Communicating the history of medicine: Perspectives on audiences and impact 9781526142474

Citation preview

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Communicating the history of medicine

SOCIAL HISTORIES OF MEDICINE

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Series editors: David Cantor and Keir Waddington Social Histories of Medicine is concerned with all aspects of health, illness and medicine, from prehistory to the present, in every part of the world. The series covers the circumstances that promote health or illness, the ways in which people experience and explain such conditions, and what, practically, they do about them. Practitioners of all approaches to health and healing come within its scope, as do their ideas, beliefs, and practices, and the social, economic and cultural contexts in which they operate. Methodologically, the series welcomes relevant studies in social, economic, cultural, and intellectual history, as well as approaches derived from other disciplines in the arts, sciences, social sciences and humanities. The series is a collaboration between Manchester University Press and the Society for the Social History of Medicine.

Previously published The metamorphosis of autism: A history of child development in Britain Bonnie Evans Payment and philanthropy in British healthcare, 1918–48 George Campbell Gosling The politics of vaccination: A global history Edited by Christine Holmberg, Stuart Blume and Paul Greenough Leprosy and colonialism: Suriname under Dutch rule, 1750–1950 Stephen Snelders Medical misadventure in an age of professionalization, 1780–1890 Alannah Tomkins Conserving health in early modern culture: Bodies and environments in Italy and England Edited by Sandra Cavallo and Tessa Storey Migrant architects of the NHS: South Asian doctors and the reinvention of British general practice (1940s–1980s) Julian M. Simpson Mediterranean quarantines, 1750–1914: Space, identity and power Edited by John Chircop and Francisco Javier Martínez Sickness, medical welfare and the English poor, 1750–1834 Steven King Medical societies and scientific culture in nineteenth-century Belgium Joris Vandendriessche Managing diabetes, managing medicine: Chronic disease and clinical bureaucracy in post-war Britain Martin D. Moore Vaccinating Britain: Mass vaccination and the public since the Second World War Gareth Millward Madness on trial: A transatlantic history of English civil law and lunacy James E. Moran Early Modern Ireland and the world of medicine: Practitioners, collectors and contexts Edited by John Cunningham Feeling the strain: A cultural history of stress in twentieth-century Britain Jill Kirby Rhinoplasty and the nose in early modern British medicine and culture Emily Cock

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Communicating the history of medicine Perspectives on audiences and impact

Edited by Solveig Jülich and Sven Widmalm

Manchester University Press

Copyright © Manchester University Press 2020

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

While copyright in the volume as a whole is vested in Manchester University Press, copyright in individual chapters belongs to their respective authors, and no chapter may be reproduced wholly or in part without the express permission in writing of both author and publisher. Published by Manchester University Press Altrincham Street, Manchester M1 7JA www.manchesteruniversitypress.co.uk British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library An electronic version of Chapter 7 is also available under a Creative Commons (CC-BY-NC-ND) licence, thanks to the support of The Wellcome Trust, which permits non-commercial use, distribution and reproduction provided the author(s) and Manchester University Press are fully cited and no modifications or adaptations are made. Details of the licence can be viewed at https://creativecommons.org/licenses/by-nc-nd/4.0/ ISBN  978 1 5261 4246 7  hardback First published 2020 The publisher has no responsibility for the persistence or accuracy of URLs for any external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Cover image: Dr. Franke’s Phantom: Anatomical-physiological atlas of the human, Berlin, 1891. National Library of Medicine, USA. Photo by Mike Sappol Cover design: riverdesignbooks.com Typeset by Toppan Best-set Premedia Limited

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Contents

List of figures List of tables List of contributors Acknowledgements

page vii x xi xv

1 Introduction: audiences and stakeholders in the history of medicine Solveig Jülich and Sven Widmalm 2 Creating reflective citizen-physicians: teaching medical history to medical students Frank Huisman 3 Feeling great? Practice, institutionalization and disciplinary context of history of medicine in Germany Ylva Söderfeldt and Matthis Krischel 4 Writing history as it happens: the historian’s dilemmas in a time of health-care reform Beatrix Hoffman 5 The audiences of eugenics: historiographical and research political reflections Lene Koch 6 Striking a chord: physician-publics, citizen-audiences and a half-century of health-care debates in Canada Sasha Mullally and Greg Marchildon

1 18 43 66 89 107

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

vi Contents

7 Mansions in the Orchard: architecture, asylum and community in twentieth-century mental health care Sarah Chaney and Jennifer Walke 8 Swedish sex education films and their audiences: representations, address and assumptions about influence Elisabet Björklund 9 On ‘the use and abuse’ of medical history ‘for life’: a disrupted digression on productive disorder, disorderly pleasure, allegorical properties and scatter Michael Sappol 10 Audiences and the history of medicine Ludmilla Jordanova

138 162

184 215

Index 227

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Figures

7.1 Photograph of Bethlem Museum of the Mind foyer during redevelopment (Max Reeves, 2014). 7.2 Photograph of interior of abandoned ward (Max Reeves, 2014), with additions by anonymous artist. 9.1 Michael Sappol, ‘zero [0] vs the cooked’, collage using material from T. Cohn, Electro-Diagnosis & Electro-Therapeutics (London/New York, 1904), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.2 Michael Sappol, ‘of “how” and “why,” for’, collage using material from W. J. S. Krieg (text) and A. Ryan Associates (art), The Brain in Anatomical Transparencies (Chicago: Abbott Laboratories, c. 1955), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.3 Michael Sappol, ‘closeted. (And remains’, collage using material from O. Scarlattini, L’huomo, e sue parti figurato, e simbolico, anatomico … raccolto, e spiegato configure, simboli, anatomie … opera … in due libri distinta … (Bologna: Giacomo Monti, 1683), in the collection of the National Library of Medicine, Bethesda, Maryland.

143 152

185

187

190

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

viii Figures

9.4 Michael Sappol, ‘mask? By’, collage using material from Dr. Franke’s Phantom anatomische-physiologischer Atlas des Menschen (Berlin: Verlag von Reinhold Kühn, 1891), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.5 Michael Sappol, ‘And yet: historical unattainable’, collage using material from E.-L. Doyen, Atlas d’anatomie topographique (Paris, 1911–1912), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.6 Michael Sappol, ‘gardens awkwardly exhibition’, collage using material from G. Venzmer et al., Hand- und Lehrbuch der Krankenpflege (Stuttgart: Franckh’sche Verlagshandlung, c. 1940), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.7 Michael Sappol, ‘contrapuntal theme: Even in death’, collage using material from G. Bidloo (author, anatomist) and G. de Lairesse (artist), Anatomia humani corporis (Amsterdam, 1685), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.8 Michael Sappol, ‘the physical space was up’, collage using material from E.-L. Doyen, Atlas d’anatomie topographique (Paris, 1911–1912), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.9 Michael Sappol, ‘An evasion. A present is past’, collage using material from A. Cleyer, Specimen medicinae Sinicae (Frankfurt am Main, 1682), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.10 Michael Sappol, ‘usefulness carries a strange’, collage using material from G. McHugh (artist), P. C. Kronfeld and S. L. Polyak (text), The Human Eye in Anatomical Transparencies (Rochester, NY: Bausch & Lomb, 1943), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.11 Michael Sappol, ‘touted one book in’, collage using material from R. Kossmann and J. Weiss, Mann und Weib (Leipzig, 1907–1908); letter Horrors, in the collection of the National Library of Medicine, Bethesda, Maryland.

192

194

196

199

201

203

206

208

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Figures ix

9.12 Michael Sappol, ‘dreary to “process”’, collage using material from F. C. Hollick, Outlines of Anatomy & Physiology (Philadelphia, 1847), in the collection of the National Library of Medicine, Bethesda, Maryland. 9.13 Michael Sappol, ‘the indifferent makes a plunderer of ’, collage using material from E.-L. Doyen, Atlas d’anatomie topographique (Paris, 1911–1912), in the collection of the National Library of Medicine, Bethesda, Maryland.

210

212

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Tables

3.1 Medical schools included in the analysis. 3.2 Categories of names of academic units. 3.3 Doctorates of professors at academic units considered.

47 48 50

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Contributors

Elisabet Björklund is a Senior Lecturer in Film Studies at Linnaeus University, Sweden. Her research is focused on sexuality and reproduction in Swedish film and television, and she earned her PhD from Lund University in 2013 with the dissertation ‘The Most Delicate Subject: A History of Sex Education Films in Sweden’. Recent publications include the co-edited volume A Visual History of HIV/AIDS: Exploring the Face of AIDS Film Archive (2019, with Mariah Larsson). Sarah Chaney is a Wellcome Trust Research Fellow at Queen Mary Centre for the History of the Emotions, University of London. Her current project explores the idea of compassion in the history of nursing. She previously worked on the history of psychiatry, and her monograph Psyche on the Skin: A History of Self-Harm was published by Reaktion in 2017. She has a background in public engagement and material culture, and has led art and heritage projects at Bethlem Museum of the Mind (funded by the Wellcome Trust) and the Royal College of Nursing (funded by the Heritage Lottery Fund). Beatrix Hoffman is Professor of History at Northern Illinois University. She is the author of Health Care for Some: Rights and Rationing in the United States since 1930 (2012) and The Wages of Sickness: The Politics of Health Insurance in Progressive America (2001), and co-editor of Patients as Policy Actors (2011). She is currently working on a history of the right to health care for migrants and immigrants.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

xii Contributors

Frank Huisman is Professor in the History of Medicine affiliated to the Medical Humanities Department of the University Medical Center Utrecht, The Netherlands. He is also a member of the Descartes Center for the History and Philosophy of the Sciences and the Humanities of Utrecht University. Among his recent publications are Health and Citizenship: Political Cultures of Health in Modern Europe (2014, co-edited with Harry Oosterhuis) and Blurring Boundaries: Towards a Medical History of the Twentieth Century (2017, co-edited with Joris Vandendriessche and Kaat Wils). Currently, he is working on a book exploring the transformation of the Dutch health-care system between 1865 and 1941. Ludmilla Jordanova is Professor Emerita of History and Visual Culture at Durham University. Her publications include The Look of the Past: Visual and Material Evidence in Historical Practice (2012) and Physicians and Their Images (2018). The third edition of History in Practice was published by Bloomsbury in 2019. Solveig Jülich is Professor of History of Science and Ideas at Uppsala University, Sweden. Her research focuses on late nineteenth- to early twenty first-century history of reproduction, and history of medical imaging and media culture. She has contributed essays on the historical trajectories of Swedish photographer Lennart Nilsson’s images of embryos and foetuses in journals such as the Bulletin of the History of Medicine and Social History of Medicine. Currently, she is directing the research programme ‘Medicine at the Borders of Life: Fetal Research and the Emergence of Ethical Controversy in Sweden’ (medicalborders.se). Lene Koch is Professor Emerita of Medical Science and Technology Studies at the Department of Public Health, University of Copenhagen, Denmark. She published her habilitation thesis on the history of eugenics and compulsory sterilization in Denmark in 2000 and has been publishing widely on the social and ethical aspects of the new reproductive and genetic technologies since the mid-1980s. Her most recent publications include: ‘Transforming Social Contracts: The Social and Cultural History of IVF in Denmark’, Reproductive Biomedicine & Society Online, 2 (2016), 88–96 (with Sebastian Mohr).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Contributors

xiii

Matthis Krischel is Lecturer in History and Philosophy of Medicine at Heinrich Heine University in Dusseldorf, Germany. He received his PhD in History and Philosophy of Medicine from Ulm University in Germany and an MA in History of Science from the University of Oklahoma. His research focuses on history of medicine and the life sciences in the nineteenth and twentieth centuries. He has published on the history of Nazi medicine and its commemoration, the history of eugenics and human genetics, the history of urology and narrative bioethics. Greg Marchildon is Ontario Research Chair in Health Policy and System Design at the Institute of Health, Policy and Evaluation at the University of Toronto. He is the Director of the North American Observatory on Health Systems and Policies and a Fellow of the Canadian Academy of Health Sciences. After obtaining his PhD at the London School of Economics, he taught at Johns Hopkins University. He then served as Deputy Minister to the Premier and Cabinet Secretary in Saskatchewan and as Executive Director of the Royal Commission on the Future of Health Care in Canada. Sasha Mullally holds a doctorate in History from the University of Toronto and is currently Associate Professor of History at the University of New Brunswick. She has published widely on the history of health services in Canada and the United States, especially on the social organization of North American rural health care. A former editor of Acadiensis: Journal of the History of the Atlantic Region, she is finishing a co-authored book examining the role that immigrant physicians played during the implementation of Canada’s universal health-care system, Medicare. Michael Sappol is Visiting Researcher at the Department of History of Science and Ideas at Uppsala University, Sweden. For many years he was curator and scholar-in-residence in the History of Medicine Division of the National Library of Medicine. He is the author of A Traffic of Dead Bodies (2002) and Body Modern: Fritz Kahn, Scientific Illustration and the Homuncular Subject (2017). Currently, he is working on two new projects: ‘Anatomy’s Photography: Objectivity, Showmanship and the Reinvention of the Anatomical Image, 1860–1950’ and ‘Queer

xiv Contributors

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Anatomies: Perverse Desire, Medical Illustration and the Epistemology of the Anatomical Closet’. Ylva Söderfeldt is Senior Associate Lecturer in History of Science and Ideas at Uppsala University, Sweden. She received her PhD from Stuttgart University/Institute for the History of Medicine of the Robert Bosch Foundation. She taught History, Theory and Ethics in Medicine at RWTH Aachen University Hospital and was a postdoctoral fellow at the Max Planck Institute for History of Science. Her research focus is disability history and patient history in the nineteenth and twentieth centuries. Jennifer Walke is a Senior Teaching Fellow at the King’s College London Institute of Psychiatry, Psychology & Neuroscience. Research interests include the sociocultural history of psychiatry, and the construction and promotion of service user expertise. Her doctoral thesis used Bethlem Royal Hospital as a case study for addressing changing psychiatric policy and practice in twentieth-century Britain, marshalling archival and oral history evidence. She has collaborated with cultural sector partners, including Tate Modern and Bethlem Museum of the Mind, in creative initiatives for mental health public engagement and stigma reduction. Sven Widmalm is Professor of History of Science and Ideas at Uppsala University, Sweden. He has worked on topics in the history of science, politics and culture from the eighteenth century onwards. Lately he has worked on the history of nineteenth-century biochemistry, research policy and scientific relations between Sweden and Nazi Germany. A recent 2019 publication, co-edited with Maria Björkman and Patrik Lundell, is Intellectual Collaboration with the Third Reich: Treason or Reason?

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Acknowledgements

The editors would like to thank the Swedish Foundation for Humanities and Social Sciences (Riksbankens Jubileumsfond) for their generous funding of the international conference ‘History of Medicine in Practice’ that took place in Uppsala, Sweden, in March 2014 and from which several contributions to this book originated. Solveig Jülich would like to thank the same foundation for supporting the research project ‘In the Light of Media: Mass Miniature Radiography Surveys for Tuberculosis in Sweden, c. 1940–1970’, which stimulated her interest in past and present audiences of the history of medicine. We would also like to thank series editor David Cantor, always helpful and not least patient, as well as two anonymous reviewers who provided valuable comments on a draft version of the book. Our most heartfelt thanks are due to Ludmilla Jordanova, whose keynote talk on ‘Audiences and the History of Medicine’ at the above-mentioned conference inspired the theme of this book.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

1

Introduction: audiences and stakeholders in the history of medicine Solveig Jülich and Sven Widmalm

According to the ivory-tower stereotype, the academic community promotes withdrawal and disengagement instead of acting in the real world.1 Another interpretation of the sometimes low visibility of academic and not least humanistic research is that its non-academic use is not acknowledged. This was recently demonstrated in Sweden when a documentary around the widely acclaimed drama television series ‘Miss Friman’s War’ (Fröken Frimans krig), produced for the national public TV broadcaster (SVT), became the topic of a heated debate. The series is based on actual events around the struggle for women’s suffrage and equal rights in early twentieth-century Sweden. Themes from medical history are also manifest, as seen in an episode when a character inspired by the female gynaecologist pioneer Karolina Widerström argues against the legislation that forced women suspected of prostitution to be subjected to medical examination for signs of veneral diseases. Several female experts on women’s history had contributed as consultants to the documentary and SVT was criticized for making it seem as if the research underlying the series had been carried out by the production company, not even acknowledging the names of the professional historians in the film’s end credits. The irony that this exclusion of female expertise clashed with the theme of the drama was not lost on commentators.2 Interestingly, the outcome of this controversy was to make visible ‘the invisible historian’ (to paraphrase Steven Shapin’s classic paper).3

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

2

Communicating the history of medicine

Historians interact with a variety of audiences; television and film is one example where their research may be said to have a societal ‘impact’, though often blunted for dramaturgical reasons, and sometimes made invisible because historical knowledge is seen as a commons (a resource generally available free of charge) where the crediting of authorship does not always seem necessary. In the history of medicine – our focus in this book – other audiences include government committees and commissions dealing with ethical issues in biomedicine; journalists asking for historical perspectives on discoveries or abuses and controversies in medicine; curators and visitors at museums; sometimes even medical researchers utilizing historical material. A particularly prominent audience for historians of medicine is practising physicians. The subject is often taught at medical schools in the context of medical (or health) humanities, a field that has undergone a rapid development in the UK and the United States, and more recently in countries like the Netherlands and Sweden. At the same time research assessments put pressure on all disciplines to account for the concrete and direct effects – ‘impact’ – of research outside of an academic context. An important aim of this book is to challenge the idea, often implicit in current discussions about impact, that communication between researchers and their audiences is unidirectional and that it takes place between pre-defined groups of actors. The book should provide fodder for a discussion about how engagements by academic historians with potential interest groups may be viewed as exercises in ‘audiencing’ – i.e. the creation of new audiences for academic knowledge production – and also how researchers develop new agendas, sometimes expanding their professional domain, to cater to the perceived needs of existing or potential audiences. The measurement of impact is rapidly becoming a policy tool, whereas the idea of audiencing is an analytical framework that can be used for understanding processes encouraged by policy. Our view is that such an analytical approach is much needed considering the current transformation of the humanities, where utility is emphasized more and more, not only because scholars are encouraged to demonstrate impact but because many are truly interested in interdisciplinary collaboration on important contemporary issues. The book explores the history of medicine’s relationships with its audiences, from the early twentieth century to the present. Throughout, the authors discuss in what ways professional historians and others with

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 3

an interest in historical issues have created and interacted with audiences and how the demands of impact have been envisioned and enacted. Addressing several national contexts and focusing on broad areas where medical history is put to use, including medical education, policy-making, exhibitions and museums, film and television, the volume makes an original historical and historiographical contribution to the field and reflects on the relevance of the history of medicine for current debates and future challenges. Audiences and audiencing

In recent years, historians in many fields have begun to take a greater interest in the roles and activities of past audiences. As noted by Ludmilla Jordanova in Chapter 10 of this book, as well as elsewhere, visual and material cultures are especially rich areas for historical research on audiences in their various performances and contexts.4 This holds true for historians of medicine who increasingly have begun to look at how media of all sorts have been used to inform, persuade, educate and entertain a diversity of audiences about health and medicine. For scholars working with historical materials relating to intersections between medicine and the media, the question of audience impact has most often been treated with a dose of scepticism of whether it is possible to know what people thought and felt in the past.5 Less attention has been directed to the ways that the professional history of medicine has been involved with issues related to audiences. To develop an awareness – critical as well as constructive – of the importance of audiences for medical history, we propose to bring in theoretical perspectives and approaches from media and cultural studies. We argue that this can help put current notions of ‘impact’ in research policy into perspective. While being inspired by the work of media and cultural studies, we maintain that discussions on audiences and impact must be historically informed, not least to avoid the ubiquitous ‘rhetoric of newness’ around digital media that assumes active and politically engaged audiences to be exclusive to our times.6 As will be demonstrated throughout this book, active audiences have always been integral to the discipline’s knowledge production as it has engaged medical students, doctors and nurses as well as policy-makers and wider non-medical groups.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

