Heike Karge, Friederike Kind-Kovacs, and Sara Bernasconi, eds., From the Midwife's Bag to the Patient's File: Public Health in Eastern Europe, Budapest: Central European University Press, 2017, vii–xix, 349 pp., $70.00/€62.00 (hardback), ISBN: 978-963-386-208-7.
Constantin Barbulescu, Physicians, Peasants, and Modern Medicine: Imagining Rurality in Romania, 1860–1910, translated by Angela Jianu, Budapest: Central European University Press, 2018, xi–xii, 292 pp., $60.00/€50.00 (hardback), ISBN: 978-963-386-267-4.
From the Midwife's Bag to the Patient's File: Public Health in Eastern Europe is a welcome addition to the rather overlooked field of public health history in Eastern Europe. While in other regions this is a blooming research area, in Eastern Europe it was until recently a domain punctuated by a few works that provided a regional perspective, such as the edited volumes by Christian Promitzer, Sevasti Trubeta, and Marius Turda (2011), Daniela Teodora Sechel (2011), and the pioneering study on Romania's eugenics by Maria Bucur (2002).1 The collection under review is aptly divided in three sections, arranged in chronological order (from mid-nineteenth to late twentieth century), and contains twelve chapters. The geographical scope of the book covers the social space from Russia to Prussia and from the GDR to Greece (the latter is not often considered part of Eastern Europe, however). Thus, this volume expands the comparative aspect of the gradually increasing body of national research. These twelve case studies argue that public health served as a laboratory for the implementation of labor, gender, and welfare policies. Furthermore, the construction of conditional access to health provision was based on “nationality, ethnicity, gender, social status, or class” (7). A common thread that runs through all contributions is the challenge to the validity of established “truths,” such as the West-East unidirectional transfer of knowledge and practices; the Cold War's isolation of the Eastern bloc; and the usual emphasis on ruptures and neglect of continuities across time and space.
The first part examines the intertwined processes of public health policy and nineteenth-century state building. Whereas the predominant role of the modernizing state with its biopolitical gaze is recognized, the section is focused on various medical participants who found their way in exercising some local agency, even if not always successfully. For example, as Maria Zarifi discuses, the professional medical elite in Greece (concentrated in the Medical Council) attempted to modernize the health legislation and institutions following Western standards; these processes, however, remained incomplete due to the state administration's intransigence and diminished funding. Similarly, Angelika Strobel argues that the emergent railway medicine in late imperial Russia, as part of the state-building process, tried to use statistics “as a tool of governance,” but was not effective in constructing a “railway population” (70). Along the same lines, the attempt at establishing the Academy of Applied Medicine in the Prussian province of Posen, as analyzed by Justyna Turkowska, was met with resistance by the local medical and administrative establishment. Sara Bernasconi also suggests that the introduction of the midwife's bag in Bosnia and Herzegovina, as part of the Habsburg's “civilizing mission,” had mixed results. In other words, all those undertakings to produce imperial and/or national loyalty by modernizing the public health system produced ambiguous effects. Each one of the four chapters in this section sheds light on the expected and unexpected impact of modernizing rhythms, deriving from the political center, on diverse peripheries and on the multiplicity of local actors.
The second section explores the impact of the two world wars on public health and the emergence of a new factor: namely, international humanitarianism, as in the case of the Rockefeller Foundation and the Health Organization of the League of Nations’ involvement in Poland (Katrin Steffen) and the Jewish Joint Distribution Committee for child relief in Hungary (Friederike Kind-Kovacs). Yet those transnational interactions were not a one-sided flow of Western relief but also included the participation of local agents. These two chapters also highlight strategies of power legitimation that linked health policies and state security. Within such discourses ethnic minorities were situated as latent threats to the healthy national body. The other two chapters in this section question the postulate that the world wars represented a rupture with the past, and instead, emphasize some continuities. Accordingly, the propagandistic use of war veterans’ well-being in the Soviet Union (Alexander Friedman) continued after its demise, and the psychiatric discourses on Partisan fighters’ mental breakdowns in post-1945 Yugoslavia followed some interwar patterns (Heike Karge).
