Conceptualising Public Health

Historical and Contemporary Struggles over Key Concepts

Johannes Kananen, Sophy Bergenheim, Merle Wessel

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351712873
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

In Germanic and Nordic languages, the term for 'public health' literally translates to 'people's health', for example Volksgesundheit in German, folkhälsa in Swedish and kansanterveys in Finnish. Covering a period stretching from the late nineteenth century to the present day, this book discusses how understandings and meanings of public health have developed in their political and social context, identifying ruptures and redefinitions in its conceptualisation. It analyses the multifaceted and interactive rhetorical play through which key concepts have been used as political tools, on the one hand, and shaped the understanding and operating environment of public health, on the other.

Focusing on the blurred boundaries between the social and the medico-scientific realms, from social hygiene to population policy, Conceptualising Public Health explores the sometimes contradictory and paradoxical normative aims associated with the promotion of public health. Providing examples from Northern Europe and the Nordic countries, whilst situating them in a larger European and international context, it addresses questions such as:

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• How have public health concepts been used in government and associated administrative practices from the early twentieth century up to the present?

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• How has health citizenship been constructed over time?

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• How has the collective entity of 'the people' been associated with and reflected in public health concepts?

Drawn from a range of disciplinary backgrounds, the authors collected here each examine a particular way of understanding public health and assess how key actors or phenomena have challenged, altered or confirmed past and present meanings of the concept. Conceptualising Public Health is of interest to students and scholars of health and welfare state development from diverse backgrounds, including public health, sociology of health and illness, and social policy as well as medical, conceptual and intellectual history.

1 Conceptualising public health

An introduction

Sophy Bergenheim, Johan Edman,
Johannes Kananen and Merle Wessel

Studying key concepts of public health: The aim of this book

This book has grown out of an insight that the concept of public health has been important in the historical development of modern societies. While connotations and associations have varied with time and place, the language around public health has expressed a concern for the health and well-being of the citizens of a nation state. It has served as a tool for constructing, developing and establishing practices, goals and discourses for health policy at a national and international level. It should therefore be given further academic attention.

Public health is conceptualised slightly differently in the English language and in other Germanic languages, such as German and Swedish. In English, the key concept is public health, accompanied by other interrelated concepts such as national health and population health (the latter often used in studies in public health, e.g., in the Scandinavian Journal of Public Health). The Nordic and German concepts share a similar etymological basis; namely, the word for public health translates literally to ‘people’s health’ (Swedish: folkhälsa, Norwegian: folkehelse, Finnish: kansanterveys, Danish: folkesundhed, Icelandic: lýðheilsa, German: Volksgesundheit). The Nordic and German concepts thus have a markedly different connotation compared to the English counterparts: they contain a stronger association with a (culturally) unified people.

The title of our book is Conceptualising Public Health: Historical and Contemporary Struggles over Key Concepts. As the title reveals, we are not focusing on one single term, e.g., ‘public health’, but on key concepts in plural. The time period of this volume encompasses the late nineteenth and the twentieth century. During this period, the medical and social discourse has been dominated and contested by various crucial concepts, and we thus extend our analytical gaze to a broader group of concepts. In addition to public health, key concepts discussed in this book include, among others: hygiene, social hygiene and social medicine; racial hygiene and eugenics; and social disability and health management. We also discuss Nordic and English variations of public health concepts, which have not necessarily always been synonymous.

A clear-cut distinction between these concepts and their various uses is sometimes demanding, or outright futile. This fuzziness, however, is not regarded as inherently problematic in this book, but, rather, as an intriguing study subject. Our aim is not to provide rigid and simplified definitions for key concepts. We do not take concepts at face value, as something possessing an essential or timeless and ahistorical nature. Instead, we approach concepts and their discourses as contingent and historical phenomena; we analyse how the uses of different key concepts and the meanings attributed to them have varied with time, place and actor. Moreover, we study the interplay of concepts and discourses. An important focus of this volume is the overlapping boundary between the social realm and the medical or scientific sphere.

The concepts related to the development of medicine and health policy can serve as a lens for understanding the historical transformations of the welfare states in general, and for analysing the changing relationship between the state and the individual, in particular. More specifically, the book aims at identifying ruptures and redefinitions in the conceptualisations of medicine and health policy in the twentieth century in the Nordic countries and elsewhere in Europe.

The objective of this volume is to provide an analytical account of the historicity, contingency and political nature of key concepts related to health and health policy. We perceive and analyse concepts as normative tools and weapons of debate that shape the understanding of contemporary realities. In this mission, we dedicate special attention to the differentiation between historical or empirical concepts and analytical terms. By this, we mean the difference between the use of, for example, ‘public health’ by contemporary actors in its original context, and an analytical reading of the actors’ understanding and use of the concepts. By being aware of and making this distinction, we seek to avoid taking concepts (be they analytical or empirical) for granted, and to thereby be wary of slipping into anachronic interpretations and labelling.

Historical development in the nineteenth and twentieth centuries

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 “Age of Catastrophe”.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 Guérin 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 – vaccination and penicillin – 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 – 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 ‘racial hygiene’, 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 Darwin’s cousin, Francis Galton. The idea was to shape and improve the quality of the population (or ‘race’). 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 “Fit” and “Unfit” groups. The “Fit” were those whose offspring were thought to be beneficial for the future of the “race”.

Positive eugenics (i.e., encouraging the reproduction of individuals with desired qualities...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• Contributors
• Acknowledgements
• 1 Conceptualising public health: An introduction
• 2 Conceptualising eugenics and racial hygiene as public health theory and practice
• 3 Female doctors, prophylactic health care and public health
• 4 The Nazis’ cloven hoof: Finnish critiques of legal sterilisation
• 5 Universal, but exclusive? The shifting meanings of pre- and post-war public health in Finland
• 6 The people’s health, the nation’s health, the world’s health: Folkhälsa and folkehelse in the writings of Axel Höjer and Karl Evang
• 7 Cherishing the health of the people: Finnish non-governmental expert organisations as constructors of public health and the ‘people’
• 8 Public health categories in the making of citizenship: The case of refugees and Roma in Sweden
• 9 Alcohol consumption as a public health problem 1885–1992
• 10 Mainstreaming concepts, discounting variations? Global policies of alcohol, drugs and tobacco
• 11 Science, politics and public health: The North Karelia Project 1972–1997
• 12 The individualisation of health in late modernity
• 13 Editors’ notes: Transitions in the conceptual history of public health
• Index