4

Communicating the history of medicine

A first lesson to be learnt from media and cultural studies is that the concept ‘audience’ is by no means clear-cut or fixed. The usefulness of the term as well as the relationship between ‘audience’ and ‘public’ have often been the subject of discussion.7 ‘Audience’ suggests a situation where a number of people simultaneously experience a play, opera, lecture or another kind of live performance. Nevertheless, audience researchers investigating the reception of mediated communication have long used the term as a collective noun that spans media to include readers, listeners and viewers of books, press, radio, television and cinema.8 It has been argued that this notion of ‘audience’ no longer applies in a media landscape like the present one, where the dichotomy between production and consumption has broken down.9 Others have found the shift away from a language of ‘audiences’ toward ‘users’ or ‘produsers’ profoundly misleading, since the large majority of people are still consuming media produced by others.10 We agree with the editors of the recent volume, Audience Transformations, that a broad notion of audience that embeds changes of communicational practices in a historical, societal, cultural, ideological, technological and economic context is productive and valid.11 Traditionally, there has been a tendency to view ‘audiences’ and ‘publics’ as mutually opposed. Theorists and cultural critics like Jürgen Habermas or Richard Sennett claim that the media have undermined the public sphere, turning publics and engaged citizens into passive audiences and consumers of mass culture.12 Sonia Livingstone has argued that even now it is commonplace to distinguish between audiences and publics: ‘In both popular and elite discourses, audiences are denigrated as trivial, passive, individualized, while publics are valued as active, critically engaged and politically significant’. But, as she notes, in the changing contemporary media environment, ‘characterized by both the mediation of publics and the participation of audiences’, this distinction becomes increasingly blurred. She suggests ‘civic culture’ or ‘civil society’ as a mediating domain positioned between ‘the public’ and ‘the audience’.13 This strategy is picked up in Chapter 6 by Sasha Mullally and Greg Marchildon where they analyse how doctors in the 1962 Saskatchewan strike against Canada’s Medicare plan became an audience for the political rhetoric surrounding the event and at the same time an empowered public working to mobilize the larger citizenry as an audience for their protesting views. But doctors did

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 5

not speak unanimously. There were two ‘medical publics’, each laying emphasis on different aspects of the history of medicine in Canada. A second and related lesson from media and cultural studies is that audiences are actively constructed by media producers and others. Sonia Livingstone and Peter Lunt use the term ‘implied audience’ to ‘make explicit the commonplace but often unnoticed and, arguably, ungrounded assumptions that get mobilized in policy discourses about how people ordinarily relate to media and communications’.14 More broadly, the term ‘audiencing’ has been coined to describe the process of creating audiences: they ‘do not exist until “called forth”, more or less successfully, by those who wish to address them’. In addition, people perform ‘audiencing’, thereby constructing themselves as audiences.15 This notion is relevant for understanding the communicative activities of historians. For instance, as she discusses in Chapter 5, Lene Koch’s academic work in the 1990s on modern biotechnology and the history of eugenics gave her a media platform to engage with general as well as specific audiences that were often driven by an interest in possible similarities between early eugenics and modern genetics. She reflects on how this exercise in audiencing increasingly raised methodological and historiographic problems for her as a professional historian of medicine as her views changed in a direction that no longer chimed with expectations among an audience she herself had helped create. Similarly, Elisabet Björklund describes in Chapter 8 how her research on sex education films easily mobilized an audience titillated by the subject matter and often, as in Koch’s case, with expectations shaped by preconceived notions rather than an interest in the historian’s perspective. Björklund analyses this same tension in the history of sex education films that developed in tandem with the medicalization of sex and where the history of medicine was used in the legitimization process of both. Third, there is much to learn from the never-ending debate on media effects in audience research. As has often been noted, the field of communications and media studies emerged from a concern about the media’s impact on society in the first half of the twentieth century. Early studies on media effects were initiated during the First World War, in large part as a response to fears about the spread of propaganda, but also in relation to an expanding advertising industry. Through metaphors of bullets and hypodermic needles the media were attributed

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

6

Communicating the history of medicine

with powerful and harmful effects on largely helpless audiences.16 Interestingly, the same metaphors were used in the medical world but with the opposite meaning – ‘magic bullets’ and ‘hypodermic needles’ symbolizing the ability to cure an infected host.17 Censorship regulation often followed anxieties over media consumption, as discussed by Björklund in her chapter on Swedish sex-education films. Yet, from the mid-1940s, empirical studies began to suggest that mass media had only partial effects on individuals and audiences. This ‘limited effects model’ was again shifted in the 1960s and a number of theories emphasizing moderate to powerful effects emerged, including Marshall McLuhan’s widely discussed idea that it is not the content but the characteristics of the medium itself that affects society, encapsulated in the phrase ‘the medium is the message’.18 During the 1970s and onwards the media-effects tradition became increasingly the target of criticism from Stuart Hall and other cultural studies researchers stressing the agency, active responses and resistant readings of consumers of popular culture.19 Today, the once dominant model of communication as information transferred from a sender to a receiver is seen as far too crude. A more productive analysis will allow for considering the circulation and transformation of meaning across time and space. There are no passive audiences, only agents that can use, rework and elaborate ‘content’ or ‘messages’ in manners that often are quite alien to the aims and intentions of the producers.20 For the purpose of this book, the questions posed in the field of audience research are a useful reminder that there are no simple ways to evaluate the impact of historical work. Historians of medicine seeking to engage with people about their work regularly find themselves navigating in a complex landscape influenced by the appearance of digital technologies, the media industry and various interest groups. Yet, even if this landscape has been shifting, the strategies for disseminating historical research seem not to have changed in any radical way. We perhaps optimistically expect that the audiences are out there somewhere and that our work has at least some sort of effect on their views of medicine and health in past societies or that our historical insights contribute relevant perspectives on contemporary dilemmas and issues. More and more, however, humanities researchers are requested to provide detailed accounts of the ‘impact’ of their work on audiences. This tendency is most evident in research policy, where

Introduction 7

media visibility is indeed counted as one important form of impact among many.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Stakeholders and impact

With the broader concepts of audiences and publics offered by media and cultural studies, the interaction between historians of medicine and their audiences may in fact be seen as a special case of a larger phenomenon: the communication of academic knowledge to interest groups, including the ‘general public’, some of which have the power to strongly influence the development of research. This phenomenon has received growing attention since the Second World War, with the rise of science policy and an increasing awareness of the transformative power of research as witnessed in, e.g., science-based technology, medicine and economics. From the 1960s there has been a growing interest in analysing science-society relations within the academic community, manifested in the emergence of Science and Technology Studies (STS) and innovation studies. Later, governments started to evaluate research from cost-benefit and new-public-management perspectives, while scientific literacy in relation to democratic decision-making has likewise come under scrutiny as the hegemony of scientific expertise is challenged (true of history as well as medicine) on political as well as grassroot levels.21 The audience-public tension in this development is illustrated by the movement from a public-understanding-of-science discourse to one of public engagement with science and technology. In research policy there has been a similar turn from the unidirectional so-called linear model of R & D to a growing realization that innovation emerges in systems and networks. The relationship between all academic fields, including history of medicine, and their audiences are currently being investigated from a broad array of perspectives, including those of media and cultural studies. More specifically, the humanities have to some extent moved in a direction where audiences have become defined from a utilitarian perspective – environmental humanities being a case in point, and with medical humanities being particularly relevant for historians of medicine. As the evaluation of direct effects of research outside of the academic system are put into practice in, e.g., the UK, the Netherlands, Australia and Sweden, these effects are routinely being described in

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

8

Communicating the history of medicine

terms of ‘impact’.22 In this context audiences are often envisioned as stakeholders and the relationship between research and stakeholders as unidirectional and measurable. Within the humanities, the reaction to these developments has been ambiguous. The common view, that the humanities represent nonutilitarian values and/or a cultural-critical ambition, has seemingly been at odds with the ambition to promote practically oriented agendas and to hold researchers ‘accountable’. These developments have been seen by some as a welcome opportunity to demonstrate the oftenoverlooked value of humanities research and by others as a threat to the field’s autonomy. In the humanities, the view of researchers as service providers and audiences as stakeholders or consumers is controversial for at least two reasons. First, it runs counter to the idea that humanist scholarship is concerned with imponderables such as culture or the development of character. Second, critically oriented humanities have long dismissed some ideas that underpin evaluations of impact, for example that there is a linear relationship between research and innovation, or between media and audiences (as discussed above). The history and sociology of medicine, science and technology, and also popular models in innovation studies deriving from evolutionary economics, have emphasized that the impact of new knowledge is a complicated and time-consuming process involving relations between many actors within historically specific cultural and economic frameworks. Furthermore, it has long been argued in these fields that knowledge, like mediated information, is not a homogenous commodity but rather, as Ludwik Fleck has already pointed out in the 1930s, a shape-shifting entity that undergoes transformations as it circulates between knowledge producers and knowledge users (making this very distinction suspect) – an analytical approach that also lies behind the recent interest in so-called knowledge history.23 These insights belie the conception that audiences are passive recipients of knowledge and, importantly, that knowledge impact is a short-term phenomenon. For historians of medicine the tension between a utilitarian and a more traditional humanist approach has been noticeable in relation to the medical community as an object of study, which is also courted for collaborative partnership, not least within the cross-disciplinary field of medical humanities. In Chapter 9, Michael Sappol comments on the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 9

sometimes problematic and sometimes constructive relationship between the history of medicine and its professional audience, not least the custodians of that profession’s status. More than that, however, the chapter’s idiosyncratic tone and content aim in a small way to break the mould of academic writing with regard to style as well as expectations of scholarly relevance or impactful utility. In a personal reflection on the driving forces behind his work on the iconography of anatomy, in connection with a particularly successful historical exhibition, he defends the historian’s right to search for insight by following the pleasure principle of research based on interest and instinct rather than the expectations of any imagined audience. Ylva Söderfeldt and Matthis Krischel comment, in Chapter 3, on what might happen under conditions opposite to those described by Sappol, demonstrating that important issues are indeed at stake when the professional audience of historians gains the upper hand over scholarship. They argue that the recent institutionalization of the teaching of the history of medicine at German medical schools has directed historical researchers towards a form of audiencing that imperils their own professional standards. The question of the history of medicine and its audiences is not only theoretical. It is, as Sappol and Koch both point out, a matter of practical concern for any academic who is interested in outreach, which is increasingly the case. Beatrix Hoffman’s chapter focuses especially on this issue; she argues that it is important to think creatively about strategies that scholars can use (e.g., blogs and social media) in order to help correct myths and misinformation about health care. Her contribution may be read as a comment on how to achieve impact, not only in a vague sense but with the purpose of effecting positive change. Because of the trend of evaluating impact when allocating funding, it is also increasingly a matter of professional survival. Most famously, impact was used in 2014, in the British Research Excellence Framework, and the discussion about this initiative in the UK has been massive, not least because impact measures have been introduced in all academic disciplines, including those – notoriously the humanities – where it has been common to disregard utilitarian notions of research, at least from a short-term perspective. Opposition to the Research Excellence Framework of evaluating impact has been far from unanimous.24 Among those who reject ‘a tribal opposition to the notion of impact’, problematic aspects of the British

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

10

Communicating the history of medicine

experiment (planned to be repeated in 2021) have nevertheless been pointed out.25 An important criticism is directed against the methodology used to evaluate impact from case studies where the uses of specific results are demonstrated.26 As mentioned above, this linear understanding of impact has long been criticized for oversimplifying very complex relations, not least through a tendency towards short-termism (obvious in the case of the Research Excellence Framework, despite the fact that older research may be used as evidence of impact if it has occurred in the last five years).27 The Research Excellence Framework has also been criticized for vagueness, for suppressing narratives regarding impact other than the linear one, for encouraging ‘game playing’ and for imposing a very costly evaluation apparatus with no obvious benefits.28 A similar discussion is ongoing in medical humanities where a trade journal in 2008 devoted a special issue to the question of how to promote humanistic issues in a utilitarian context, framing it in terms of ‘Humane Health Care or Tool of Governance’. The editors claimed that the common view regarding the value of humanities in health education is that they provide a ‘counterbalance to the relentless reductionism of the biomedical sciences’.29 They asked if ‘evidence-based practice corrupts the humanity of the medical humanities’, and several contributors to the special issue indeed pointed to such dangers:30 The humanities […] are not evidence-based in a positivist sense. They tend to emphasize process over product; hence any argument for a ‘product’, defined for example as the ‘development of humanity’, must rest upon the hermeneutic enterprise. But as anyone who has ever applied for government funding well knows, it’s hard to argue for process. Products so much more readily fit into categories and lend themselves to quantitative assessment; products, we think, belong in the real world.31

On the other hand, some researchers have taken a more positive attitude to the idea of impact in the humanities. Charlotte Blease has argued against the idea that the value of the humanities is somehow ‘intrinsic’, maintaining that the dichotomy between instrumental and intrinsic value is not only false but harmful to the medical-humanities agenda, as it deepens ‘the fissure between the humanities and the sciences’.32 What is usually meant by ‘intrinsic value’ – the development of critical thinking, sound judgement, etc. – should, according to Blease, be seen as no less instrumental than, e.g., the therapeutic uses of book

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 11

reading: ‘Learning is prized […] because it yields outcomes’.33 The humanities should be valued because they provide health workers with expertise in understanding the conditions of their profession and with tools for scrutinizing a plethora of professional issues, including scientific ones. Frank Huisman’s chapter indeed shows how this may be done in an educational context – teaching students in the Netherlands about the societal conditions for medical work and disease prevention with the aim to prepare them for the realities of professional life. Taking the question ‘What does good medical citizenship entail?’ as a point of departure, he relates experiences from the development of medicalhumanities teaching at the University Medical Center (UMC) at Utrecht. Sarah Chaney’s and Jennifer Walke’s chapter likewise discusses a form of outreach that goes well beyond the linear model of media communication or research implementation, using ‘community engagement’ in the context of a series of exhibitions and related activities at the Bethlem Museum of the Mind in London to effect changes in, e.g., the perception of mental illness. So what happens when historians of medicine are actually asked to provide evidence of the impact of their work? Useful indicators are the reports in the Research Excellence Framework database of ‘impact case studies’ from 2014.34 Searching the database using ‘history of medicine’ as keywords results in 26 hits (a sample of research in this area in the UK, unclear how representative this is). An analysis of how impact is described in these case studies shows – perhaps not surprisingly – that a majority (16) are didactically oriented, emphasizing that new knowledge has been disseminated to specific groups or the general public. Phrases like ‘enhance/advance/raise/expand awareness/understanding’ indicate the general tenor of these descriptions of impact: they tend to stress the importance of research for education on different levels, as well as what has often been called the ‘public understanding of science’ (including impact on museums and in the media). Authors of case-study reports also stress that they have contributed to an improved ‘understanding’ among stakeholders, e.g. in policy, among patient groups, health professionals or even local historians. A smaller group (5) focuses on concrete impact among health professionals, e.g. by providing ‘historical evidence’ in areas of interest, by ‘influencing’ conceptions of medicine, such as how it is affected by culture. A few (4) reports focus more concretely on the critical (or emancipatory) understanding

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

12

Communicating the history of medicine

of medical issues, e.g. how research has helped change attitudes to Muslim medicine or mental illness. A few describe policy (3) and commercial (1) impacts in a sense that is in line with the Research Excellence Framework’s general ambition to measure direct effects. In this sample of (enforced) descriptions of the utility of research in history of medicine, the general tendency is hence to emphasize something close to the ‘intrinsic value’ discussed by Blease. The historians mostly portray impact as a form of enlightenment, producing and disseminating knowledge that is of interest to the general public and also to special interest groups, though its practical utility is often not well defined. * It has become increasingly evident that there are indeed huge potential audiences for the history of medicine. As demonstrated by best-selling books such as The Immortal Life of Henrietta Lacks and The Emperor of All Maladies, many people beyond the academic audience are eager to engage with histories of medicine, successful as well as problematic ones. Notably, neither of these books was written by a historian.35 But some academic historians of medicine have achieved considerable impact as measured by media attention and/or policy influence, for instance Susan Reverby with her research on US syphilis experiments in Guatemala, Lene Koch as detailed in her chapter in this volume, or similarly Mattias Tydén and Gunnar Broberg, whose work resulted in substantial government compensations to victims of eugenic sterilization in Sweden.36 The growing demand for impact in policy is problematic because it is used in evaluations and might therefore encourage opportunism and short-termism. On the other hand, we recognize that impact is important as long as it is not imposed in the form of a policy straitjacket. The chapters in this book give ample evidence that the history of medicine not only has an audience but that it has made a difference in numerous ways, touching the severely afflicted as well as the architects of health-care systems. The audience concept is central for understanding how advanced knowledge reaches beyond the confines of professional expertise, achieving a broad impact in real-life circumstances.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 13

Insights from media and cultural studies, as well as from STS, indicate several ways in which the study of audiences is relevant for the history of medicine and therefore also for the medical community. We want to emphasize three such areas. First, the multiplicity of past audiences (and publics) in the history of medicine, and the various techniques of audiencing adopted by the medical community and other actors with a stake in health issues, offer a rich field for scholarly exploration. Second, awareness of the intricacies of audiencing is key to identifying, mobilizing and connecting with audiences for the history of medicine itself. Third, an understanding of audiences is central for critical and constructive engagement with policy in the area of research and higher education – not only because of the trend towards impact assessment but generally, because all matters concerned with ‘knowledge politics’ include interaction between the sometimes overlapping categories of knowledge producers and knowledge consumers.37 If those who are professional researchers and teachers do not grasp the mechanisms behind – and repercussions of – such interaction, they divest themselves of power to control their own fate. Notes 1 For a recent discussion on the modern reworking of the metaphor of the ivory tower, see S. Shapin, ‘The Ivory Tower: The History of a Figure of Speech and its Cultural Uses’, The British Journal for the History of Science, 45:1 (2012), 1–27. 2 ‘Miss Friman’s War’ (Fröken Frimans krig), written by P. Oljelund, directed by M. Hellström and H. Hamrell, was aired on SVT in 2013–2017, and the documentary ‘The Women at the Time of Miss Friman’ (Kvinnorna på fröken Frimans tid), produced and directed by L. Wahlbom, was aired on SVT in 2016. The criticism was targeted against SVT as well as the production company Mediabruket, see, for instance, K. Östberg, ‘Forskningen nämns inte med ett enda ord’, Expressen, 4 January 2017; E. WittBrattström, ‘Sluta att sexualisera kulturkvinnan, SVT!’, Expressen, 6 January 2017. As a result of this debate Mediabruket published a ‘reference list’ covering all the people and literature that had ‘helped with information and facts’; see SVT’s website: https://www.svt.se/kvinnorna-pa-frokenfrimans-tid/referenslista-for-kvinnorna-pa-froken-frimans-tid (accessed 29 January 2018).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

14

Communicating the history of medicine

3 S. Shapin, ‘The Invisible Technican’, American Scientist, 77:6 (1989), 554–563. 4 L. Jordanova, The Look of the Past: Visual and Material Evidence in Historical Practice (Cambridge: Cambridge University Press, 2012), see especially chapter 4, ‘Audiences and Display’, pp. 154–206. 5 For a discussion and bibliography of this research, see T. Boon, ‘Medical Film and Television: An Alternative Path to the Cultures of Biomedicine’, in M. Jackson (ed.), The Oxford Handbook of the History of Medicine (Oxford: Oxford University Press, 2013), pp. 627–633. Also see V. Berridge and K. Loughlin (eds), Medicine, the Market and Mass Media: Producing Health in the Twentieth Century (London: Routledge, 2005); B. Hansen, Picturing Medical Progress from Pasteur to Polio: A History of Mass Media Images and Popular Attitudes in America (New Brunswick, NJ: Rutgers University Press, 2009); N. Hopwood et al. (eds), ‘Communicating Reproduction’, special issue, Bulletin of the History of Medicine, 89 (2015), 379–556; A. Nathoo, Hearts Exposed: Transplants and the Media in 1960s Britain (Basingstoke: Palgrave Macmillan, 2009). 6 A. Ekström et al., ‘Participatory Media in Historical Perspective: An Introduction’, in Ekström et al. (eds), History of Participatory Media: Politics and Publics, 1750–2000 (New York: Routledge, 2011), pp. 1–9. 7 For useful overviews, see R. Butsch (ed.), Media and Public Spheres (Basingstoke: Palgrave Macmillan, 2007); S. Livingstone (ed.), Audiences and Publics: When Cultural Engagement Matters for the Public Sphere (Bristol: Intellect, 2005); and V. Nightingale (ed.), Handbook of Media Audiences (Malden: Wiley-Blackwell, 2011). 8 V. Nightingale, ‘Introduction’, in Nightingale (ed.), Handbook of Media Audiences, pp. 1–15. 9 A. Bruns, Blogs, Wikipedia, Second Life, and Beyond: From Production to Produsage (New York: Peter Lang, 2008); H. Jenkins, Convergence Culture: Where Old and New Media Collide (New York: New York University Press, 2006). 10 J. Van Dijck and D. Nieborg, ‘Wikinomics and its Discontents: A Critical Analysis of Web 2.0 Business Manifestos’, New Media & Society, 11:5 (2009), 855–874. 11 N. Carpentier et al., ‘Audience/Society Transformations’, in Carpentier et al. (eds), Audience Transformations: Shifting Audience Positions in Late Modernity (New York: Routledge, 2013), p. 4. 12 Ekström et al., ‘Participatory Media in Historical Perspective’, p. 3. 13 S. Livingstone, ‘On the Relation Between Audiences and Publics’, in Livingstone (ed.), Audiences and Publics, p. 18.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 15