The last section challenges some concepts of state socialist forms of biopolitics and social engineering. For instance, Fanny Le Bonhomme's chapter shifts the focus from the political instrumentalization of psychiatry in the GDR to the clinic as a space that “allowed both patients and healthcare professionals to distance themselves from the official political line” (222). While Le Bonhomme analyzed family patients, Esther Wahlen pays attention to women alcoholics in Czechoslovakia. By the 1960s the disease model of alcoholism gained currency internationally, including behind the Iron Curtain. It superseded and depoliticized the notion of transforming the socioeconomic structures that produced alcoholism. Consequently, within this new individual-centered framework, women's drinking (and gender-specific treatment) became salient and corresponded to a new concern about family life. In her contribution, Eszer Varsa offers an intersectional perspective of gender and race/ethnicity on Hungary's policies and practices of “qualitative reproduction” (280). By examining the “Gypsy question,” she traces the transition from direct state interventions such as abortion to indirect means of both the pro-natalist agenda for the “well-situated women” and anti-natalist measures for the “work shy” Romani women (273–274). In the last chapter, Andre Thiemann analyzes the work of local social workers in postsocialist Serbia. They applied their professional discretion and late socialist “humanism” (297) in welfare distribution in order to attenuate the negative impact of the market economy on the needy. These contributions also address the existence of the “common European realm of communication, practice, and negotiation” between the West and the East during the Cold War (18).
The volume is successful in illustrating (through the use of diverse primary sources) the establishment of statistical knowledge and control over access to public health through quantification. Furthermore, it provides persuasive evidence of chronological continuity in policies and discourses between the interwar, socialist, and postsocialist periods. One wishes, though, for a clearer thematic delineation of the common threads among such diverse contributions. Additionally, inclusion of other countries such as Bulgaria and Romania would have brought more comparative dimensions. While there is a wealth of East-West parallels, there is a paucity of East-East similarities, which seem quite pertinent.
In his book, Physicians, Peasants, and Modern Medicine: Imagining Rurality in Romania, 1860–1910, originally published in Romanian in 2015, Constantin Barbulescu analyzes the modernization of the Romanian rural world through the social history of medicine. By offering a study of what he calls “social imagology” (3), Barbulescu focuses on the discourses of the urban medical elites and traces not only how they imagined but also how they altered the peasants’ way of life. The book consists of three sections: the first one depicts the hierarchical medical organization and the health reports on hygiene, which are a major primary source, in addition to medical articles and some doctors’ memoirs (no women, though). In general, most of the reports were critical and highlighted failures to observe sanitary norms. According to Barbulescu, the negativity of the medical discourse was marked by the cultural and educational backgrounds of the doctors, as well as by “undisguised agenda for ‘improvement’” (31). Therefore, this discourse was informed by the “primitivist paradigm” that viewed the peasant as “savage.” This representation would change in the second half of the nineteenth century into its opposite: the peasantry would become a repository of the nation's true identity, or the “indigenist paradigm,” and would even lead to nostalgia about the “good old times” at the beginning of the twentieth century (117–118).
Part II, which forms the nucleus of the book, analyzes the main themes that emerged in the medical discourse: hygiene of the body and clothes; sanitation of the home and the household; eating habits and alcoholism; specific illnesses that afflicted the rural population (pellagra); and racial degeneration. It was the latter that coalesced anxieties of depopulation with nationalism, racism, and anti-Semitism. Within this amalgam, statistics and social hygiene were to play a significant role, and they permeated public debates. Conceptually, racial degeneration was an import from France and Germany, where most Romanian doctors were educated, but was readily adapted to local conditions and presented in demographic rates of stagnation or decline. Not surprisingly, the moral tone of hygiene's discourse, reminiscent of a “civilizing mission” to educate the popular classes, derives from Western medicine, especially France, which was the “template for modernization in Romania” (58). Consequently, health education was deemed as a panacea of all hygienic ills.
