and Bolt show how she behaved as a ‘boundary person’, integrating roles (medical doctor, hospital administrator and politician) and connecting domains (medicine and politics). By framing herself as a doctor in politics, she succeeded in creating credibility – first in Parliament (‘trust me: I know what I am talking about’), then among medical professionals (‘don’t be afraid: I am one of you’). Borst was keen on depoliticizing the problem of rising costs by introducing Evidence-Based Medicine. Because of its numerical logic, EBM was believed to make medical practice transparent, accountable and cost-effective.
At the University of Leuven during the 1960s, the modalities of medical expansion rather than cost reduction in health care were subject to debate. The construction of new academic hospitals was an essential part of the Belgian post-war welfare state. Joris Vandendriessche and Liesbet Nys connect these debates to contemporary linguistic struggles between the Dutch- and French-speaking communities in Belgium. In 1968, the University of Leuven was split into a Dutch-speaking and a French-speaking university after strong public protests. By rereading the turbulent history of the university in the 1960s as a chapter of medical history, they show the relevance of the field to political historians. Medical expansion, they put forward, not only facilitated linguistic separation; matters of language (including patients’ right to be treated in their own language) were used as instruments in the competitive ideological struggle (between universities and between political parties) over the implantation of new academic hospitals. By including more medical context, Vandendriessche and Nys claim, political historians may better understand post-war political compromises.
Medicine has often been presented as a unified ‘tool of empire’, used to either civilize or discipline the colonised. However, as Sokhieng Au shows in her article, medicine was in no way a unified discipline unambiguously serving the interests of the metropole. Au begins by pointing out that ‘western medicine’ had a very limited presence in the Belgian Congo. There was only superficial contact in a limited number of enclaves between the colonizers and the colonised. Having said that, the most important dynamic in the Congo was the competition between the Catholic and the Protestant missions. Each of them tried to win over the souls of the indigenous population by treating their bodies. Ever since the Protestants had criticised the colonial policies of the Belgian king, the Catholics were privileged by the Belgian state. Volunteering as a physician to serve in the Congo was not just considered a religious task, but a national duty as well. Still, because Protestants were more successful in mobilizing international organisations and raising international funds, there were more Protestant than Catholic doctors in the region.
The world is parceled out into disciplines, professions and institutions. While this can be very efficient and productive for the health and wealth of the nation, there are pitfalls to this way of organizing things as well. Zoonoses (infectious diseases that can be transmitted from animals to humans) are a case in point. Difficulties arise in the space between disciplines and institutions, where nobody takes responsibility – or rather: where no one claims ‘problem ownership’. The issue is complicated even further because the economic interests of specific groups here and now are not always in line with the health interests of the general public in the future. Building on the case of salmonella in the 1950s, Floor Haalboom shows how problem ownership was negotiated and contested between physicians and veterinarians and between the Ministry of Health and the Ministry of Agriculture. Who was to decide what caused salmonella, and what measures needed to be taken against it? By choosing a problem-based approach rather than a discipline-oriented one, Haalboom meticulously analyses the ‘boundary work’ of the stakeholders involved. Physicians and veterinarians working for the Ministry of Health and the Ministry of Agriculture did their best to take initiative, define the problem and suggest the solution, but in the end the agricultural domain prevailed. In this case, science was unable to depoliticize the issue. In 1964, the confessional parties (representing the farmers), the liberal party (in favour of free trade) and the social democratic party (in favour of state intervention in the general interest) debated a Salmonella Bill, with the former two triumphant.
The three other articles in this special issue each use a particular methodological approach, expanding the range of actors in the medical field and questioning established categories in the process. The first of these methodologies is employed in the history of drugs. Gemma Blok is keen on having drug users talk about themselves, and she succeeded in getting former drug users to reflect on their period of use. Building on interviews with former drug users, she is curious to know how they (re)construct their ‘life story’. Although this entails obvious methodological problems, it is an experiment worth exploring. Oral history has the potential of shedding light on the many levels included: what people wanted to do, what people actually did, and – above all – how people today give meaning to what they did (or think they did). It is difficult to generalize about the motives the interviewees gave to engage in drug use. For some, it was curiosity or youthful longing for adventure; for others, it was fleeing from oppressive parents or stifling bourgeois morals; for still others, it meant authenticity, creativity and absolute freedom. From all stories it becomes clear that we are not dealing with passive patients but rather with active persons engaged in ‘a practice of the self’, liberating and reinventing themselves. By putting the drug user’s voice in the picture, Blok is presenting a counter-narrative to the medicalised story about the nihilistic ‘heroin epidemic’ of the 1970s and 1980s. The article raises the question who owns history, and who gets to direct the historiographical narrative.
Hieke Huistra explores the benefits of another methodological approach, borrowed from the field of digital humanities: the digital analysis of newspaper advertisements. She examines four advertising campaigns for slimming remedies – examples of ‘patent medicine’, drugs that were available without prescription – in the Netherlands during the 1920s and 1930s. Digital source selection allows her to construct a corpus of non-medical sources (advertisements), which put the medical authority over pharmaceuticals by doctors into perspective. Even if references to medical expertise were far from absent in these advertisements, ‘lay experience’ – in the form of formerly corpulent laypersons who recommended the remedies in short letters to potential buyers – proved far more important. Huistra sheds new light on the relation between twentieth-century mass media and the rise of medical consumerism, and shows – through the eyes of medical advertisers – that the boundaries of the medical field may not be so easily determined. The consumption of drugs, she argues, was not limited to strictly medical problems (i.e. illness as defined by doctors) but was also directed to non-medical problems (e.g. ugliness) that were connected to contemporary cultural norms and beauty ideals.
Ever since the groundbreaking work of Michel Foucault, marginality and deviance have been important topics for historical research. Until recently however, historians have mainly been looking at discursive theories of psychiatrists or at dominant discourses in society – in short: at ideas and ideals set in language. After the so-called material turn, new sources presented themselves, leading to new questions and new answers in writing the political history of madness. By looking at the architectural design of psychiatric institutions, at the organisation of space within those institutions and at the use of pills by patients, Benoît Majerus shows how domination is ‘inscribed’ into bodies through materiality, using the Brussels Institut de psychiatrie as his case. When plans materialised to build a new psychiatric hospital in the 1920s, this offered an opportunity to rethink and recreate ‘psychiatric space’, taking into account the many criticisms on the old ‘lunatic asylum’. Majerus argues that historians should take the doings of architects, engineers, manufacturers and craftsmen just as seriously as the academic ideas of psychiatry. In doing so, it becomes clear that many more people than just the director debated the classificatory function of walls (according to gender and danger-levels) and the soothing function of gardens. The tension between confinement and (the appearance of) liberty was to be solved by the design and material make-up of the institution. The introduction of psychotropic drugs in the 1950s caused a fundamental break in the spatial dealings with deviant behaviour. Because patients calmed down, there was no need for physical restraint anymore and patients were even allowed to move outside the institution. Thus, pills can be said to have facilitated patient mobility and even agency.
Collectively, the articles in this issue show that traditional (‘modernist’) categories and boundaries have been blurred. They show that in the twentieth-century policy domain of health care, it may be misleading to think in terms of clear-cut medical disciplines, each with their own epistemological and societal missions and goals. It may be more appropriate to frame health care as a rather amorphous domain where many competing interests interact. Similarly, the image of the patient who is passively waiting at the receiving end seems mistaken. Patients do have agency – either as individual consumers, or as part of a collective patient lobby. Of course, there will always remain asymmetry in knowledge and power between the ‘stakeholders’ in the domain of health care. It is up to historians to bring them to light and to put them up for debate.