14 S. Livingstone and P. Lunt, ‘The Implied Audience of Communications Policy Making: Regulating Media in the Interests of Citizens and Consumers’, in Nightingale (ed.), Handbook of Media Audiences, p. 171. 15 N. Castree, Making Sense of Nature: Representation, Politics and Democracy (London: Routledge, 2014), p. 185. It was John Fiske who coined the term ‘audiencing’ to convey the active role of participating as an audience in communication. See J. Fiske, ‘Audiencing: A Cultural Studies Approach to Watching Television’, Poetics, 21:4 (1992), 345–359. 16 J. Bryant and D. Zillman, ‘A Retrospective and Prospective Look at Media Effects’, in R. L. Nabi and M. B. Oliver (eds), The SAGE Handbook of Media Processes and Effects (Los Angeles: SAGE, 2009), p. 11. 17 On this suggestive link between media studies and contagion narratives, see G. Thibault, ‘Needles and Bullets: Media Theory, Medicine, and Propaganda, 1910–1940’, in K. Nixon and L. Servitje (eds), Endemic: Essays in Contagion Theory (Basingstoke: Palgrave Macmillan, 2016). 18 For a brief overview, see Bryant and Zillman, ‘A Retrospective and Prospective Look at Media Effects’, p. 13. 19 Stuart Hall’s ‘encoding–decoding’ model of communication had a major influence on early cultural and media studies, see his ‘Encoding/Decoding’, in S. Hall et al. (eds), Culture, Media, Language – Working Papers in Cultural Studies, 1972–79 (London: Routledge, 1980), pp. 117–127. 20 This argument is summarized by S. Livingstone in ‘Media Audiences, Interpreters and Users’, in M. Gillespie (ed.), Media Audiences (Maidenhead: Open University Press, 2005), pp. 9–50. 21 On scientific literacy and democracy, see P. Kitcher, Science in a Democratic Society (New York: Prometheus Books, 2011). 22 See the overview of initiatives to measure impact produced by the Swedish Research Council (Vetenskapsrådet): B. Myrman, B. Sandberg and S. Söderberg, Om utvärdering av forskningens genomslag utanför akademin: Översikt över några nationella modeller, metoder och initiativ (Stockholm: Vetenskapsrådet, 2017). 23 P. Burke, What is the History of Knowledge? (Cambridge: Polity Press, 2016); L. Daston, ‘The History of Science and the History of Knowledge’, KNOW: A Journal on the Formation of Knowledge, 1:1 (2017), 131–154; J. Östling et al. (eds), Circulation of Knowledge: Explorations in the History of Knowledge (Lund: Nordic Academic Press, 2017). 24 According to the Swedish Research Council (Myrman et al., Om utvärdering av forskningens genomslag utanför akademin) there has been no opposition to the Research Excellence Framework at all. The report claims that impact evaluation has been especially appreciated in the humanities and social sciences, where researchers have welcomed being asked to produce

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

16

Communicating the history of medicine

evidence of the usefulness of their work. The same tendency characterizes two reports commissioned by UK higher education funding bodies, including HEFCE, and by the UK minister of Universities and Science: C. Manville et al., Assessing Impact Submissions for REF 2014: An Evaluation (Santa Monica, CA and Cambridge: RAND Corporation, 2015); Lord N. Stern, Building on Success and Learning from Experience: An Independent Review of the Research Excellence Framework (London: Department for Business, Energy & Industrial Strategy, 2017), https://www.gov.uk/government/ publications/research-excellence-framework-review (accessed 30 January 2018). 25 A. N. Mhurchú, L. McLeod, S. Collins and G. Siles-Brügge, ‘The Present and the Future of the Research Excellence Framework Impact Agenda in the UK Academy: A Reflection from Politics and International Studies’, Political Studies Review, 15:1 (2017), 60–72, on p. 61. 26 N. K. Shortt et al., ‘Taking Health Geography Out of the Academy: Measuring Academic Impact’, Social Science and Medicine, 168 (2016), 265–272. 27 K. Grandin et al. (eds), The Science-Industry Nexus: History, Policy, Implications, Nobel Symposium 123 (Sagamore Beach, MA: Science History Publications, 2004). 28 Mhurchú et al., ‘The Present and the Future of the Research Excellence Framework Impact Agenda in the UK Academy’; B. R. Martin, ‘The Research Excellence Framework and the “Impact Agenda”: Are We Creating a Frankenstein’s Monster?’, Research Evaluation, 20:3 (2011), 247–254. 29 A. Petersen et al., ‘The Medical Humanities Today: Humane Health Care or Tool of Governance?’, Journal of Medical Humanities, 29:1 (2008), 1–4, on p. 1. 30 Ibid., p. 2. 31 C. M. Gillis, ‘Medicine and Humanities: Voicing Connections’, Journal of Medical Humanities, 29:1 (2008), 5–14, on p. 6. 32 C. Blease, ‘In Defence of Utility: The Medical Humanities and Medical Education’, Medical Humanities, 42:2 (2016), 103–108, on p. 103. 33 Ibid., p. 107. 34 http://www.ref.ac.uk/2014/ (accessed 1 December 2017). 35 R. Skloot, The Immortal Life of Henrietta Lacks (New York: Crown Publishers, 2010); S. Mukherjee, The Emperor of All Maladies: A Biography of Cancer (New York: Scribner, 2010). Skloot is a science writer and Mukherjee a doctor and oncologist. 36 For their own reflections on these events, see S. M. Reverby, ‘Enemy of the People/Enemy of the State: Two Great(ly Infamous) Doctors, Passions, and the Judgment of History’, Bulletin of the History of Medicine, 88:3 (2014), 403–430; G. Broberg and M. Tydén, ‘När svensk historia

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Introduction 17

blev en världsnyhet: Steriliseringspolitiken och medierna’, Tvärsnitt, 3 (1998), 2–15. The research by Broberg and Tydén is reported in ‘Eugenics in Sweden: Efficient Care’, in Broberg and N. Roll-Hansen (eds), Eugenics and the Welfare State: Sterilization Policy in Denmark, Sweden, Norway, and Finland (East Lansing: Michigan State University Press, 1996). 37 N. Stehr, Knowledge Politics: Governing the Consequences of Science and Technology (Boulder: Paradigm Publishers, 2005).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

2

Creating reflective citizen-physicians: teaching medical history to medical students Frank Huisman

It is often claimed that we are living in a democratic knowledge society. But what does that mean? At first sight, it is a nice phrase with an optimistic ring to it. It seems to refer to a society that is organized using the latest scientific principles. Because society is transparent, with knowledge available to everybody, every citizen is capable of using his or her democratic participatory rights for the benefit of humankind. On closer examination, however, it turns out that it is difficult to establish what the phrase means in practical terms. How do citizens – who are in effect lay people – acquire scientific knowledge? Is it possible for them to have access to all available knowledge and critically evaluate its value? And if knowledge is power, should we not grant power to (scientific) experts? It seems like the logical thing to do, since they are the ones who know what they are talking about. But then again, should we be happy to abstain from our democratic rights and let experts decide on issues that affect us all? And what to do when experts disagree on the issue at stake? More often than not, ‘knowledge’ is not a value-free phenomenon, but rather biased by political ideology or commercial interests. We only have to think of issues like global warming or the financial crisis to realize that there is no simple scientific solution for every issue or problem. In short, when we claim to be living in a democratic knowledge society, there is a paradox involved in the relationship between democracy and ‘expertocracy’.1 Who has the knowledge, and how should it be implemented? Who has the power, and how should it be

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

19

distributed? To answer these questions, ‘audience’ is an important category. This volume is devoted to the creation of, and interaction with, audiences for medical history. Who constitutes the audience, and how is it created? As studies in the field of media and cultural studies have made clear, ‘audience’ is never a given entity, but rather a context-specific construction.2 Being part of an audience is a role that people temporarily perform, producing representations of audiences in the process. One could argue that the concept rhetorically separates insiders (belonging to the audience) from outsiders (belonging to ‘the crowd’). For example, in nineteenth-century European liberalism, citizenship could be characterized as a right of the white bourgeois male, while all of the others (workers, women, non-whites) belonged to ‘the crowd’.3 Citizenship was considered a privilege of the qualified: whoever had a certain level of wealth and education was supposed to have the civic virtue needed to transcend self-interest and serve the public interest in a rational, humanitarian way. Over the course of time, the criteria for suffrage were extended. As a result, the discourse on audience – understood as judgement of fitness for citizenship – changed considerably. Until now, ‘audience’ has been a rather underdeveloped category in the history of medicine.4 This is rather surprising, since medical students have always been the obvious audience for medical history.5 Conceived as history of ideas, medical history was used as a didactic instrument in the medical curriculum. At university, students were trained to become ‘gentleman-physicians’, expected to set aside their narrow self-interest for the sake of the common good. The Halle professor of botany Kurt Sprengel is often presented as the founding father of this concept of medical history.6 Sprengel had a ‘pragmatic’ approach to history, meaning that he thought one can learn from the past: history contains lessons for the present and hence serves a very practical goal. In his multi-volume Versuch einer pragmatischen Geschichte der Arzneykunde (1792–1803) Sprengel used medical history to show the gradual development of the human mind. Because history would teach students to find something of value in theories that looked strange at first sight, it would teach them modesty and tolerance. With its philosophical idealism and its didactic imperative, pragmatic historiography would never lose its attraction. Later generations canonized his pragmatic conception of medical history, making Sprengel the most important point

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

20

Communicating the history of medicine

of reference for the legitimation and institutionalization of medical history in medical faculties. Today, this situation of the self-evident value of medical history for medical students seems to have changed: over the course of the twentieth century, medical history lost much of its credibility and legitimacy in a medical teaching context, so there is every reason to rethink the audience category of medical students. One could argue that medical students make up a group that is more or less given (i.e. consisting of everybody enrolled in a medical programme), but I will also be looking at the ways in which teachers perceive the relevance of medical history for the shaping of responsible citizen-physicians – being researchers as well as clinicians. I will be dealing with the teaching of medical history in a very specific context, at the University Medical Center (UMC) Utrecht in the Netherlands. Bologna declaration, framework and site committee

As was pointed out above, discourses on audience are hardly ever dispassionate, universal or eternal. Rather, they are politically and normatively charged because they are dealing with the standards of citizenship. Further, they are culturally and historically contingent: every nation state defines its own standards of good citizenship, just as every generation does.7 So what does good medical citizenship entail in the Netherlands in the early twenty-first century? Context matters: the way in which the medical curriculum is organized at any given time mirrors societal needs and demands. Three developments created a situation in which the eight-week course, ‘Medical Humanities’, in Utrecht could be established: one European, one national and one local. In 1999, the Ministers of Education of 29 European countries convened in Bologna to discuss the harmonization of the European space with regard to higher education.8 The Bologna Declaration, which came out of this, has been the guiding document for the so-called Bologna process. It is meant to create a European Higher Education Area, in which students and graduates of EU member states can move freely between countries, using prior qualifications in one country as acceptable entry requirements for further study (or work) in another. Once the ideal was set, there was a need for a unified system of higher education. The European Ministers of Education opted for the Anglo-Saxon undergraduate/graduate system: a Bachelor’s phase

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

21

of three years was to be followed by a Master’s phase of one or two years. In 2002, the Bachelor/Master structure was introduced in the Netherlands; a few years later medical faculties followed suit, despite a lack of interest in applying this model to medical education in most EU countries.9 In 1994, a Framework for Undergraduate Medical Education (Raamplan artsopleiding) had been published in the Netherlands. The Framework was issued by the Dutch Federation of University Medical Centers (NFU) and was inspected through site visits made by the QANU (Quality Assurance Netherlands Universities). Because the world changes continuously, curricula will have to respond and adapt periodically. The Framework was renewed in 2001 and again in 2009. A further renewal is scheduled for 2019. Since its inception, the Framework has been a crucial document for medical education and, consequently, medical practice. Its legal context is the Law on the Professions in Individual Health Care (Wet BIG), which implies that medical certification is grounded in Dutch medical legislation. In the Framework of 2001 it was observed that medical education in the Netherlands was focusing too much on the technicalities of biomedicine, disregarding the societal and clinical dimensions of medicine and health care. Henceforth, having basic medical knowledge was no longer considered enough. The Framework called for more attention in the curriculum to social medicine (creating an awareness of health determinants), to translational medicine (bringing knowledge from the bench to the bedside), and to disciplines like medical ethics, health law and medical history. Since the Second World War, a plethora of technological and pharmaceutical innovations had changed medical practice profoundly. Together, they had led to an increased life expectancy and to towering expectations of what science could do for humankind. At the same time, however, they had led to spiralling costs of health care and – maybe paradoxically – to discontent among both doctors and patients.10 During the 1980s and 1990s, medical research witnessed a situation of diminishing returns, while patient demands were rising. Citizens became more vocal, accusing physicians of being paternalistic and holding them accountable for their actions. Western health-care systems seemed to be out of control; there was a need to rethink the goals and limits of medicine and to put new forms of health-care governance in

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

22

Communicating the history of medicine

place.11 One way of accomplishing this was to educate and socialize medical students in different ways than had been done before. Shaping technological biomedical experts no longer sufficed. Modern Western societies were in need of reflective citizen-physicians: people who realized that there was more to health care than knowing everything about the human body in sickness and in health. A reflective physician would be able to consider both the content of medicine and its context; (s)he was prepared to think beyond the narrow boundaries of the discipline and strive to contribute to equal access to health care for all and to a fair distribution of rights and duties among the population. In short, a reflective physician was expected to behave responsibly and be accountable to society. What do the humanities and (medical) history have to offer in this respect? Not so long ago, Helen Small identified five arguments for the value of the humanities; together, they offer a pluralistic account of value. Small argued that the humanities keep our democracy vital; they study the meaning-making practices of our culture; they have intrinsic value; they contribute to our individual and collective happiness; and they are (laudably) useless.12 The first argument in particular is of interest to us here, since it concerns the cultural practices of reflection, argument and criticism, and the shaping of good citizens through education. According to Small, the humanities can make a vital contribution to a healthy democracy. Bearing Socrates in mind, she claims that they have the potential to be a modern institutionalized gadfly to the polis. A year later, Jo Guldi and David Armitage claimed that our time is being haunted by short-termism.13 The fact that politicians tend to plan only as far as their next bid for election may have very detrimental effects, they argued, for example for the ecology (global climate change) and the economy (financial crisis). The world is hungry for long-term thinking, which can only be supplied by history. For the sake of our public future, we need to engage the big picture. Historians can help in doing so, since history has the potential to explain where things come from, ‘tacking between big processes and small events to see the whole picture, and reducing a lot of information to a small and shareable version’.14 In a very similar vein, Richard Horton, editor-in-chief of The Lancet, commented: ‘Medicine pays almost exclusive homage to the shock of the new. We place a constant emphasis on novelty […] Ours is an era of the instantaneous and immediate fact, a time when

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

23

traditions are dissolving and the perceived need for a dialogue with the past is all but invisible’.15 Elsewhere, he argued that ‘medical history should provide a humanistic counterweight to the claims of allegedly irresistible developments – teasing out aims, attitudes, motives, moral and religious convictions’.16 Medical history, in short, may serve as a counterpoint and an antidote to the whims of the day. This programme was recently developed by four leading North American medical historians who claim that medical history does many things that can be useful in the shaping of responsible citizenphysicians.17 History, they explain, not only contextualizes medical practice, but it also reveals the contingency and fallibility of knowledge, it fosters humility, it instils humanity, it trains critical thinking, it complements bioethics, it improves history-taking and it contributes to professional identity. Thus, medical students may learn from history that disease changes over time (both biologically and conceptually), that medicine is a product of history (i.e. medical knowledge is produced, implemented and evaluated in a specific context), that health inequalities continue to exist (in terms of race, class or gender), that health-care systems are in constant flux (any arrangement being the outcome of political struggle and compromise) and that ethical dilemmas are specific to context. And, finally, there is the local level of Utrecht. When in 2004 the Utrecht Medical School was visited by a Site Committee (using the criteria set by the Framework of 2001), it felt that the focus of the Utrecht curriculum was too technically biomedical, with only a very limited awareness of the context in which physicians and researchers are working. The first recommendation of the Site Committee for the University Medical Center Utrecht was to devote more attention to the development of academic skills.18 This triggered profound (self-) reflection on the curriculum, most notably by Olle ten Cate, Professor of Medical Education.19 Traditionally, the emphasis in medical training had been on biomedical knowledge, he maintained. Over the course of the twentieth century, however, the available biomedical knowledge had grown to such an extent that there was simply too much knowledge around to be mastered and integrated by one individual. This situation needed to change, if only because much of that knowledge turned out to be superfluous in clinical practice. Therefore, medical education moved toward problem- and outcome-based training, with the didactic focus

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

24

Communicating the history of medicine

changing from knowledge to problems, roles and competences. The Royal College of Physicians and Surgeons of Canada published the Canadian Medical Education Directions for Specialists (CanMEDS), identifying seven roles, 28 key competencies and 126 more specific enabling competencies. In thinking about (innovating) medical education at the beginning of the twenty-first century, identifying and assessing competencies had become all the rage. However, when it comes to translating a general framework into a concrete curriculum, the meaning of competence is not all that clear and is therefore difficult to assess.20 Rather than using long checklists of competencies, which tends to reduce medical professionalism to a rather mechanical activity, Ten Cate planned to use so-called entrustable professional activities (EPAs). Trust and responsibility are the key concepts in this approach: assessing a trainee is not done at a specific moment (an exam), but it is a process. Over the course of time, the instructor is granting ever more trust, while the trainee is prepared to bear ever more professional responsibility, to the point where (s)he can be left alone with the patient. In this situation, a medical degree is no longer an end point, but rather an intermediate phase in a long educational trajectory.21 Because biomedical knowledge has proliferated, because the health-care system has become very complex and because public confidence in the healthcare system has decreased, the time has come to rethink and to redefine the tasks we want medical graduates to be able to perform. Medical humanities and science in transition

One way to rethink the twenty-first-century physician is through redefining medical students as an audience for medical history. In the new Utrecht medical curriculum medical history was incorporated – together with medical ethics, health law, medical sociology and philosophy of science – in an eight-week course called ‘Medical Humanities’. After it had been in use in the United States for some decades, the concept gained currency in Great Britain in the early twenty-first century.22 Harold Cook, former Director of the Wellcome Trust Centre for the History of Medicine at University College London, observed: ‘The complexities and ambiguities of the human condition inform medicine profoundly, and exploring them often goes by the term “medical humanities”’.23 As such, Medical Humanities seemed more

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

25

like a pedagogical ideal aimed at forming good judgement than a discipline with a unified research programme. The Utrecht Medical Humanities programme understands itself as an interdisciplinary field that incorporates the humanities (medical ethics, health law and medical history), the social sciences (medical sociology and medical anthropology) and the arts (literature, movies, paintings). The programme started in 2008 and was developed by a committee consisting of two medical ethicists, a health lawyer, a medical historian (i.e. the author of this chapter), a social scientist, a general practitioner and two medical students. It sets out to understand modern health care by inviting students to reflect on its historical and philosophical roots as well as on its current ethical and legal dilemmas. It is keen on training responsible citizen-physicians by creating an understanding of the contextual meanings of health, illness and healing that is complementary to their biomedical knowledge. Furthermore, it tries to create an awareness of the duties and responsibilities of physicians towards their patients. Because students are stimulated to train their skills of observation, critical analysis and self-reflection, Medical Humanities hopes to contribute to the academic and social shaping of the future physician. As such, it fits the call for EPAs very well. The course is not elective, but compulsory to all students (approximately 300 on a yearly basis). In the third year of the undergraduate programme, two courses of four weeks each are available. After a general introduction, seven topics are dealt with: medical research, scientific literacy, scarcity in health care, prevention, the doctor-patient relationship, the end of life and medical technology. Overall, students are supposed to learn the basics of Dutch health law and be able to put this legal knowledge to practice, be able to tell the difference between several types of arguments (legal, ethical, economic), be aware of the fact that medicine and health care are contextual and therefore different according to time and place, be able to critically reflect on modern medicine and health care and take a personal position, and be able to formulate a research question, retrieve relevant data and write a coherent academic essay. During the course, students are expected to take two written exams and write a paper on a topic of their choice, taking a ‘Medical Humanities perspective’. While the course as a whole is interdisciplinary and each week is devoted to a topic rather than to a discipline, we start by presenting the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