The last section is composed of three chapters: the first depicts public health legislation and its biopolitical obsession with population increase and quantification; the other two chapters present two case studies of empirical healers and illustrate how laws were translated into (and contested by) the realities of rural life. While the modernizing impulses from the urban centers were aligned with European standards, their implementation in the rural world was selective at best. Thus, the two case studies flesh out the gradual medicalization of the national space and the tensions between the “dominant medical culture” and the “peasant medical culture” (245). The process of professional inclusion/exclusion was carried out through examinations and licenses, and gradually empirics were marginalized.
Examining nineteenth-century Romania's state and nation building through the eyes of doctors provides both advantages and disadvantages. While focusing on the medical elite that took an active part in establishing public health infrastructures, laws, policies, and discourses, this elite's medical gaze is also quite limited. Barbulescu argues convincingly that the medical discourse evolved, but it was never an innocent one. On the contrary, it consistently presented the peasant world in a negative way by promoting top-down modern hygienic norms, which were imported from different European contexts. The resistance to such interventions was constructed as ignorance and laziness. I wish that additional archival sources, such as doctors’ correspondence, diaries, other medical practitioners’ perspectives such as midwives, and newspapers were also included. Another interesting angle would be to provide some comparisons to other agrarian countries, such as Bulgaria and Serbia, whose peasantry was equally devastated by the advancement of modernity and capitalism and whose elites were using similar technologies to impose European public health norms.
There are several common strands between the two books under review. First, both argue cogently that public health issues were central to modern nation and state building. Second, both highlight the emergence of various health experts (local and international) who possessed some autonomy and contributed to the professionalization and standardization of public health practices. Whereas medical concepts and hygienic discourses and practices were often instrumentalized for political and social purposes, both books disclose a more nuanced and fluid picture. Third, both studies deal with issues of center-periphery as more complex than just elements within a hegemonic framework. Fourth, the use of the case studies approach introduces the reader to local perspectives that often destabilize commonly held formulas. Last but not least, both texts place public health trends in Eastern Europe within European and global frameworks and a longue durée modernization, with the corresponding continuities and ruptures. One missed opportunity, though, is that interrogation of gender norms and practices was not made more visible. Public health is a topic that offers rich intersectional possibilities for gender-specific analysis wherein not just ethnicity/nationality but also class is a prominent component. Whereas Barbulsecu's research overlooks women's presence in nineteenth-century Romania (either as patients or as medical practitioners), Karge, Kind-Kovacs, and Bernasconi's anthology includes a few gender-sensitive contributions on midwifery, women's alcoholism, and politics of reproduction but does not explore issues of masculinity in the chapters focusing on war heroes. In other words, gender regimes are not comprehensively integrated within the analytical framework for interpreting modernization of public health.
From the Midwife's Bag to the Patient's File: Public Health in Eastern Europe and Physicians, Peasants, and Modern Medicine: Imagining Rurality in Romania, 1860–1910 are valuable contributions to the study of the social history of medicine and the modernizing nation-states’ discourses and practices within national, regional, and transnational contexts. Hence, they endorse the decentering of research on Western European public health. The authors promote academic dialogue and suggest fruitful venues for future studies. Readers interested in structural issues in healthcare, in which power and gender imbalances are highly palpable, will be encouraged by the use of rich primary sources and nuanced conceptualization of public health. The books would be of interest to international students and researchers engaged not only in the European social history of medicine but also in the study of global public health.
Christian Promitzer, Sevasti Trubeta, and Marius Turda, eds., Health, Hygiene and Eugenics in Southeastern Europe to 1945 (Budapest: Central European University Press, 2011); Daniela Teodora Sechel, ed., Medicine within and between the Habsburg and Ottoman Empires: 18th–19th Centuries (Bochum: Dieter Winkler, 2011); Maria Bucur, Eugenics and Modernization in Modern Romania (Pittsburg: University of Pittsburg Press, 2002).