26

Communicating the history of medicine

disciplines that make up Medical Humanities: medical ethics, health law, medical history and medical sociology. While there is, of course, no intention to turn students into ethicists, lawyers, historians or social scientists, an attempt is made to explain what an ethical, legal, historical or sociological stance entails, inviting them to decondition themselves as biomedical experts and to ‘resocialize’ as responsible citizenphysicians who can account for the role they will be playing in the health-care system. Medical history is presented as a discipline that – contrary to their expectations – is not devoted to (boring) names and dates in the past, but rather to the relationship between change and continuity in medicine and health care, in an attempt to gain an understanding of the human condition with regard to health, illness and healing. For that purpose, the past is presented as a ‘social laboratory’. It is claimed that one can learn from the past: not in a direct, utilitarian way, but in terms of developing a professional attitude (habitus) by reflecting on the ideas and practices of past societies. Another week deals with medical research involving human subjects. This week intends to show students that medical research is much more complex than one might expect, due to the fact that laboratory research is not in a one-on-one relationship to reality and because many political, financial, ethical and legal factors are involved in scientific research. A third week topic concerns scarcity in the health-care system. At first sight, solving scarcity simply seems a matter of putting in more money and effort into research and health care. However, whatever is defined as scarcity is highly dependent on the social and political context. It is a relative notion, depending on supply and demand, on the accessibility of care and on societal checks and balances. This week sets out to make students aware of this fact, both on a micro and on a macro level. The final week of the first course deals with prevention. It has been argued that preventive health measures have always made an important contribution to health and wellbeing. On top of that, they are often cheaper than curative interventions. However, in modern health care, the emphasis is on the latter. This week analyses the relationship between preventive and curative measures, also taking into account individual responsibilities and collective costs. During the clinical encounter, the patient – a human being with pain, complaints and insecurities – meets the expert. Their interaction is highly dependent on their world views and expectations. A whole week

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

27

is devoted to recent developments in the doctor-patient relationship in all of its dimensions. Death is both frightening and fascinating. How and where do we die, who is taking care of us? Who should be in charge of our death? Patients or doctors – or indeed both, in close interaction? What options are available to us, either to extend life or to speed up death? What role does the doctor play in this process? This week shows the different approaches to life and death – scientific, religious and humanitarian – and looks into the dynamics of end-of-life decisions. Technology has become an integral part of modern life, including medicine. Although medical innovations have brought impressive improvements in the field of diagnostics and therapy, technology can be said to be Janus-faced, causing man (both doctor and patient) to become its slave rather than its master. This week sheds light on the medical, financial and humanitarian repercussions of medical technology. Finally, there is the topic of ‘scientific literacy’, which was introduced a few years after the course started, replacing the subject of the beginning of life. The choice for this week’s topic was informed by the Dutch reform movement ‘Science in Transition’, established in 2013. The founding members of Science in Transition24 believe that the scientific system is suffering from serious systemic flaws and is in need of fundamental reform. Since around 1970, science has grown into an international, capital-intensive and hypercompetitive endeavour.25 Small academic science has become Big Science, and everything has grown exponentially: the number of scientists involved, the money spent and the scientific data produced. These changes have not always been for the better – to put it mildly. Complaints abound that science is no longer a calling of the few but has become a huge enterprise, involving enormous sums of money not always well spent; that an incentive and reward system has been created, leading to research carried out in haste and to research that cannot be reproduced; that bureaucratic controls have been put in place leading administrators to count rather than to read scientific publications; that peer review has become ineffective and that all of this has led many researchers to commit scientific fraud by forging, trimming and cooking their data.26 Similar analyses were made by Plos Medicine (‘Why most published research findings are false’), Plos Biology (‘The granting system turns young scientists into bureaucrats and then betrays them’), The Triple Helix (‘Data are massaged, modified or made up entirely until they conform’), PNAS (‘a highly significant correlation

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

28

Communicating the history of medicine

was found between the journal-impact factor and the number of retractions for fraud’), The Economist (‘How science goes wrong’), The Lancet (‘We need less research, better research, and research done for the right reasons’), Nature (‘Many fields of science now resemble war zones’) and many other leading journals.27 The initiators of Science in Transition call for a debate in academia and the wider society about the ways in which science and the university are organized, because they are concerned about the role of science as producer of useful knowledge, about the role of the university as producer of the intellectual elite of the future and about the way in which these challenges are met using financial incentives and rewards and quantitative evaluation criteria. Among the recommendations of Science in Transition is the call to all universities to include scientific literacy in the curriculum of all faculties. Topic of the week: scientific literacy

It is crucial for medical students to realize that science is not a neutral, curiosity-driven activity. Science is deeply embedded in society, funded with public money and working for the health and wealth of the people. Therefore, there are not just epistemological dimensions to science, but political, normative and financial ones as well – and students should be made aware of this. Whoever wants to become a scientist – either an academic researcher or a scientifically informed professional with a job outside academia – should, of course, know about the contents of scientific knowledge, but about its context as well. Including ‘scientific literacy’ in the medical curriculum seems like an ideal way of contributing to the shaping of responsible citizen-physicians. However, how to organize and present it? When we define scientific literacy as being knowledgeable about how science works and how it is embedded in society, it implies that we will have to deal with serious questions. What is the basis for our belief in science? What sets it apart from common knowledge? Are scientific facts discovered or rather socially constructed? Who should we trust in case two scientists disagree in a hotly debated issue? Is scientific knowledge something special to be emulated or ‘just another opinion’? Is science a vocation or just another profession? How are science and technology embedded in society and how do they change over time? How much do we really know about the production, implementation and evaluation of scientific knowledge?

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

29

These are important questions, which belong to the domains of the philosophy of science and the sociology of science (or STS). However, expecting medical students to engage with these and similar questions by asking them to read the work of people like Ludwig Wittgenstein, Karl Popper, Robert Merton, Thomas Kuhn, Bruno Latour and Michel Callon does not work. At best, they find it potentially interesting but difficult and abstract, more often they will consider it boring and irrelevant to their medical studies. Of course, it is not, but third-year medical students are already socialized into biomedical thinking to such an extent that they tend to regard their knowledge as essentialist and unproblematic. To open them up and make them susceptible to the kind of questions raised above, the week on scientific literacy is embedded in a recent case of medical history: the vaccination campaign against human papillomavirus (HPV).28 In 2009, Dutch citizens challenged the authority of medical science and the state, using the Internet as their weapon.29 The year before, they had been informed that a new vaccine against HPV had been developed. HPV is known to cause abnormal cell growth of skin and mucous membranes, and may even cause cervical cancer. It is estimated that, in the Netherlands, 200 women die from cervical cancer every year. In 2008, two vaccines became available: Gardasil (developed by Merck) and Cervarix (produced by GlaxoSmithKline). They were said to decrease the risk of developing cervical cancer by 70%. The Health Council – the highest advisory body of the Minister of Health – concluded that the vaccine was safe and effective and advised its inclusion in the National Vaccination Programme. Expectations were that the vaccine was capable of protecting women against the HPV virus – which is sexually transmitted – provided that they had not been sexually active yet. The Minister agreed, and he decided to provide the vaccine for free to girls of 12 years and older. A huge informational campaign was launched by the National Institute of Public Health and Environmental Hygiene (RIVM), which was supported by the Ministry of Health, the Health Council, the Dutch Society of General Practitioners (NHV), the Municipal Health Services (GGD) and the Dutch Vaccine Institute.30 A website and a newsletter were developed, and folders, brochures, posters and keyrings produced. Finally, there was a special phone number that people could call to report complications. In terms of information and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

30

Communicating the history of medicine

organization, nothing was left to chance. However, when vaccination started in March 2009, it became clear that the information campaign had not really caught on. The turnout was much lower than was to be expected based on earlier experience. In advance, it was thought that more than 85% of the girls summoned would show up. In the end, only 45% completed the whole series of three vaccinations.31 What had happened? Doubt with regard to vaccination had been created on the Internet. Stories were circulating, claiming that the vaccine was genetically manipulated and even life threatening. The low turnout was mainly attributed to the Internet campaign that the Dutch Society for Critical Vaccination (NVKP) had launched. The Society had been established in 1994, by people with bad vaccination experiences.32 It argued that citizens were not informed about the potential dangers of vaccination, while research into harmful side effects was delayed because of the financial interests of pharmaceutical companies and the career interests of biomedical researchers. On its website, the Society complained about the great social and medical pressures with regard to vaccination. They were considered a threat to a citizen’s autonomy and freedom of choice. It was claimed that education and screening could work just as well as vaccination and should therefore have priority. One could consider the website of the Dutch Society Critical Vaccination as an attempt to educate the general public by informing it. But on the Internet there is much more on offer. For lay people it is difficult to distinguish between ‘good’ and ‘bad’ information – which in liberal democracies is a matter of attribution by definition. Another website, hosted by an organization called Niburu, claimed to supply ‘awarenessbuilding news’.33 With regard to the HPV vaccination, it ‘revealed’ a plot of the authorities to counter overpopulation. It was suggested that the vaccine contained nanochips that would cause a slow but certain death. The campaign was said to be coordinated by the Global Alliance for Vaccines and Immunization, which was a ‘global health partnership’ in which the Rockefeller Foundation, the Bill Gates Foundation, the United Nations, the World Bank, UNICEF, the World Health Organization and many Western governments were said to participate. Whoever doubted that this was actually happening was referred to witnesses like a top official in the American army, a Cambridge professor and a professor affiliated to the French Centre National de la Recherche

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

31

Scientifique. Another website claimed that the Netherlands were transforming from a democracy into a police state.34 What is the meaning of this? It has been argued that, today, science in the service of the common interest is threatened, as scientists and policy-makers have come to see science mainly as a servant of interest group politics.35 This is by no means an academic issue, interesting only to medical historians. It is a concern to medical practitioners as well. To quote from an editorial published in the authoritative British Medical Journal: Today, clinical reality as perceived by clinicians has to be reconciled with patients’ beliefs, ‘resources’ have to be balanced against individual patient need, and ethical dilemmas spring hydra-headed from medical advance […] Utterly unquestioned biological givens are disintegrating all around us […] Doctors will become purveyors of choice – or agents of control – within the plastic limits of the flesh […] To the postmodernist the question is whose ‘evidence’ is this anyway and whose interests does it promote?36

Whereas some celebrate the triumph of the autonomous citizen-patient who has finally liberated themself, others deplore the erosion of professionalism, arguing that our national health-care system is under threat. Over time, we did not just see linear progress through the doings of medicine and the state. Today, modern Western health care is characterized by all kinds of contradictions and paradoxes.37 Big issues are at stake. They include truth, professionalism, political leadership, responsibility, distributive justice, trust and citizenship, and it is crucial that medical students are informed about these trends.38 The case of HPV is interesting because it incorporates two levels of health care and responsibility (collective and individual), two patterns of morbidity (infectious and chronic) and two paradigms of coping (vaccination and lifestyle). From the late nineteenth century onwards, the state had taken ever more responsibility for collective health by putting sanitary measures in place.39 This had led to a dramatic fall in mortality caused by infectious disease, especially after antibiotics and vaccination had been introduced. However, the second half of the twentieth century witnessed a shift in morbidity patterns from infectious to chronic disease.40 After the 1940s, infectious diseases had ceased to be the dominant killers. Due to lifestyle changes (smoking, eating,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

32

Communicating the history of medicine

drinking behaviour), chronic diseases like cancer and cardiovascular disease were on the rise. Because these were related to lifestyle, they could not be prevented or cured by ‘magic bullets’ supplied by the state, but only through changes in lifestyle, suggested by expert advice on causal patterns. Whereas accepting expertise became increasingly problematic in the democratic knowledge society, this was especially true in the case of HPV vaccination, in which a ‘quick fix’ (using the logic of infectious disease) was used to counter the risks of sexual behaviour (belonging to the domain of chronic and lifestyle disease). The week on scientific literacy begins by asking students about their conception of science, and requesting that they write it down in 200 words and bring it to class (which has the form of a seminar) to discuss it with the other students and their tutor. During the week, they have five seminars and two lectures. By the end of the week, they return to their one-pager, seeing if their understanding of science has changed and, if so, how. During the week, students become familiarized with the most important issues of twentieth-century philosophy and sociology of science. They read about these thinkers rather than reading the original works, and they read texts in Dutch rather than in English. All of this is meant to make the theories as accessible as possible to students, helping them to learn about verification and falsification, CUDOS and ANT,41 normal science and paradigm shift, the empirical cycle and the credit cycle, mode 1 and mode 2 science, realism and constructivism, and hybrid fora. The historical lecture during this week is called ‘Science in the democratic knowledge society’. In part, it deals with recent medical history (looking at the case of HPV), and in part with philosophy and sociology of science. It starts by showing a documentary made by Zembla, a TV programme devoted to investigative journalism. On 19 October 2008, Zembla broadcast ‘The contested cancer vaccine’.42 During the programme, the most relevant stakeholders (scientists, the industry, the media, parents and politicians) shed light on their positions. As it turns out, there is no such thing as ‘the truth’. Rather, there is uncertainty among scientists, insecurity among parents, commercial goals of pharmaceutical marketeers, conflict of interests within the Health Council and political activism of all sorts on behalf of the builders of websites. In a democracy, citizens are allowed to give their opinion about everything, the paradox being that they do not have the required expertise

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

33

to do so. For that, they have to rely on scientific experts, who have their own agendas. After dealing with Wittgenstein, Popper, Merton, Kuhn and Latour, the lecture returns to the case of HPV, mainly raising questions about the fact that, of the 400,000 girls who were invited to get their vaccination, only 45% showed up. During one of the seminars, students are expected to engage in a role play for which they have prepared themselves at home by looking at the websites of the parties involved in the HPV issue: the National Institute of Public Health and Environmental Hygiene, the two pharmaceutical companies, the Health Council, the Health Ministry, the Dutch Society Critical Vaccination and the Society against Quackery (which denounced the policy of the critical vaccinators). Regardless of their own personal views on the matter, students are expected to immerse themselves in the arguments of the party assigned to them, trying to win the argument. It is an attempt to decondition them from their self-evident biomedical stance and invite them to rethink priorities in the health-care system and their role in it as a physician. The goal of the role play is to make them sensitive to the complex hybridity of the HPV case and the colliding and colluding motives and goals of its most important stakeholders. From defining goals to measuring impact

The course committee had spent two years of meetings building the Medical Humanities programme. It entailed an interesting – and sometimes daunting – process of learning to understand each other’s discourse and voice, trying to agree on the means to achieve the didactic goals. After two years the committee (which also included two medical students) was satisfied. But, of course, the proof of the pudding is always in the eating. The course started in the academic year of 2008/2009 and was offered in six cycles of 50 students. After each term, the course was evaluated among students. Student representatives of the third year produced an overall evaluation of the course, and at the end of the academic year all evaluation data were assembled by the Department Quality Care of the Education Office of the University Medical Center, to be discussed with the course coordinators (one of them the author of this chapter). Many dimensions were evaluated: questions related to the architecture and the practical organization of the course, the accessibility of its coordinators, the quality of the teachers, the level

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

34

Communicating the history of medicine

of the teaching materials, the appropriateness of the questions on the exam and the didactic form in which the course was offered (lectures, seminars, paper). On top of that, students were asked to score the week’s topics and the participating disciplines. In total, 257 students (87%) responded to the evaluation, which was considered very good. In general, students felt the topics of Medical Humanities 2 (on the microdimension of medicine and care) to be more interesting than those of Medical Humanities 1 (on the macrodimension of medicine and care). On a scale from 1 (very uninteresting) to 10 (very interesting) scores were as follows: medical research (7.6), scarcity in health care (7.6), prevention (7), doctor/patient relationship (6.4), end of life (8.7), medical technology (6) and beginning of life (8.6). The contributing disciplines were given a grade on a scale from 1 to 10 as well. In their individual comments at the end of the evaluation students wrote that they had experienced trouble in shifting from a biomedical to a humanities style of thinking, and also that they found the readings too much and too difficult. Whereas some indicated that they wanted more ethics and health law, others wanted less ethics and more history. On the positive side, students commented that they very much liked ‘the other way of thinking’ that Medical Humanities entailed. Many appreciated the questions and paradoxes raised by the course, which made them think about their role as physicians in the bigger picture of society. In 2012, the Utrecht Medical School was visited by a Site Committee again. In its end report, it singled out Medical Humanities as good practice and an example to be followed by the other medical centres in the Netherlands.43 Still, the course coordinators felt that there remained issues to be dealt with. Among other things, it was decided to replace the week on the beginning of life by a week devoted to scientific literacy (see above). Over the years, student evaluations improved. An evaluation of June 2016 looked back on the academic year 2015/2016. The response was 277 or 93% of the students. On a scale from 1 (very bad or totally disagree) to 10 (excellent or totally agree), they responded as follows. What do you think about the coherence between week topics? (7.8) Did you learn a lot? (7.6) Should the course be included in the curriculum? (8.4). In 2016, the topics scored much better than they had done seven years before: research (8), scarcity (8), prevention (7.6), scientific literacy (7.2), end of life (9), medical technology (7.2) and doctor/patient relationship (7.8). Individual comments at the end of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

35

the evaluation mainly concerned procedural remarks, while there was much praise (‘valuable addition to my biomedical knowledge’; ‘passionate teachers’; ‘an important enrichment’). In comparison to the medical courses, Medical Humanities is not doing badly at all. In 2016, the Department Quality Care of the Education Office decided to compare evaluations of all courses offered between 2012 and 2016 in the third year of the undergraduate medical programme. Grades were as follows: Acute Medicine (6.6), Infection and Immunity (6.6); Acute Surgery (6.7); Healthy and Sick Cells (7); Clinical Research (7); Medical Humanities (7). Conclusion

Over the course of time, there has not just been linear progress through science, medicine and the state. Today, Western health-care systems are challenged to rethink their governance structure.44 This chapter has tried to make this point by developing the case of the HPV vaccination campaign. Although it was supported by the highest medical and political authorities, scientific claims of experts were cast in doubt and their authority challenged. This leads to the question of who gets to educate and socialize the researchers and clinicians of the future. Or, to put it differently, who ‘owns’ the medical curriculum? The medical faculty? The medical profession? The state? The tax-paying public? Patients? It is a crucial question, which has been raised by medical historians before. The answer one gives to it determines the kind of challenges anyone keen on introducing history in the medical curriculum will face. As was stated above, context matters, so it is impossible to give clear-cut prescriptions or even a blueprint that is universally valid. As Jacalyn Duffin once observed (when given the opportunity to start a medical history course for undergraduate medical students): ‘I began to think that no single format could be perfect in every situation. Effective solutions inevitably depend on individual teachers and their institutions’.45 During the 1980s and 1990s – when the ‘Science Wars’ raged within medical history – physicians and historians discussed the nature, the boundaries, the methods and the audience of the field, sometimes denying each other the right to move on it. Today, the very same question is on the table in the field of medical humanities. While some define it as a humanistic educational ideal supporting professional

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

36

Communicating the history of medicine

identity formation, others maintain that it should critically analyse the definition and status of ‘the medical’.46 While the answer to the question will differ from one institutional context to the next, in the end medical teaching is about getting students ready to help citizens in the most responsible way. Therefore, in our era of ‘shared-decision-making’ 47 there is much to be said for the development of a medical curriculum that is geared towards creating reflective physicians who are aware of their position in the health-care system and capable of making a rational consideration between public and private interests. Medical students are in need – now maybe more than ever – of a comprehensive image of the past before moving to more depth and detail. To an increasing extent, however, the teaching of medical history is considered a problem. Both the basic sciences and clinical training demand their place in the medical curriculum, pushing medical history to the periphery – or even out of it. ‘Pragmatic’ history of medical ideas of the kind that Kurt Sprengel advocated no longer caters to the needs of the modern audience of medical students. A new type of handbook is called for, doing justice to the complexities and paradoxes of modern medicine and health care. In 1997, Roy Porter published a similar handbook, entitled The Greatest Benefit of Mankind: A Medical History of Humanity from Antiquity to the Present. Porter felt that medical historians have a responsibility towards society: not just to medical students and physicians, but to everybody.48 He considered it the task of medical history to supply the perspectives and the materials to inform intelligent discussion and policy-making in a puzzling, rapidly changing world. Because he felt that the past could – and should – be made relevant to the present, he called historians to step down from their ivory tower. Porter’s focus was on medicine because it has always been the most powerful discourse on health, illness and healing in the West, and was on Western medicine because it has become uniquely global. The broad trends in the book are those from Graeco-Roman holism to modern reductionism, and from medical anarchy to professional organization and even dominance. The book ends with a chapter on the paradox of our times, when science-based medicine can do more than ever, yet public suspicion of medicine and anxiety about health are greater than ever. In the end, this may be the most important difference between the handbooks of the Prussian physician Kurt Sprengel and the English

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

37

social historian Roy Porter: whereas Sprengel wanted to contribute to the making of responsible physicians who were capable of acting autonomously, 200 years later Porter considered it as his duty to contribute to the making of responsible citizens – meaning both patients and physicians – who should be in dialogue with each other. The Utrecht Medical Humanities programme intends to contribute to that goal as well.49 Acknowledgement

I would like to thank Professor Olle ten Cate (Directorate of Education and Training of the University Medical Center Utrecht, The Netherlands) for his comments on an earlier version of this chapter. Notes 1 Further to this topic: R. A. Pielke, The Honest Broker: Making Sense of Science in Policy and Politics (Cambridge: Cambridge University Press, 2007); M. B. Brown, Science in Democracy: Expertise, Institutions, and Representation (Cambridge, MA: MIT Press, 2009); P. Kitcher, Science in a Democratic Society (Amherst: Prometheus Books, 2011); S. Jasanoff, Science and Public Reason (London and New York: Routledge, 2012). 2 See, for example, R. Butsch, The Citizen Audience: Crowds, Publics, and Individuals (New York and London, 2008); V. Nightingale (ed.), The Handbook of Media Audiences (Malden: Wiley-Blackwell, 2011); N. Carpentier et al. (eds), Audience Transformations. Shifting Audience Positions in Late Modernity (New York and London: Routledge, 2014); R. Butsch and S. Livingstone (eds), Meanings of Audiences: Comparative Discourses (London and New York: Routledge, 2014). 3 Butsch, The Citizen Audience, pp. 3–11. 4 There are, however, exceptions. The European Association for the History of Medicine and Health (EAHMH) tends to invite a keynote speaker to its biennial conferences to deliver the ‘Virchow lecture’, which is devoted to the societal impact of medical history. Recent examples include J. Duffin (on teaching), J. Moscoso (on museums) and V. Berridge (on public health policy). See also R. A. Stevens et al. (eds), History & Health Policy in the United States: Putting the Past Back in (New Brunswick, NJ: Rutgers University Press, 2006). 5 F. Huisman and J. H. Warner (eds), Locating Medical History: The Stories and their Meanings (Baltimore: Johns Hopkins University Press, 2004) esp. pp. 1–30, and F. Huisman, ‘The Dialectics of Understanding: on Genres

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

38

Communicating the history of medicine

and the Use of Debate in Medical History’, History and Philosophy of the Life Sciences, 27 (2005), 13–40. 6 On Sprengel and his context, see T. Broman, The Transformation of German Academic Medicine (1750–1820) (Cambridge: Cambridge University Press, 1996) and H.-U. Lammel, Zwischen Klio und Hippokrates. Zu den kulturellen Ursprüngen eines medizinhistorischen Interesses und der Ausprägung einer historischen Mentalität unter Aerzten zwischen 1750 und 1850 in Deutschland (Habilitationsschrift Rostock, 1999). 7 R. Butsch and S. Livingstone, ‘“Translating” Audiences, Provincializing Europe’, in Butsch and Livingstone, Meanings of Audiences, pp. 1–19. 8 J. M. Piro, Revolutionizing Global Higher Education Policy: Innovation and the Bologna Process (Abingdon: Taylor & Francis, 2016). 9 M. Patrício, C. den Engelsen, D. Tseng and O. ten Cate, ‘Implementation of the Bologna Two-Cycle System in Medical Education: Where do we Stand in 2007? Results of an AMEE-MEDINE Survey’, Medical Teacher, 30:6 (2008), 597–605. 10 J. Le Fanu, The Rise and Fall of Modern Medicine (London: Abacus, 1999). 11 See also E. J. Cassell, The Nature of Suffering and the Goals of Medicine (Oxford: Oxford University Press, 1991); K. Fleischhauer and G. Hermerén, Goals of Medicine in the Course of History and Today: A Study in the History and Philosophy of Medicine (Stockholm: Kungl. Vitterhets Historie och Antikvitets Akademien, 2006); Governance for Health in the 21st Century (World Health Organization, 2012). 12 H. Small, The Value of the Humanities (Oxford: Oxford University Press, 2013). Cf. M. Nussbaum, Not for Profit: Why Democracy Needs the Humanities (Princeton: Princeton University Press, 2010). 13 J. Guldi and D. Armitage, The History Manifesto (Cambridge: Cambridge University Press, 2014). 14 Ibid., p. 13. 15 R. Horton, ‘A Manifesto for Reading Medicine’, The Lancet, 22 March 1997, quote on p. 872. 16 R. Horton, ‘Offline: The Moribund Body of Medical History’, The Lancet, 26 July 2014, quote on p. 292. Of course the gist of the article is Horton’s complaint that medical historians currently fail to do so, but here it is the mission of medical history that matters. 17 D. S. Jones, J. A. Greene, J. Duffin and J. H. Warner, ‘Making the Case of History in Medical Education’, Journal of the History of Medicine and Allied Sciences, 70 (2015), 623–652. See also J. Duffin, ‘Infiltrating the Curriculum: An Integrative Approach to History for Medical Students’, The Journal of Medical Humanities, 16 (1995), 155–174.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

39

18 See http://www.nfu.nl/img/pdf/GeneeskundeRapportwebsite.pdf, pp. 101–115 (accessed 9 February 2018). 19 Articles that O. ten Cate (co-)authored include: O. ten Cate, ‘CompetencyBased Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice?’, Academic Medicine, 82 (2007), 542–547; O. ten Cate, ‘What is a 21st-Century Doctor? Rethinking the Significance of the Medical Degree’, Academic Medicine, 89 (2014), 966–969; O. ten Cate, D. Hart, F. Ankel, J. Busari, R. Englander, N. Glasgow, E. Holmboe, W. Lobst, E. Lovell, L.S. Snell, C. Touchie, E. van Melle and K. Wycliffe-Jones, ‘Entrustment Decision Making in Clinical Training’, Academic Medicine, 91 (2016), 191–198. 20 Ten Cate and F. Scheele, ‘Competency-Based Postgraduate Training’. 21 Ten Cate, ‘What is a 21st-Century Doctor?’. For a theoretical foundation of this new approach to workplace training and assessment, see Ten Cate et al., ‘Entrustment Decision Making’. 22 Since 2000, the journal Medical Humanities has been published twice a year by the BMJ. Since then, several attempts have been made to come to an understanding of the concept. See, for example, D. Greaves and M. Evans, ‘Medical Humanities. Editorial’, Journal of Medical Ethics: Medical Humanities, 26 (2000), 1–2; J. Coulehan, ‘What is Medical Humanities and Why?’, Literature, Arts & Medicine Blog, 25 January 2008, http:// medhum.med.nyu.edu/blog/?p=100 (accessed 23 June 2016); J. Holden et al. (eds), Where Does it Hurt? The New World of the Medical Humanities (Wellcome Trust, 2014); B. Dolan (ed.), Humanitas: Readings in the Development of the Medical Humanities (San Francisco: University of California, 2015); T. R. Cole, N. S. Carlin and R. A. Carson (eds), Medical Humanities. An Introduction (Cambridge: Cambridge University Press, 2015). The concept was critically analysed by R. Cooter with C. Stein, Writing History in the Age of Biomedicine (New Haven and London: Yale University Press, 2013). See also below, in the Conclusion. 23 H. J. Cook, ‘Borderlands: A Historian’s Perspective on Medical Humanities in the US and the UK’, Medical Humanities, 36 (2010), 3–4, quote on p. 3. See also J. H. Warner, ‘The Humanising Power of Medical History: Responses to Biomedicine in the 20th Century United States’, Medical Humanities, 37 (2011), 91–96. 24 They include F. Miedema, Dean of the Medical Faculty and Vice-President of the Executive Board of the University Medical Center Utrecht; W. Mijnhardt, Professor in Comparative History of Science at Utrecht University and Director of its Descartes Center for the History and Philosophy of the Sciences and the Humanities; H. Dijstelbloem, Professor of Philosophy of Science and Politics at the University of Amsterdam and Senior Research

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

40

Communicating the history of medicine

Fellow at the Netherlands Scientific Council for Government Policy in The Hague; and F. Huisman, Professor in the History of Medicine at the Julius Center of the University Medical Center Utrecht. For the website of Science in Transition, see http://www.scienceintransition.nl/english; for the position paper, see http://www.scienceintransition.nl/wp-content/ uploads/2013/10/Science-in-Transition-Position-Paper-final.pdf (accessed 25 June 2019). 25 For a general background, see P. Stephan, How Economics Shapes Science (Cambridge, MA and London: Harvard University Press, 2012). 26 G. Schatz, ‘The Faces of Big Science’, Nature Reviews. Molecular Cell Biology, 15 (2014), 423–426. 27 J. P. A. Ioannidis, ‘Why Most Published Research Findings Are False’, Plos Medicine, 2 (2005), 696–701; Ioannidis, ‘Why Most Clinical Research is Not Useful’, PLoS Medicine, 21 June 2016 (doi:10.1371/journal. pmed.1002049); P. Lawrence, ‘Real Lives and White Lies in the Funding of Scientific Research’, Plos Biology, 7 (2009), 1–4; C. Stoneking, ‘Hoaxing, Forging, Trimming and Cooking: The Cases and Causes of Scientific Fraud’, The Triple Helix (Spring 2011), 24–25; F. Fang et al., ‘Misconduct Accounts for the Majority of Retracted Scientific Publications’, Proceedings of the National Academy of Sciences of the United States of America (PNAS), 16 October 2012; The Economist, 19 October 2013; I. Chalmers et al., ‘How to Increase Value and Reduce Waste When Research Priorities are Set’, The Lancet, 11 January 2014; Schatz, ‘The Faces of Big Science’. 28 On the HPV vaccination campaign in the Netherlands, see P. Lips, ‘Over de grens van wetenschap: de vaccinatie tegen baarmoederhalskanker’, in H. Dijstelbloem and R. Hagendijk (eds), Onzekerheid troef. Het betwiste gezag van de wetenschap (Amsterdam: Van Gennep, 2011), pp. 75–95. See also K. Wailoo et al. (eds), Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine’s Simple Solutions (Baltimore: Johns Hopkins University Press, 2010). 29 Parts of the introduction to the HPV case were taken from F. Huisman, ‘Expertise and Trust in Dutch Individual Health Care’, in J. Vandendriessche, E. Peeters and K. Wils (eds), Scientists’ Expertise as Performance: Between State and Society, 1860–1960 (London: Pickering & Chatto, 2015), pp. 173–190. 30 http://www.prikenbescherm.nl (accessed 25 January 2010). 31 HPV Nieuws, 19 March, 9 April and 17 December 2009. 32 http://www.nvkp.nl/ (accessed 25 January 2010). 33 http://www.niburu.nl/index.php?articleID=17538 (accessed 25 January 2010). 34 https://worldthechanges.wordpress.com/ (accessed 25 January 2010).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating reflective citizen-physicians

41

35 B. Goldacre, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (London: Fourth Estate, 2012). 36 P. Hodgkin, ‘Medicine, Postmodernism, and the End of Certainty’, British Medical Journal, 313 (1996), 1568–1569. 37 R. Porter, The Greatest Benefit of Mankind: A Medical History of Humanity from Antiquity to the Present (London: Harper Collins, 1997); Le Fanu, The Rise and Fall of Modern Medicine; C. E. Rosenberg, Our Present Complaint: American Medicine, Then and Now (Baltimore: Johns Hopkins University Press, 2007). 38 S. P. Turner, Liberal Democracy 3.0: Civil Society in an Age of Experts (London: SAGE Publications, 2003); F. Huisman and H. Oosterhuis (eds), Health and Citizenship: Political Cultures of Health in Modern Europe (London: Pickering & Chatto, 2014). 39 A. de Swaan, In Care of the State: State Formation and the Collectivization of Health Care, Education and Welfare in Europe and America During the Modern Era (Amsterdam: University of Amsterdam, 1987); D. Porter (ed.), The History of Public Health and the Modern State (Amsterdam: Rodopi, 1994). 40 G. Weisz, Chronic Disease in the Twentieth Century: A History (Baltimore: Johns Hopkins University Press, 2014). 41 CUDOS (communalism, universalism, disinterestedness and organized sceptisicm – Robert Merton), ANT (actor–network theory – Bruno Latour). 42 http://zembla.incontxt.nl/seizoenen/2008/afleveringen/19–10–2008 (accessed 25 January 2010). 43 Geneeskunde onderwijs in Nederland 2012. State of the art rapport en benchmark rapport van de visitatiecommissie geneeskunde 2011/2012 (QANU 2012), to be found on http://iwooweb.umcn.nl/fmw/PDFforms/ Algemeen/Visitaties/QANU_ConceptStateOf TheArtRapport_ Geneeskunde_2012.pdf (accessed 29 August 2013). 44 Y. Yishai, ‘Participatory Governance in Public Health: Choice, but no Voice’, in D. Levi-Faur (ed.), The Oxford Handbook of Governance (Oxford: Oxford University Press, 2012), pp. 527–539. 45 J. Duffin, ‘Infiltrating the Curriculum: An Integrative Approach to History for Medical Students’, The Journal of Medical Humanities, 16 (1995), 155–174, on 155–156. 46 Cole et al., Medical Humanities; A. Whitehead and A. Woods (eds), The Edinburgh Companion to the Critical Medical Humanities (Edinburgh: Edinburgh University Press, 2016). 47 See, for example, C. Charles et al., ‘Shared Decision-Making in the Medical Encounter: What Does it Mean? (or It Takes at Least Two to Tango)’,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

42

Communicating the history of medicine

Social Science & Medicine, 44 (1997), 681–692; E. Topol, The Patient Will See You Now. The Future of Medicine is in Your Hands (New York: Basic Books, 2015). 48 See his (untitled) essay in J. Gardiner (ed.), The History Debate (London: Collins & Brown, 1990), pp. 13–21. 49 A new handbook on medical history for undergraduate medical students was recently published in Dutch: H. Hillen, E. Houwaart and F. Huisman (eds), Leerboek medische geschiedenis (Houten: Bohn, Stafleu van Loghum, 2018). The handbook has a thematic rather than a comprehensive approach. The 17 chapters of the handbook are divided into four sections: Disease, Knowledge, Doctor and Patient, and Health Care and Society.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

3

Feeling great? Practice, institutionalization and disciplinary context of history of medicine in Germany Ylva Söderfeldt and Matthis Krischel

The question of audiences for medical historians is closely connected with the institutional structures in which we work. Although many of us reach out across disciplinary boundaries, and to audiences outside academia, arguably the colleagues and students we encounter on a daily basis, i.e. the institution to which we formally belong, has the most direct influence on how we conduct research. The traditional and current location of history of medicine in the academic landscape varies between countries and, as we shall argue, this also has very tangible effects on the research profiles developed. In Germany, the strong institutionalization of history of medicine as part of medical school curricula directs researchers towards particular audiences, and sometimes defines impact in a manner that risks sacrificing the quality of research. However, this is not due to having physicians as audiences per se. Instead, as we shall argue, while audiences are important factors in shaping how medical history is presented, who the audiences are is not the core problem, rather it is our choices in how to address them. Since 2002, the German Medical Licensure Act has listed education in ‘theoretical, historical and ethical foundations of medical conduct’ as one of seven basic requirements of medical education in Germany. Medical schools have taken different approaches to fulfil this requirement, with many establishing departments of history, theory and ethics tasked with teaching mandatory courses. In addition to teaching, these departments engage in research and, in several cases, provide resources

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

44

Communicating the history of medicine

such as clinical ethics committees. This has had an effect on the institutionalization of history of medicine at German universities and directed it towards a new disciplinary profile where it is merged with ethics and theory. In this chapter, we will reflect upon how the research environments thus created are primarily directed towards the medical sphere, and specifically medical faculties, journals and funding institutions within medicine. In other words, the medical school curriculum has had an ‘audiencing’ effect. It made the core audience for historians of medicine in Germany a medical one, not only within, but beyond the classroom. This audiencing has both positive and negative effects: it has the potential of interdisciplinary synergy effects and extended outreach of the humanities, but when the medical audience fosters a particular rationality regarding the contents of what we do it ultimately becomes detrimental to research quality. Our perspective on the institutional environments and practices comes from the inside, as we have both worked at German history of medicine (and theory, and ethics) departments for a number of years. By no means, therefore, are we exempt from the criticism we express; on the contrary, we have been active participants in most of the strategies that we present as potentially detrimental to the quality of historical research. This inside view is precisely why we strongly believe that awareness needs to be raised within our academic community in order to secure the integrity of the field. The making of a new discipline

Medical history has had a comparatively strong standing at German medical faculties for over a century. The first department was opened 1906 in Leipzig and, in the 1920s, universities in Würzburg, Freiburg, Frankfurt and Berlin followed suit.1 Throughout its history, it has also been the subject of numerous controversies and academic conflicts.2 At the core of this is the question of how closely history of medicine should be affiliated with the field it sets out to study, i.e. medicine. Is history useful to doctors (or doctors to be)? Should it aspire to be? Or does such an ambition obscure the view of the historian, reducing her to a chronologist in service of the medical ‘court’?3 But if historians reject the demand to be useful, why should medical faculties keep them on their payrolls?

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

45

Structurally, this issue was resolved in 2002 by marrying history of medicine with medical ethics. The usefulness of the latter had become urgently clear due to new developments in medicine that seemed to question the borders of human life and push the boundaries of human intervention in matters of life and death. Improved intensive care medicine, organ transplants and reproductive technologies were among those new possibilities that posed questions that medical expertise did not appear to be able to answer on its own. As a result, the currently valid 2002 version of the Medical Licensure Act (Approbationsordnung für Ärzte) requires a graded course in ‘History, Theory, Ethics of Medicine’ (‘Geschichte, Theorie, Ethik der Medizin’; GTE). Together with the tradition of medical history in Germany, this broad mandate to teach is what institutionalizes history of medicine at German universities today. The Medical Licensure Act is not a research policy document. Its purpose is to define the requirements of medical education and training, making sure that students acquire the skills and knowledge they need to practice medicine. The Medical Licensure Act lists GTE as one of several cross-sectional fields (Querschnittsbereiche), such as ‘prevention, health promotion’ or ‘emergency medicine’. GTE is not at present an academic discipline in its own right. A discipline is defined by the sociologist Robert Stichweh as mainly a communication system. Characteristics that GTE possesses include ‘structures of institutions of higher education’,4 i.e. departments, and careers in the field. Characteristics it lacks are journals, societies and congresses, which are still largely divided into medical ethics and history of medicine. The latter has a significant overlap with history of science. As Mariacarla Gadebusch Bondio and Heiner Fangerau observe, for many historians this just meant that another discipline – ethics – was added to the conflict between medicine and history.5 As we will discuss, the creation of a new discipline in this way and its particular position in the German academic landscape, together with developments in research management on a more general level, has far-reaching consequences for the work being done in history of medicine today. Institutional structure

In order to fulfil the requirement of a course in GTE laid out in the Medical Licensure Act, most medical faculties decided to rely on

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

46

Communicating the history of medicine

teaching and research departments devoted to precisely this task. But there was no need to create entirely new departments – there were in fact already chaired professorships in medical history at the vast majority of German medical faculties.6 Hence, the novelty of the 2002 Medical Licensure Act was not to establish history of medicine at German medical schools, but to combine it with theory and ethics. More than 15 years have passed since the new subject was established, and it has had an influence on the structure of departments. Today (2018) there are 39 active medical schools in Germany that educate students according to the German Medical Licensure Act. In addition, there are three private medical schools that are affiliated with foreign universities, meaning that the curriculum is regulated by foreign laws. These are Asklepios Campus Hamburg (affiliated with Semmelweis University, Hungary), Kassel School of Medicine (affiliated with the University of Southampton, UK) and Paracelsus Medical University (with a campus in Nuremberg, part of private Paracelsus Medical University, Austria). These three have been excluded from our analysis. Among the 39 medical schools running according to the German curriculum, one is part of a private university (Witten/Herdecke University), one is a private medical university (Brandenburg Medical School Theodor Fontane). Thirty-seven medical schools are public, either as independent medical universities (Berlin, Hannover), or affiliated with a public university. Of the 39 medical schools that are required to educate students in GTE, two have been excluded from our analysis, because they enrolled their first class only recently (Oldenburg in 2012 and Brandenburg 2015). The 37 schools included in our analysis are shown in Table 3.1. Of these 37 medical schools, 31 have departments that carry ‘history of medicine’ in their names (28 ‘Institute’, 1 ‘Fachbereich’, 1 ‘Fachgebiet’; the latter two denote that the unit may not have the same status as academic departments and/or that the head may not be a full professor; one of those 30 [Lübeck], is part of ‘Sektion Naturwissenschaften’ instead of ‘Sektion Medizin’). The department at the only private university considered here is called ‘Ethics and Communication in Healthcare’, which is tasked with educating students in GTE, but does not include ‘history’ in the title. This department is part of the faculty of health, which educates physicians, dentists and other health-care professionals. Kiel University houses a working group on medical ethics as

Feeling great?

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Table 3.1  Medical schools included in the analysis. RWTH Aachen Charité – Universitätsmedizin Berlin Ruhr-Universität Bochum Friedrich-Wilhelms-Universität Bonn Technische Universität Dresden Heinrich-Heine-Universität Düsseldorf Friedrich-Alexander-Universität Erlangen-Nürnberg Universität Duisburg-Essen Johann-Wolfgang-Goethe-Universität Frankfurt am Main Albert-Ludwigs-Universität Freiburg Justus-Liebig-Universität Gießen Georg-August-Universität Göttingen Ernst-Moritz-Arndt-Universität Greifswald Martin-Luther-Universität Halle-Wittenberg Universität Hamburg Medizinische Hochschule Hannover Ruprecht-Karls-Universität Heidelberg Universität des Saarlandes Homburg Friedrich-Schiller-Universität Jena Christian-Albrechts-Universität Kiel Universität Köln Universität Leipzig Universität Lübeck Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät Mannheim der Universität Heidelberg Johannes-Gutenberg-Universität Mainz Philipps-Universität Marburg Ludwig-Maximilians-Universität München Technische Universität München Westfälische Wilhelms-Universität Münster Carl-von-Ossietzky-Universität Oldenburg Universität Regensburg Universität Rostock Eberhard-Karls-Universität Tübingen Universität Ulm Universität Witten/Herdecke Julius-Maximilians-Universität Würzburg

47

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

48

Communicating the history of medicine

part of another department of the faculty of medicine. This means that in the table below, we consider 33 academic units. There are additional museums, libraries, academic departments and one major independent research institute devoted to the history of medicine. They contribute to research and education in history of medicine in Germany. They include Ernst-Haeckel Haus. Institut für Geschichte der Medizin, Naturwissenschaften und Technik. Museum und Archiv ( Jena), Institut für Geschichte der Medizin der RobertBosch-Stiftung (Stuttgart), Berliner Medizinhistorisches Museum der Charité and Deutsches Medizinhistorisches Museum (Ingolstadt). However, because they do not directly teach medical students, they have been excluded from our analysis.

Table 3.2  Categories of names of academic units. Categories of names

Variation of names (in German)

Number of academic units

History of Medicine

Geschichte der Medizin, Medizinhistorisches Institut, Geschichte der Medizin und Naturwissenschaften, Medizingeschichte und Wissenschaftsforschung Geschichte und Ethik der Medizin Geschichte, Theorie und Ethik der Medizin, Geschichte, Ethik und Philosophie der Medizin Ethik und Geschichte der Medizin Ethik, Geschichte und Theorie Medizinethik Ethik und Kommunikation im Gesundheitswesen

9

History and Ethics of Medicine History, Theory and Ethics of Medicine (including one History, Ethics and Philosophy of Medicine) Ethics and History of Medicine Ethics, History and Theory Medical Ethics Ethics and Communication in Healthcare

8 7

5 2 1 1

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

49

Of the 33 academic units considered, the names of all but two (94%) include history. The most common designation is History of Medicine, with an extra two designated History of Medicine and History of Science (9, or 27%), followed by History and Ethics of Medicine (8, or 24%) and History, Theory and Ethics of Medicine (7, or 21%). Twentyfour units (73%) put history first in their name, while nine (27%) put ethics first. Nine departments (27%) have a name that closely references the cross-sectional field GTE. To some extent, the names of the institutions denote the kind of research being done there. There are examples of departments being renamed after a new director assumes office to reflect his or her research profile. Some departments, regardless of name, exclusively house historians of medicine or medical ethicists, but most are home to a mix of faculty. The background of the staff varies considerably: it is fairly common among both ethicists and historians to hold medical degrees in addition to an education in the humanities or social sciences, for instance in philosophy, theology, history, anthropology or sociology. However, since a career in history or ethics is at least in terms of salary and employment opportunities not an attractive alternative to practising medicine, institutes often find it hard to recruit physicians, at least on the pre- and postdoctoral levels. Of the 33 medical schools that have a unit to teach GTE, the vast majority of institutions (28, or 84%) have only one position at the academic rank of professor. Of these, one is at the rank of junior professor. Five units have a second professorship. We have identified 38 such positions. Currently, there are 33 people (21 men and 12 women) in such positions; another five are filled by visiting professors. These will not be included in our analysis. In addition, many departments have senior members of academic staff who hold the title of professor extraordinary, but hold the academic rank of lecturer or senior lecturer (‘akademischer Mittelbau’). They usually receive a significantly lower salary and may not have job security. Members of this group will also be excluded from our analysis. Of the 33 people in professorial positions, 24 (72%) hold doctorates in medicine (Dr. med.), two (6%) hold doctorates in theoretical medicine (Dr. rer. med., Dr. rer. medic.), typically bestowed by German medical schools on graduates who are not physicians or surgeons, 14 (42%) hold doctorates in the humanities (Dr. phil.) and one (3%)

50

Communicating the history of medicine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Table 3.3  Doctorates of professors at academic units considered. Dr. med. Dr. med., Dr. phil. Dr. phil. Dr. phil., Dr. rer. med. Dr. rer. medic. Dr. rer. nat.

16 8 6 1 1 1

holds a doctorate in the natural sciences (Dr. rer. nat.). Of these, nine professors (27%) hold more than one doctorate. In addition, a sizeable number of medical doctors hold degrees at the Master’s level in philosophy, history or medical anthropology and almost all hold a Habilitation, a postdoctoral qualification in either history of medicine, theory of medicine or medical ethics, or any combination of these. Nevertheless, considering the backgrounds of professors, it is safe to say that the history of medicine as a discipline is still firmly rooted in medicine. This has also been the case historically, and not only in Germany; before the mid-twentieth century, research in history of medicine was overwhelmingly carried out by physicians, while general historians showed remarkably little interest in medicine as a factor in their work.7 While the latter has certainly changed, so that there is no shortage of young historians interested in medicine, the particularities of German history of medicine favours physicians in the later career stages. Most of this is indirect, but it is fairly common that announcements for chairs in history and ethics of medicine require that candidates hold a medical licence. With this background established, we will take a closer look at the factors that determine the output and profiles of these institutions. How researchers can qualify themselves for positions, how the research is funded and the publication practices within the field are three intertwined features of academic life that, in the case of history of medicine in Germany, have dire consequences. Qualification

The requirement to provide medical students with a course in GTE creates a demand for people to do this teaching, i.e. it creates job

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

51

opportunities. For a young historian, it is an attractive option to take a position at one of these departments, as there are a good number of entry-level teaching jobs available there, compared to other subdisciplines of history. A teaching position will usually come with the possibility to do research, which is also, of course, mandatory in order to be able to continue one’s career. Here, however, the problems begin. A particularity of the GTE institutes is that they offer at least two different kinds of doctorates: the German equivalent to a Ph.D., and the M.D., where the German equivalent of the Ph.D. can be the doctorate in theoretical medicine (most often called Dr. rer. med., Dr. rer. medic. or Dr. hum. biol.), or the Dr. phil. in cooperation with the faculty of humanities. The German medical doctorate has been debated in recent years. Medical students usually earn their title during or shortly after their education and often with little independent research effort. Instead, many work on a topic and with methodology designed by the advisor. The value of the medical doctorate as proof of scholarly ability is therefore meagre, to the point that the European Research Council does not recognize the degree as research experience.8 Although it is not the most popular choice, some physicians (to be) pursue their doctorate in medical history or ethics, and here the same problems apply. Apart from downright scandals involving clearly insufficient dissertations or even the trade of titles for money, representatives of the discipline admit that there is a more general problem of low standards for dissertations in history of medicine.9 Further along the career path, other potential problems arise. In the German university system, there is no way to move but up. As a basic rule, a researcher can be employed on a fixed-term basis for a maximum of 12 years. After that, they must acquire a permanent position, i.e. a chaired professorship, or leave academia.10 Although there are myriad different exceptions and sub-regulations to this, and a few loopholes, this puts postdoctoral-level scholars under an immense pressure.11 As rewarding as a teaching and research position at a GTE institute can be, remaining there indefinitely is not an option, and, in order to make sure it is not a dead end, they must be highly strategic. At German universities, the Habilitation is still the standard path to a chaired professorship in many disciplines, including history and medicine. This is a postdoctoral degree awarded mostly on the basis of research quality and quantity since the doctorate, and to some extent

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

52

Communicating the history of medicine

on teaching and continuing education. The candidate gains his or her Habilitation in a specific field, making him or her eligible to apply for a professorship in that discipline. How much leeway will be allowed here, i.e. whether a candidate with a Habilitation in ‘History of X’ can be considered qualified for a professorship in ‘Social Studies of Y’, is up to the individual faculty to decide. Hence, when pursuing postdoctoral-stage research, the aspiring candidate must consider the medical faculty as an audience whose approval must be solicited, and the question becomes: how can expertise in history be presented in a way that appeals to a search committee consisting of medical professionals? This issue has been debated for several years now within the Fachverband Medizingeschichte (German Association for the History of Medicine) and the Akademie für Ethik in der Medizin (German Academy for Ethics in Medicine). At stake is whether scholars should seek, advisors should allow and faculties should grant Habilitationen in the crosssectional field of ‘History, Theory and Ethics of Medicine’ or only in one or two of the components. Proponents of the single-discipline Habilitation argue that it should be granted only in the discipline in which the candidate has done significant research. Anyone wishing to qualify themselves in history or ethics of medicine must produce research in that field comparable in quality to that done in reference disciplines (history and ethics, respectively). This makes it, they believe, impossible to grant a qualification in both history and ethics – they are just too different as disciplines for it to be reasonable that a candidate can display the sufficient expertise in both. From this it becomes clear that proponents of the singlediscipline Habilitation understand GTE as multidisciplinary in nature. On the other hand, proponents of the ‘composite-discipline’ Habilitation point out that the Habilitation is a teaching qualification, signifying the Facultas docendi (ability to teach) and leading to the Venia legendi (licence to teach independently). They allow that scholars will most likely focus their research on one area, but point out that it is feasible and practical to expect senior scholars to be able to teach history, theory and ethics of medicine, even if their research expertise is most pronounced in only one of those fields. In addition, they point to other medical subjects in which the Habilitation is granted for rather broad fields, even though the actual research is highly specialized (e.g. internal medicine or surgery). In fact, they argue, history, theory and ethics of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

53

medicine are more closely related to each other than they are to any other medical sub-disciplines. With this perspective, thus, GTE is held to be interdisciplinary in nature. For the individual scholars seeking to qualify themselves, this reasoning about the extent of interrelatedness between disciplines may, however, be overshadowed by more practical concerns. Given the criteria set up in the Medical Licensure Act, it makes most sense for medical faculties to try to recruit professors for ‘History, Theory and Ethics of Medicine’. The audience that matters here are the search committees – consisting mostly of faculty from the biomedical sciences – and they are unlikely to take interest in debates of whether or not an ethicist can teach history or vice versa. They are looking for the candidate whose diploma matches the job announcement, and whose credentials make sense according to quality metrics common in biomedicine. A candidate who has chosen to stay true to their ‘home’ discipline of history or ethics might therefore face a pedagogic challenge in trying to convince the committee of the broadness of their teaching ability, whereas it is unlikely that a composite Habilitation will put them at a disadvantage under any circumstances. For this reason, the composite Habilitation is in the interest of pragmatic candidates. Pragmatism, however, comes with its own consequences. The question of the Habilitation and the hiring practices is not merely a matter of putting the most attractive buzzwords on a CV – it influences what research is being done. In order to balance between the two standpoints, postdoctoral researchers are often advised to produce measurable output in their secondary area, i.e. for mid-career historians of medicine to demonstrate their competency in medical ethics. At the moment, there are several options for this. Some pursue a second doctorate (often a Dr. rer. medic., a doctorate in theoretical medicine, which usually can be obtained with a cumulative dissertation of two or three peer-reviewed papers). Others choose a research area in which history and ethics overlap, most markedly history of medical ethics or history of medicine in National Socialism, or otherwise try to adapt their research interests in history to address ethical problems. It is open to debate whether this is beneficial or detrimental to both fields – history and ethics. Proponents of GTE have argued that engagement with history (and theory) is indispensable in ethics.12 We will leave it up to the ethicists to decide whether this is true. Perhaps history is crucial to ethics, as it was once

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

54

Communicating the history of medicine

– and according to some still is – crucial to medicine. But with this perspective history of medicine remains an auxiliary to another discipline and it seems less clear that a marriage to ethics is advantageous to history as well. A benefit both of the diversity of departmental staff and the incitements for young researchers to qualify themselves in history as well as ethics is the resulting close connection to medical practice. Becoming engaged in medical ethics provides the opportunity of a mutual, fruitful exchange with physicians, as colleagues and project partners, on a daily basis. This furthers our own competence and gives us access to perspectives that are helpful in understanding our research topics. Next, we will address the downsides that come from forced interdisciplinarity and culture clashes between the disciplines. These are further enhanced by the particular role of GTE as a humanities discipline within a medical faculty. Funding

Today, at least some aspects of New Public Management have been almost universally adopted at European universities. This style of governance centres on measurability and efficiency, which in turn requires a high level of central control. Academic quality must be measurable by purportedly objective, quantitative criteria, and the individual researcher is under continuous pressure to demonstrate that they live up to the set goals. Scholars are incentivized to curate their reputation with their managers at least as carefully as their reputation with their peers.13 It has been recognized that this has led to some less-thandesirable trends in academia in general.14 It is well known that this has far-reaching consequences for the research being done: at the end of the day, researchers need jobs and funds, and therefore need to convince the people who make these decisions. As much as German historians of medicine might want to speak to an international audience of historians, the audience they first need to convince are medical faculty hiring committees and funding institutions. Since they speak the language of New Public Management, they need to be addressed accordingly. In addition, as Chris Lorenz has pointed out, being an academic under New Public Management often

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

55

means carrying out tasks and adopting strategies that are experienced as cynical and hypocritical.15 Lorenz makes this point regarding the participation in auditing; in GTE, such cynicism and hypocrisy is widespread, especially in the efforts to acquire external funding and in publication practices. It is a well-known fact that the humanities have a harder time than, for instance, STEM disciplines in acquiring third-party funding. However, the specific context of history of medicine in Germany places scholars in a situation where the pressure to acquire funding is considerably higher than for historians in other institutional settings. It is common practice at many German universities to distribute internal funds by the LOM-System, i.e. ‘Leistungsorientierte Mittelvergabe’ or performance-based funding allocation. Influenced by New Public Management, public funds are allocated based on quantifiable performance criteria. These criteria and the extent to which they determine funding vary. In general, however, they consist of a combination of acquired external funding, publications and evaluation of the teaching. The departments within a faculty are ranked and funded according to these factors. Medical faculties, where almost all GTE departments are located, were especially quick to adopt this system and now all use some version of it.16 Thus, GTE departments are compared not to other humanities disciplines, but to medical departments, which is, as one can imagine, very unfavourable. The number of grants available for humanities research, and their size, is simply so much smaller than for clinical medicine. This inevitably puts GTE in a weak position in faculty politics and under constant threat of diminishing internal funds. GTE is not the only discipline in trouble within the LOM-System. Not only can it be questioned whether it has the desired effects even on a more general level;17 it also threatens the continued existence of a number of medical sub-disciplines that share the traits of having little to no direct part in treating patients, limited teaching loads and less opportunity for large-scale funding as well as publishing in top journals. With LOM, size is everything, so these so-called ‘small disciplines’ are constantly at risk of further diminishing.18 Reliance on external funding in the face of shrinking university budgets has been criticized by German academics on more general grounds. According to the sociologist Stefan Kühl, success in acquiring

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

56

Communicating the history of medicine

external funding does not in itself represent excellence in research, but only excellence in acquiring external funding.19 In response to Kühl, the president of the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) Peter Strohschneider has remarked that he sees funding of German universities by individual states, as opposed to the federal government, as part of the problem. The federal government is paying increasingly large sums of money to universities, but because of funding restrictions the money must be given for grants won in competitions, not as a general budget for the universities to use as they see fit.20 This pressure to acquire external funding has led to departments developing strategies to do this with as little effort as possible. The best way of achieving this is by applying as a part of an interdisciplinary consortium, together with medical or other STEM disciplines. Funding agencies have increasingly begun to favour projects that address socalled ‘ELSAs’, i.e. ethical, legal and social aspects of science and technology, which has opened up a new ‘market’ of potential funding for humanist scholars. This can be an exciting option to us as historians, offering opportunities to try new methods and learn from other disciplines. However, these types of projects are rarely driven by research interests in the humanities as such, but attach a humanities scholar to add another perspective to the exploration of a topic in medicine or science. Or, with a less forgiving viewpoint, to act as a fig leaf. Furthermore, the perspectives in demand here are rarely historical ones, but ethical. For strategic reasons, in order to not fall too far behind in the internal ranking, many historians see themselves forced to ‘moonlight’ as ethicists. The price for this is taking part in projects that do not fit their qualifications or actual research interests very well. There is also a tendency to adjust the methodology in order to facilitate the communication with other disciplines, i.e. favouring quantitative methods. Working in interdisciplinary research groups can be valuable, especially for historians of science and medicine. Cooperation with physicians and scientists is a great help in understanding the particularities of the topics we study. In other instances, however, the interdisciplinarity can be a wide gap to bridge. When it is based on requirements from funding institutions rather than the desire of researchers, situations arise where one or more partners take a passive role, or where the different theoretical and methodological frameworks clash.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

57

There is also, of course, funding for historical research available, but it is generally scarcer. Facing a limited amount of time to invest and a high pressure to be successful, historians are incentivized to go with ‘safe’ research subjects when applying for funds for historical research. Physician-centred projects tend to be more attractive than those that focus on medicine as a knowledge system and on other vocational groups within medicine. One option is to court professional associations in medicine for funds to explore their history in the Third Reich, or to write the history of the clinics where we work. Less attractive, and therefore considerably less represented at German institutes for the history of medicine, are pre-1800 topics, the history of health care and long-term, theoretically and methodically challenging projects. Publications

The perils of ‘publish or perish’ culture in academia have been discussed for a long time. Depending on exactly how various publications count, and for what purpose, different disciplines and institutional environments experience specific consequences for the way they do research and publish results. For GTE, situated between disciplines, adverse effects typical of medicine and the humanities come into play. ‘Salami’ publishing, i.e. cutting up results in small pieces and publishing them separately in order to maximize the impact-points-per-study ratio, is one adverse effect of LOM, apparently widespread at German medical faculties.21 On the other hand, in the humanities, the massive competition for tenured positions pushes young scholars to publish more and earlier in their careers. It is unclear how much this actually enhances the quality or relevance of research. Instead, critics like Frank Donoghue have pointed out that the system has made publishing houses almost the gatekeepers of academic jobs. Publications are less valuable as texts to be read, but more as currency on the job market. Donoghue makes this observation about the humanities, and the publications he talks about are monographs published by university presses.22 A similar situation, but far more incongruous, can be found in GTE. Even in the age of publish-or-perish, criteria for quality assessment vary between disciplines. In a comparative study of Swedish assessment reports, Björn Hammarfelt (unsurprisingly) found that historians were less concerned with bibliometrics than mathematicians and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

58

Communicating the history of medicine

biomedical scientists. Instead, they valued monographs and judged their impact based on positive reviews and prizes.23 It is not far-fetched to assume that this would be the case for Germany as well. The monograph remains a format that is well suited to present historical research, according to historians. So, even if the university press monograph, as Donoghue has shown, has its own problematic consequences as a scholarly product, it still, at least in theory, harmonizes quite well with our professional ethos. Within the LOM-System, however, this way of doing research is hardly recognized. Historians working in GTE are under immense pressure not only to publish, but to put out the right kind of publications as defined by the medical faculty. In order to maintain a reasonable ranking within the faculty, which equals funding, GTE scholars need to adjust to this and try to accumulate impact points. There are, of course, journals with impact factors within our field that contain high-quality research. Publishing in these would be a way of making the international academic community in history of medicine an audience for our work. In 2016, the Bulletin for the History of Medicine had an impact factor of 0.667, Social History of Medicine had 0.676 and Isis 1.288.24 But this cannot compete with even mid- to lower-tier medical journals, several of which are open to publishing articles on historical topics. Using journals where we have had work published ourselves as examples, we see that the 2016 impact factor of World Journal of Urology was 2.743, European Archives of Oto-RhinoLaryngology had 1.660 and American Journal of Clinical Dermatology 2.755.25 While the difference of one or two impact points might not seem terribly significant, it is in fact substantial when considering the vast difference in the effort it takes to earn them. Publications in medical journals are usually significantly shorter than those in historical journals. They are often descriptive, with only limited analytical power, and in many cases they feature only a limited discussion of trends in the historiography and humanities methodology. Instead, they require different skills from the author: to make history of medicine palatable to an educated audience of clinicians. Peer review is sometimes carried out not by scholars from the humanities, but by medics with expertise or interest in history. In contrast, publishing in one of the more prestigious historical journals requires not only usually a longer paper but also one that contains

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

59

novel and thorough research of historiographical value. The papers are reviewed by historians, and it is not unusual for this process to take a year or (significantly) longer. Hence, publishing in a history journal is far more labour intensive and yields a smaller reward than turning to a medical journal. Spending years completing a major monograph is an even worse decision, as it will in most cases yield no points at all in the LOM-System. The same is true for journals not listed in the Science Citation Index or Social Science Citation Index, which include only a limited number of journals in languages other than English. Publishers therefore become the gatekeepers of academic jobs, and of department funding – however, not primarily humanities-focused publishers, but the editors and reviewers of medical journals. Apart from their competence to assess the quality of historical research being questionable, their criteria have little to nothing to do with what constitutes important historical research. They ask, instead, whether a submission would be of interest to the readership of a medical journal, i.e. physicians. An example of what is likely to be a successful article is therefore, for instance, a two- to five-page biography of, say, a famous cardiologist, on the anniversary of his death, submitted to a (reasonably) high-ranking cardiology journal. It would be difficult to find another instance that better exemplifies the perils of using impact factors as indicators of scholarly quality. For decades now it has been pointed out that the impact factor of a journal says little about the impact of a specific article in that journal. While some articles in highranking journals receive many citations, and therefore raise the journal impact factor, other contributions to that journal – such as that biography of the famous cardiologist – may have very few citations.26 Nevertheless, within the LOM-System, this type of article makes or breaks the funding of departments and individual careers. Not only are these kinds of publications crucial for department funding, but they are also required for the gaining of academic qualifications. In many places, both the doctorate and the Habilitation are either usually or exclusively cumulative. As little as two of these publications can suffice for a doctorate, and the impact points are a decisive factor in the grade. The same goes for the Habilitation, where the extent of work required is often determined in terms of accumulated impact points. While there are certainly doctoral students and Habilitation candidates who produce valuable research under these conditions, this

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

60

Communicating the history of medicine

is due to internal motivation and the efforts of individual heads of department to require a certain quality beyond this framework. Within the system itself, however, there is little that would encourage them to do so as long as assessment criteria from biomedicine are allowed to rule. Instead of these criteria, the humanities do have their own traditions for ensuring the quality of research. Björn Hammarfelt emphasizes ‘critical evaluation in seminars, lengthy reviews and discussions’ 27 as well-established parts of the culture within our fields. Whereas one ‘small discipline’ such as GTE can hardly overthrow LOM, it can mitigate its effects by cultivating this tradition. Department heads have far-reaching power over this and can choose to put structures in place that can at least in part counteract misleading LOM incentives. Such measures include seminars for discussion of works in progress, and hiring practices that value quality over impact points. Individual professors therefore have great responsibility in the matter, as the direction they give can fully go along with the quantifiable-impact-oriented culture of the medical faculty or create institutional environments suited for humanities research. In short, the incitements direct us towards ways of doing research that are less than ideal for our discipline, and it takes dedication from professors as well as from younger scholars to create research environments that allow for such things as the development of methods, theoretical studies and participation in the wider scholarly community in history. Conclusion: the commodification of history

History of medicine in Germany is tied up in an institutional setting where survival means adapting to quality criteria that are questionable in themselves, and particularly ill-suited to a humanities discipline. Because of their direct and strong financial impact, these criteria threaten to define the kind of work that we do, in a way that is contrary to what would constitute good historical research. This way of organizing research practice around economic measures amounts to a commodification of academia.28 At its most extreme, German history of medicine literally became a commodity in the 2012 scandal

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

61

of doctoral degrees being sold at the Würzburg History of Medicine department.29 Not everything in German medical history is bleak. Several factors we have presented in fact lend a relatively strong standing in Germany to history of medicine compared to history or other fields in the humanities, often in terms of quantity, but also in terms of quality. There are a good number of entry-level jobs, and success in securing third-party funding. While research is about the history of medicine, often there is much leeway, including the choice of time period, historiographical approach and research object. As a career option for young historians, history of medicine is, at least initially, a good choice with considerably better chances of finding a junior position than at the philosophical faculty. Through adaptation to the medical faculty, researchers in history of medicine are furthermore relatively successful in an academic landscape increasingly structured around measurable performance criteria and interdisciplinary work modes. Being able to work close to clinical practice gives access to the knowledge of physician-colleagues and STEM-field project partners and enables the dissemination of historical perspectives in ways that would otherwise not be possible. This has the potential of giving medical history not impact points, but actual impact, in the sense of influencing ideas and practices. Leaving the ivory tower to speak across disciplinary boundaries and address medical audiences is valuable. Historians and humanities scholars in many other fields are often far less privileged in this regard. Historians of medicine in Germany are well equipped to reach out not only beyond the humanities but also to parts of society that affect people in a direct and tangible way, as medicine does. Publishing in medical journals, teaching at medical school, being part of medical research are opportunities to be relevant outside the confines of history departments. But being relevant cannot be a question of access to audiences alone. We also need to have a perspective that medical audiences will find relevant to share. That perspective needs to be developed during tedious hours in archives and libraries, and we need to be able to make it part of the critical discourse of a qualified audience that engages with content, not measurement. Of course, in reaching out to other disciplines and audiences beyond professional historians, the language and presentation would need to be adapted to let what we do as historians

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

62

Communicating the history of medicine

make sense to them. But the problem arises when this kind of adaptation is all there is. The way the system is designed, it discourages the investment of time required to develop and pursue complex questions regarding the history of medicine, i.e. doing research that could only at a later stage be popularized or applied to current challenges. Instead, what is presented to the medical audiences is often merely a number, an impact factor or a research grant, that helps us motivate our continued existence within an New Public Management logic. Metrics become the product presented to the audience, while research is designed as a means to generate the product. History of medicine in Germany is, thus, in danger of being reduced to an ancillary discipline, either to medicine or ethics, and conditional on foreign quality criteria. There is a tendency for the pressure to produce quantifiable results, and to do research that is immediately relevant to medical practice, to decide what we do. Trying to match up to these expectations, it is easy to get lost in chasing easy fixes, and have little time left for serious historical research. Hence we get a bias towards quantity instead of quality. The kind of studies that are rewarded (biographies, preferably of great white men in white coats or studies of notorious Nazis, ethical commentaries and advice) serves the purpose of a moral conscience for today’s medicine rather than furthering historical research. We believe that the incentives for reaching out to other (medical) disciplines and relating to the present can benefit our research, but that the model also entails the risk of more advanced historiographical approaches being neglected, not least because the demands of the audience are sometimes incompatible with such approaches. In many regards, the German model has great potential to revitalize research in history of medicine and build fruitful alliances between historians, ethicists and physicians. At the same time, the assessment criteria and their impact on funding allocation put us at risk of returning to a narrow interpretation of the history of medicine that mainly serves the interests of one set of audiences: medical institutions and the medical profession. Being part of the medical school and its structures can lead to ‘blind spots’ of observation and may undermine the ability of historians of medicine to act as critical external observers to the system of medicine.30 Thus, traditional history of medicine, according to the popular historian joke ‘the history of great doctors, written by a great doctor, to

Feeling great?

63

make doctors feel great about themselves’, seems to be alive and well in many places.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Notes 1 V. Roelcke, ‘Medizingeschichte’, in W. E. Gerabek (ed.), Enzyklopädie Medizingeschichte (Berlin: Walter de Gruyter, 2005). For a review of the literature on the development of history of medicine as an academic discipline in Germany, cf. H. Fangerau and M. G. Bondio, ‘Spannungen in der jüngeren Medizingeschichte: Legitimationsstrategien und Zielkonflikte – ein Beitrag zur Diskussion’, NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin, 23:1–2 (September 2015), 33–52. 2 See, for instance, W. Eckart and R. Jütte, Medizingeschichte: Eine Einführung (Köln: UTB GmbH, 2014), p. 167; Fangerau and Bondio, ‘Spannungen in der jüngeren Medizingeschichte’, pp. 33–52. 3 L. Sturlese, ‘Rezension: Sachbuch: Nicht nur für Onkel Doktors Feierabend’, Frankfurter Allgemeine Zeitung, 10 July 1996, sec. Feuilleton, p. 15. 4 R. Stichweh, ‘Scientific Disciplines, History of ’, in J. D. Wright (ed.), International Encyclopedia of the Social & Behavioral Sciences (Amsterdam: Elsevier, 2015), pp. 13727–13731. 5 Fangerau and Bondio, ‘Spannungen in der jüngeren Medizingeschichte’. 6 Ibid. 7 M. Bickel, ‘Medizinhistoriker im 19. und 20. Jahrhundert: Eine vergleichend-biographische Betrachtung’, in A. Frewer and V. Roelcke (eds), Die Institutionalisierung der Medizinhistoriographie: Entwicklungslinien vom 19. ins 20. Jahrhundert (Stuttgart: Franz Steiner Verlag, 2001), pp. 213–234. 8 M. Spiewak, ‘Mediziner: Flachforscher’, Die Zeit, 25 August 2011. Available online at: http://www.zeit.de/2011/35/Doktorarbeit-MedizinForschung/komplettansicht (accessed 15 April 2018). 9 O. Trenkamp, ‘Promotion bei Medizinern: Herr Doktor Schmalspur’, Spiegel Online, 5 April 2013, sec. Leben und Lernen. Available online at: http://www.spiegel.de/lebenundlernen/uni/christoph-moergeli-sollmedizin-doktorarbeiten-durchgewunken-haben-a-892363.html (accessed 15 April 2018). 10 BMBF-Internetredaktion, ‘Wissenschaftszeitvertragsgesetz – BMBF’, Bundesministerium für Bildung und Forschung – BMBF. Available online at: https://www.bmbf.de/de/karrierewege-fuer-den-wissenschaftlichennachwuchs-an-hochschulen-verbessern-1935.html (accessed 19 March 2018).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

64

Communicating the history of medicine

11 This period can be extended for parental leave. After 12 years, academics can be employed with third-party funding, but not university funding. 12 C. Wiesemann, ‘Die Beziehung der Medizinethik Zur Medizingeschichte Und Medizintheorie’, Ethik in der Medizin, 18:4 (2006), 337–341; H. Schott, ‘Die Situation der “kleinen Fächer” am Beispiel der Geschichte, Theorie und Ethik der Medizin’, Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz, 52:9 (September 2009), 933–939. 13 On science as a reputation system, cf. R. Whitley, The Intellectual and Social Organization of the Sciences (Oxford: Oxford University Press, 2000). 14 For an overview of the multiple ways in which this strategy hurts academia, see U. Schimank, ‘Reputation statt Wahrheit: Verdrängt der Nebencode den Code?’, Soziale Systeme, 16:3 (2010), 233–242. 15 C. Lorenz, ‘If You’re So Smart, Why Are You Under Surveillance? Universities, Neoliberalism, and New Public Management’, Critical Inquiry, 38:3 (March 2012), 599–629. 16 Wiesemann, ‘Die Beziehung der Medizinethik’. 17 R. Krempkow and P. Schulz, ‘Welche Effekte Hat Die Leistungsorientierte Mittelvergabe? Das Beispiel Der Medizinischen Fakultäten Deutschlands’, Die Hochschule, 2 (2012), 121–141. 18 Schott, ‘Die Situation der “kleinen Fächer”’. 19 S. Kühl, ‘Schafft Tausende kleine Leibniz-Preise’, Working Paper, no. 1 (2014), p. 6. 20 A. Lehmann, ‘Peter Strohschneider über Forschung: Selbsthilfegruppe für Wissenschaftler’, Die Tageszeitung: taz (20 February 2014), sec. Gesellschaft. Available online at: http://www.taz.de/!5048228/ (accessed 15 April 2018). 21 Krempkow and Schulz, ‘Welche Effekte’. 22 F. Donoghue, The Last Professors: The Corporate University and the Fate of the Humanities (New York: Fordham University Press, 2008), pp. 39–49. 23 B. Hammarfelt, ‘Recognition and Reward in the Academy: Valuing Publication Oeuvres in Biomedicine, Economics and History’, Aslib Journal of Information Management, 69:5 (18 September 2017), 607–623. 24 https://www.journals.uchicago.edu/journals/isis/about; https:// academic.oup.com/shm; https://www.press.jhu.edu/journals/bulletinhistory-medicine/impact-factor (accessed 6 March 2018). 25 https://link.springer.com/journal/40257; https://link.springer.com/ journal/405; https://link.springer.com/journal/345 (accessed 6 March 2018). 26 P. O. Seglen, ‘Why the Impact Factor of Journals Should Not Be Used for Evaluating Research’, BMJ: British Medical Journal, 314:7079 (15 February 1997), 498–502.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Feeling great?

65

27 B. Hammarfelt, ‘Four Claims on Research Assessment and Metric Use in the Humanities’, Bulletin of the American Society for Information Science and Technology, 43:5 (2017), 33–38. 28 H. Radder, in H. Radder (ed.), The Commodification of Academic Research: Science and the Modern University (Pittsburgh: University of Pittsburgh Press), pp. 1–23, on p. 4. 29 D. Müller, ‘Promotionen: Würzburger Doktorfabrik’, Die Zeit, 14 August 2013. Available online at: http://www.zeit.de/2012/47/ProfessorMedizingeschichte-Dissertation-Spenden (accessed 15 April 2018). 30 N. Luhmann, Die Wissenschaft der Gesellschaft (Frankfurt am Main: Suhrkamp Verlag, 1990).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

4

Writing history as it happens: the historian’s dilemmas in a time of health-care reform Beatrix Hoffman

In June 2012, I received a request from Perspectives, the newsletter of the American Historical Association. The United States Supreme Court was preparing to issue its opinion in National Federation of Independent Businesses v. Sebelius, the case that would decide the constitutionality of President Barack Obama’s Affordable Care Act (ACA). Perspectives asked three historians, including myself, to write brief statements providing historical analysis of the Court’s opinion. There was a catch: the statements were to be published immediately following the Court’s announcement. In other words, we had to prepare our commentary without knowing the final outcome of the justices’ deliberations. Journalists have to do it all the time, but for a historian accustomed to much longer periods of research, writing and contemplation, this was a new type of challenge. The goal of the assignment was to ‘demonstrate that historians can enter public dialogue as it is unfolding’.1 A few days later, the Supreme Court upheld most of the ACA.2 Despite my nervousness about the Perspectives writing assignment, it turned out that I did not really need to prepare two separate blog posts depending on the Court’s decision. Either way, I knew my argument would centre on the United States’ long history of refusing to adopt universal health care. Even if the ACA continued as planned and was fully implemented, at least 20 million residents of the United States would remain without health coverage (many more if some states refused to expand Medicaid, the health-insurance programme for the poor).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

67

No matter the outcome, my analysis would focus on the limited and incremental nature of United States health reform. I added a couple of paragraphs on the Supreme Court’s decision, and the post was published.3 How can historians contribute to public debates without resorting to sound bites that gloss over the complexity of our research findings? What role can and should scholars play in historic developments that are happening right now? This chapter contemplates these questions with a focus on the aftermath of the passage of the ACA in the United States, although such dilemmas certainly apply in other contexts in which historians seek to have an impact on public discourse and on policy. New types of assessment and accountability are beginning to require evaluation of the ‘impact’ of arts and humanities research. Many scholars object to this trend, seeing it as an aspect of the corporatization of the university and an attack on long traditions of academic freedom. Indeed, it is crucial for researchers in all fields to defend the noninstrumentalist pursuit of knowledge, as well as the humanities’ ‘historic role of critique’.4 Still, given the current climate, our ability to demonstrate the wider impact of some types of arts and humanities research may be essential to defend these fields in general and the discipline of history in particular. In this chapter, I argue that health-policy history offers important opportunities for external impact, especially in times of rapid healthsystem change when the public, media and policy-makers are paying attention to the topic. I will discuss four categories of historical activity that can allow scholars to be heard beyond the academy: myth-busting, dissemination, cautioning and advocacy. Myth-busting

Historians are needed to provide better accuracy in public debate. When it comes to health-care reform, this need is acute, because mythology, or misinformation, is especially pervasive in media and political discourse on this subject. In a century of reform struggles in the United States, false notions of history have played a major role. One claim heard repeatedly is that the American health-care system is superior to systems in Europe and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

68

Communicating the history of medicine

Canada. To cite a recent prominent example, during the second United States presidential election debate on 9 October 2016, then-candidate Donald Trump called the Canadian health-care system ‘a disaster […] the Canadians, when they need a big operation, when something happens they come into the United State in many cases. Because their system is so slow it’s catastrophic […]’. In response, New York Times columnist Nicholas Kristof tweeted a statistic commonly cited by health-policy scholars: ‘Fact check: Canadian life expectancy 81 years, US 78 years’.5 In fact, the United States ranks badly – and, in a recent study, the worst – among wealthy nations on health measures such as life expectancy, infant mortality, equity, accessibility and quality of health care.6 Other countries put citizens on waiting lists for health care, the argument goes, and if the United States adopted a national insurance system, it would have to do the same, and the result would be un-American and erode the quality of health care.7 Advocates of universal health coverage have countered that the United States’ expensive and fragmented system has always rationed, by ability to pay. In fact, the American health system is based on an anti-universalism that rations health care by dividing citizens into categories of income, occupation, residence, health status and numerous others. Ample evidence exists to demonstrate this history of rationing, which I attempted to do in my 2012 book Health Care for Some: Rights and Rationing in the United States since 1930.8 (Whether such a book may have any impact is discussed below.) Misinformation about American health care reached a fever pitch in debates over the ACA in 2009–2010. The ACA, or ‘Obamacare’, proposed an ambitious system of reforms (although, as noted, falling short of universalism) to increase health-insurance coverage and reduce costs. Obama and the ACA’s framers were taken by surprise when their proposal – intended to mollify opposition, incorporate special interests and tread a centrist path – was greeted with cries of ‘socialism’ and ‘government takeover of health care’ from vocal opponents on the far right. Alaska governor Sarah Palin and members of the ultra-conservative ‘Tea Party’ movement promulgated the completely false claim that the Act’s provisions for discussing end-of-life care and evaluating the efficacy of medical procedures amounted to ‘death panels’ that would deny medical care to the elderly. In 2009, this claim was named ‘Lie of the Year’ by the fact-checking website Politifact.9

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

69

Less extreme, but potentially more damaging, myths and misinformation about health-care history shaped the legal challenges to the ACA after it was passed in 2010. In the landmark court case that became NFIB v. Sebelius, conservative opponents of health reform insisted that the law’s ‘individual mandate’ requiring the purchase of health insurance, and its requirement that states expand their Medicaid programmes for the poor, violated central principles of the United States Constitution. Specifically, NFIB v. Sebelius lawyers argued (and a lower court agreed) that the ACA usurped the states’ traditional role in the provision of health care, and therefore represented a ‘wholly novel’ intervention by the federal government.10 This stance reasserted a pervasive myth about the United States health-care system: that it is based primarily on the private market and the rejection of government-run health care. Yet public provision of health care dates back to the colonial period, and in the twenty-first century tax-funded health services, especially the Medicare and Medicaid programmes, constitute nearly twothirds of US health spending. As the distinguished medical historian Charles E. Rosenberg has noted, the United States is exceptional not in its devotion to individualism and the private market, but in its ‘inattention’ to the reality of a mixed public-private system.11 The ACA opponents’ case rested on a false narrative of United States health-care history. In response, legal scholar Timothy Jost of Washington and Lee University organized a group of scholars to write an amicus curiae (‘friend of the court’) brief to submit to the United States Supreme Court. The brief, written by Jost and two other scholars, aimed ‘to assist the Supreme Court in understanding the history of health care regulation in the United States, and thus, the legitimacy of the use of the Commerce Power to require Americans to purchase health insurance’. It argued that the ACA’s requirement that individuals purchase health insurance ‘is consistent with, and not different in kind from, the historical role of the federal government in health care’. The 53-page-long brief described the long history of the United States national government’s involvement in the medical system, from federal support for hospital construction in the 1930s to the Medicare and Medicaid programmes to drug regulation. The brief was signed by 34 individuals (including myself) identified as ‘health policy history scholars’, and scholarly historical publications appear in the Table of Authorities cited.12

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

70

Communicating the history of medicine

Although the Supreme Court did declare the individual mandate constitutional, the written opinion in NFIB v. Sebelius does not specifically cite the historians’ brief, and Chief Justice Roberts’ reasoning was based on Congress’s constitutional taxation power, not the Commerce Clause. Still, the amicus brief ’s main author thinks it likely that it did serve its purpose of informing the Justices about the history of healthcare regulation. And Justice Ruth Bader Ginsburg, in her concurrence with the opinion on the individual mandate, echoed the historical scholars’ argument when she noted that the Affordable Care Act does not operate ‘in [an] are[a] … where States historically have been sovereign’. As evidenced by Medicare, Medicaid, the Employee Retirement Income Security Act of 1974 (ERISA), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Federal Government plays a lead role in the health-care sector, both as a direct payer and as a regulator.13

Three years later, the ACA came before the Supreme Court again, in King v. Burwell. In this case, opponents of the ACA argued that premium subsidies should not be allowed for individuals purchasing health insurance in the new federal exchanges. This was a potentially devastating challenge to the ACA, because, without subsidies, most people in states with federal (rather than state-run) exchanges would not be able to afford to purchase coverage – an estimated 5 to 8.5 million people.14 Jost once again sent out a call for scholars to sign a historical brief on the case, writing that ‘The health care of millions of Americans depends on us convincing the Court to support the government’s interpretation of the statute’.15 Unlike NFIB v. Sebelius, the scholars’ case in King v. Burwell did not rest on a particular interpretation of the nature of the United States health system. Rather, it was a simple restatement of a historical sequence of events: the legislative history of the ACA itself, which clearly embodied Congress’s intent that subsidies be available to all persons in the health-insurance exchanges, not just in those run by the states. The authors of the amicus curiae put it mildly and elegantly: ‘Because that historical record is relevant under this Court’s precedents, its presentation in this brief is likely to assist the Court’.16 The scholars’ brief in King v. Burwell outlines the history of states’ experiences with insurance regulation to argue that Congress was aware

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

71

that subsidies would be required to make private insurance exchanges viable. It goes on to summarize the legislative history of the exchange and subsidy portions of the ACA, demonstrating that no evidence existed that any member of Congress believed that the proposed subsidies would only be used for health-insurance exchanges run by the states. The brief includes references to writings by scholars Jill Quadagno and Paul Starr on the history of health reform.17 On 25 June 2015, with an even stronger majority (6–3) than in NFIB v. Sebelius, the Supreme Court in King v. Burwell upheld federal subsidies to all health-insurance exchanges under the ACA. Again, the historians’ brief was not specifically cited in the Court’s opinion, so it is difficult to gauge its impact. But it is certainly noteworthy that, in both cases, the scholars’ briefs came in on the winning side. Without knowing to what extent the Justices took the briefs into account, we can only surmise from the opinions that historical scholarship played some role in the Court’s affirmation of parts of the ACA, and therefore in the survival of the Act itself.18 In the United States, historians’ testimony has proven central to other health-care policy cases, particularly lawsuits over private companies’ liability in tobacco use and lead poisoning.19 But historians’ impact on the Supreme Court was most evident in the recent ruling that ended state laws against same-sex marriage. The amici curiae in this case were not scholars of medicine or health policy, but historians of marriage and the family. Their impact on judicial decision-making is much easier to measure than in the health-care cases, because Justice Anthony Kennedy repeatedly cited the historians’ briefs in his opinion for the Court. The findings of United States historians of marriage echo in Kennedy’s wording: Throughout American history, marriage has served multiple state interests and has evolved to reflect social and legal changes. The historical record contradicts attempts to cast marriage as serving any single, overriding purpose. And it contradicts attempts to present marriage as a static institution so rooted in ‘tradition’ as to insulate it from constitutional challenge.20

In the quest to correct historical misinformation, the United States courts have proven to be a particularly powerful venue for academic historians and health-policy scholars to make themselves heard. In the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

72

Communicating the history of medicine

case of the ACA, the prevalence of deliberate distortions and falsifications in political debate indicates that historians’ voices are needed more than ever. But can scholars do more to ensure that their findings and arguments reach the general public? What venues for dissemination of our work are most effective for allowing historians to increase their impact on public debates and health-care policy? Dissemination

In 2005, Susan Reverby, a distinguished historian of medicine at Wellesley College in Massachusetts (USA), was doing archival research in the papers of a United States Public Health Service physician when she came upon a set of previously unseen documents. The materials showed that United States public health officials had conducted human experiments in Guatemala in the 1950s that involved deliberately infecting research subjects, including prisoners and prostitutes, with syphilis and gonorrhoea. Some of the subjects died. Reverby, she recounted later, was ‘floored’ by her findings.21 The historian’s discovery became frontpage news, capturing the attention of the president of Guatemala and, eventually, the United States White House. Using Reverby’s work as evidence, in October of 2010, President Barack Obama officially apologized for the United States medical experiments on Guatemalans.22 Few historians of medicine can hope to achieve the impact of a blockbuster revelation like Reverby’s that draws extensive media attention and a serious policy response to redress a human rights violation. Archival discoveries rarely merit mention in the New York Times or on the nightly news. Certainly, historians will continue to unearth past events, both heinous and marvellous, that will put our profession in the limelight. But, even short of that, there are other possible avenues for medical history scholars to disseminate their findings beyond the academy. There has long been a sharp divide between academic and popular history. As the lament goes, academic historians write for a narrow, specialized audience of other academics, while popularizers regularly appear on bestseller lists. Although some professional historians continue to show disdain for popular history writers,23 for many the ‘cross­ over’ book – a publication based on rigorous academic research, but reaching a wider audience – has increasingly become the new holy grail.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

73

Books about health-care reform history are unlikely to approach the popularity of the type of history books that sell the most copies in the United States: those perennial bestsellers about the Founding Fathers and the Second World War.24 But nationwide interest in health reform due to the ACA has led more health policy scholars to try and cross the academic-popular divide. One notable example is a graphic novel, published in 2011, which uses a comic strip format to explain and defend the ACA.25 This comic book treatment’s primary author is Jonathan Gruber, an economist at the Massachusetts Institute of Technology who served as policy advisor to the White House during the development of the ACA. The graphic novel received a significant amount of attention and appeared on the Amazon.com list of bestselling books on health-care policy (even, or especially, after Gruber received notoriety for his injudicious comments on the American public’s gullibility). However, overall the Amazon lists indicate that how-to books and conservative titles attacking ‘Obamacare’, mostly written by non-academics, dominated this market in the early 2010s.26 (Because they are proprietary, the accuracy and usefulness of the Amazon lists are unclear, but their importance has been growing due to the Internet giant’s dominance of book sales.27) When my own book, Health Care for Some, was published in 2012, I hoped that the current interest in health-care reform would lead to that elusive goal, a crossover bestseller. Although it has not exactly achieved that status, the book has sold far more copies than my first monograph, and could be termed a modestly successful academic bestseller – approximately 3,000 copies sold as of mid-2015. While this is a small number compared to ‘real’ bestselling books, it is on the high end for scholarly publications containing footnotes (many scholarly monographs sell about 250–350 copies).28 How does an academic historian go from publishing obscure monographs to a modestly selling book read by at least some non-academics? For me, the key was television. A canny marketer at my publisher, the University of Chicago Press, was able to garner some interest from BookTV, a TV programme shown on the public access channel C-Span in the United States. Unlike in the UK and many other Western European countries, academics and their books are not regularly featured on United States’ television; BookTV is often the only venue for such exposure.29 The programme recorded a talk I presented on Health Care

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

74

Communicating the history of medicine

for Some, which was broadcast at least three times on the C-Span network. BookTV’s audience is made up primary of general book lovers (and insomniacs), not academics, and it was those three broadcasts that pushed sales of my book from the hundreds into the low thousands. Sales of Health Care for Some have also been helped by the classroom market. Although I did not direct the book specifically at an undergraduate audience, I did think about classroom potential when writing it, which meant I tried to eliminate jargon and specialized language. I also did not assume expert knowledge on the part of the reader. At the urging of my editor, I included a glossary of terms related to the healthcare system to assist non-specialists in understanding the story. The book is now being used in undergraduate courses in the history of medicine or health-care policy at several colleges and universities. Unlike a TV broadcast, which in my case led to a brief but significant rise in sales, classroom adoption may allow a book to continue selling modestly but steadily over a longer period of time – and hopefully to have an influence on students’ knowledge of, and thinking about, health care and its history. This is not to say that more specialized monographs cannot have an impact on audiences and discourses outside the academy. My first book, The Wages of Sickness, is a history of the defeat of the New York State health-insurance campaign of 1915–1920. Its status as the only recent monograph on that topic led to the book being quoted in more highly selling volumes by more high-profile authors. The story I told in The Wages of Sickness is summarized and cited in policy-oriented books by former Bill Clinton advisor Paul Starr and former United States Senate Majority Leader Tom Daschle.30 Authors and policy-makers want to use history to support their arguments about the health-care system, so they need our work (and, hopefully, will cite it accurately). This raises the question of how to demonstrate ‘impact’ through quantifying the citations of scholarly publications. Long used in the natural and social sciences, citation indexes have become increasingly important for humanities scholars in the age of impact assessment. Databases like the Social Science Citation Index are being supplemented – perhaps supplanted – by new open-access venues such as Google Scholar, Academia.edu and Research Gate. These new sites not only count citations, but boost them considerably by making previously inaccessible scholarship available for download. A 2015 (admittedly

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

75

self-serving) self-study commissioned by Academia.edu found that a paper uploaded to its site receives on average ‘41% more citations after one year than a similar article not available online, 50% more citations after three years, and 73% after five years’. It also found that ‘articles also posted to Academia.edu had 64% more citations than articles only posted to other online venues, such as personal and departmental home pages, after five years’.31 Open-access sites for sharing scholarship are especially important for historians who publish chapters in edited collections, which are notoriously difficult to search and download. These formerly free citation websites are, however, increasingly pushing paidonly ‘premium’ services. In any event, scholars hoping to have a wider public impact may need to supplement citation indexes and the newer academic websites, which do not include citations from popular books or media, with broader searches for quotation of their works. Historians can also seek to be published or quoted in high-impact mass-media outlets. However, they have difficulty doing so. For example, a search for history professors quoted in New York Times and Washington Post articles on health-care reform in 2015 turned up zero scholars of medical history (there were a few quotations from prominent political historians, especially scholars of presidential history). Political historian Julian Zelizer did publish a major piece in the influential New Yorker magazine commemorating the 50th anniversary of the passage of Medicare and Medicaid.32 Zelizer’s article proved that historians can provide insight into current events, not just 50-year-old ones. His argument that the debates over Medicare were just as contentious as those over the ACA today, yet did not result in weakening the Medicare programme over time, was quoted in other news outlets and circulated on the Internet.33 Scholars often hope to achieve higher visibility for their research findings by submitting opinion pieces, also known as ‘op-ed’, to major newspapers and magazines. In the United States, perhaps the most coveted goal is an appearance on the Opinion page of the New York Times. But it is not easy to get published in the Times, which receives ‘a flood of submissions’ for this prized spot.34 During the 2012 United States presidential election, when Republican candidate Mitt Romney mentioned that he thought hospital emergency rooms were an appropriate safety net for the uninsured, I submitted a piece to the Times arguing that the right to emergency care had been established as a

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

76

Communicating the history of medicine

stopgap measure, not a permanent solution to the lack of universal coverage. I thought I came up with a nice headline/sound bite: ‘A safety net is not a solution’. But the Times rejected the piece; according to the editor, it was too mired in historical detail. This may be a particular challenge for historians, who are reluctant to jettison our hard-earned detail and evidence. ‘It’s complicated’ is one of historians’ favourite phrases, but that does not play well on the editorial page. Successful opinion pieces by historians manage to capture the reader’s attention right away, pose a policy solution to an important current problem, and briefly and effectively support their argument with historical evidence. One example is a 2012 New York Times editorial by labour and policy historians Eileen Boris and Jennifer Klein, arguing that home health workers should be placed under the minimum wage and other protections of the United States Fair Labor Standards Act (FLSA). The authors begin the piece with an anecdote about Barack Obama’s visit with a home care worker, introduce the debate on the FLSA protections and then bring in the history of how the law came to treat these workers differently from other categories of domestic labour (the subject of Boris and Klein’s book Caring for America). They present a clear policy recommendation and effectively, but briefly, demonstrate how history can help readers understand present-day debates.35 And opinion pieces are not the only way for historians to appear in the Times. The feature article, which tends to be longer and offer a deeper analysis than a standard news item, is a particularly attractive form for historians. Two historians of medicine, Howard Markel and Barron Lerner, often publish Times features on topics as diverse as cancer, cocaine and drunk driving.36 As these examples show, there are many excellent scholars who have become well versed in the art of writing for a broader readership. However, it is still hard to break into traditional media, so many scholars are now looking to electronic formats and social media to extend the audiences for their work. The website History News Network publishes brief pieces by historians offering historical perspectives on current events, including over a dozen posts on the ACA. The Philadelphia Inquirer has a blog entitled ‘The Public’s Health’ that is coordinated by a prominent historian of medicine, Janet Golden, and frequently features posts written by medical historians. A group of history of medicine graduate students started an innovative blog,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

77

Nursing Clio, that describes itself as ‘a gathering site for historians, health care workers, community activists, students, and the public at large to engage in discussion of current and historical debates over medicine and the gendered body’. Using the tag line ‘The personal is historical’, Nursing Clio has published historical analyses of reproductive health, childbirth, women in the medical profession, disability and race, as well as a delightful weekly feature entitled ‘Sunday Morning Medicine’ that provides a wrap-up of medical history topics in the news.37 How useful are blogs and other types of social media as forms of dissemination for historical research? For scholars who are required to report measurable impact for their work, some services, such as Google Analytics, offer ways to track the amount of traffic to a website and such details as the geographic location of site visitors. Other ‘metrics’, such as the number of followers of a Twitter feed, can help provide new types of data on scholarly dissemination and impact.38 Cautioning: the perils of the ‘lessons of history’

Even though we must insist that history is important and seek to provide accurate information based on evidence, we need to correct false assumptions about the role of history itself. Historians need to promote scepticism of the kind of historicism that claims to discern patterns or cycles of history that can then be used predictively. We should also be wary when the lessons of the past are used to argue for constraints on action or agency in the present – when they limit, rather than inspire, policy imaginations. The ACA debates in the United States offer a fascinating case study in the use of history by policy-makers, because President Barack Obama was acutely aware of the historic nature of his reform leadership. In speeches, he referred to the long history of presidential failure to pass health reform, and declared that he would be the one to finally break that pattern. In a 2009 speech to Congress, he declared, ‘I am not the first President to take up this cause, but I am determined to be the last […] It has now been nearly a century since Theodore Roosevelt first called for health care reform’.39 Obama and his advisors did indeed study history carefully (although not always accurately – Roosevelt proposed social insurance during his failed campaign for President

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

78

Communicating the history of medicine

on the Progressive ticket, not during his presidency). But to what effect? A 2012 article published in the Journal of Policy History by two political scientists, Kevin P. Donnelly and David A. Rochefort, draws our attention to ‘The Lessons of “Lesson Drawing”’ that can be learned from Obama’s use of history. The authors write that, for Obama, ‘avoiding the mistakes of the past approached the level of obsession’. He particularly sought to avoid the mistakes made by Bill Clinton’s administration during its disastrous health-care battle of the early 1990s. A consensus emerged among Obama’s advisors: Clinton had been ‘excessive[ly] ambitious’. Obama advisor Paul Starr (who had also advised the Clintons) urged, ‘the lesson is […] faster, smaller’. As a result, Obama ‘did not insist on universal coverage’. He emphasized ‘incremental market reform’, not sweeping changes to the health-care system.40 Both media and scholarly analyses agree that the Clinton reform attempt in the 1990s had been derailed in part by attacks from for-profit insurance companies and other private health-care interests. Learning from this ‘lesson’, Obama gave the insurance and pharmaceutical industries a large role in drafting the ACA in an attempt to head off their opposition. Donnelly and Rochefort cast doubt on the efficacy of this historically informed strategy, noting that it did not thwart conservative or insurance company opposition to reform. The ACA did not win a single Republican vote in Congress, and the insurance industry launched a campaign of attack ads against the ACA, even though the legislation would benefit them financially. Indeed, Obama’s shift away from his original strategy – including taking a more active role after having let Congress take the lead, moving against the insurance companies and giving up on bipartisanship – might have had more to do with the Act’s success than his earlier, more cautious approach based on historical lessons from the Clinton era.41 Donnelly and Rochefort conclude that even careful policy learning from the lessons of history does not guarantee the desired results. I would also add that Obama’s use of the past reminds us that history is not an agreed-upon set of facts, but rather is contested. The framers of the ACA relied not on ‘history’, but on a particular version of history that emphasized the Clinton failure. This version led policy-makers to focus on compromise, on placating the opposition and on ensuring that

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

79

the system of private insurance would remain intact. This led to a very different kind of policy and strategy than if Obama instead had looked to, for example, an earlier history of success: the Medicare programme, passed in 1965 under the leadership of President Lyndon Johnson, whose style was based more on arm twisting and back-room deals than on compromise. It is not that following the lessons of Medicare would have guaranteed similar results – clearly, the context had changed hugely since 1965 – but it seems to me that Obama chose the lessons he was comfortable with, since compromise, bipartisanship, incrementalism and pragmatic centrism fit with his pre-existing methods and ideas.42 All this is to say that the lessons of history, and who invokes them and how, are not ideologically neutral. Like history itself, the lessons of history depend on who is interpreting them and in what context. This raises a seeming contradiction with the section above on mythbusting. Historians seek to provide accuracy and ‘the facts’, yet history itself is contested. To bust myths, insist on evidence and counter disinformation while reminding students and the public that history is interpretation is a delicate balancing act, but one we must attempt. Historians as advocates

Medical historian Virginia Berridge has written that ‘Historians should not become activists, and such a stance would detract from, not add to, what they have to offer’.43 But does advocacy for present-day policy goals preclude commitment to solid scholarship about the past? Are advocacy and scholarly integrity indeed incompatible? In a time of rapid changes in health-care systems, is objectivity possible, or even desirable? Historians have been having this discussion for many years.44 In the field of medical history, debates came to a head over the participation of some medical historians as expert witnesses for tobacco companies in liability cases in the 1980s and 1990s. In those and other instances of historians appearing in court, the tension between sound scholarship and advocacy was at its most stark; the courtroom encourages onesidedness, not nuance.45 At the opposite end of those who say that historians must not be advocates lies the committed scholarship of historian-activists like the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

80

Communicating the history of medicine

late Howard Zinn, who argued in his very book title that You Can’t Be Neutral on a Moving Train and whose People’s History of the United States books have been hugely influential outside the academy. Yet this may pose a false dichotomy. Intellectual historian Thomas Haskell argues that ‘objectivity is not neutrality’: Most historians would indeed say that the historian’s primary commitment is to the truth, and that when truth and ‘the cause’, however defined, come into conflict, the truth must prevail. But to say that is not to prohibit political advocacy; it is only to set intellectually responsible limits to it – limits without which advocates would discredit not only scholarship but their own cause.46

My students state repeatedly that objectivity means ‘not having bias’. But this is not the correct definition. Objectivity is an approach called into being by the very existence of bias. In a discussion of the idea of objectivity in journalism, the American Press Institute notes that ‘Objectivity called for journalists to develop a consistent method of testing information – a transparent approach to evidence – precisely so that personal and cultural biases would not undermine the accuracy of their work’.47 Objectivity, then, requires neither dispassion nor detachment, but faithfulness to the evidence. Since historians seek as well as use evidence, this is an essential task of our profession. We need to follow the evidentiary trail wherever it leads, even if the results conflict with what we hoped to find. As the historian Carl Degler put it, scholars must include and even embrace evidence that is ‘ideologically embarrassing’.48 We can give voice to a variety of historical actors, as much as possible letting them speak for themselves and not putting words in their mouths. We must pay relentless attention to historical context, thereby avoiding presentism even while we seek to illuminate history’s value to the present. Adherence to the ethics and tenets of our profession will enhance, not detract from, our attempts ‘to create a passionate historical practice’, as Susan Reverby puts it.49 Finally, it would be nice if our committed scholarship would be read by, and even appreciated by, people whom we disagree with and who disagree with us. This may be the most difficult task of all. If we reach beyond the academy but only to publics of the ‘converted’, is that

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

81

enough? Or should the task of persuading, as well as informing, be left to other disciplines? This last point underscores even more the importance of meticulous historical methodology. Scholars contributing to volatile policy debates can be discredited if their works are read by politicized opponents who search for inaccuracies and errors.50 This leads me to conclude that not only is there not a contradiction between commitment and scholarship, but that effective commitment requires the most careful scholarship. In the UK, the 2014 Research Excellence Framework was the first to measure the comparative ‘impact’ of academic research by university faculties. The Research Excellence Framework defines impact as ‘any effect on, change or benefit to the economy, society, culture, public policy or services, health, the environment or quality of life, beyond academia’ and counts for 20% of the ‘overall results’ of the assessment exercise. Examples in this chapter suggest that historical work faces certain disciplinary and systemic barriers to achieving impact on a par with other fields: the length of time necessary for rigorous archival work, the difficulty and perhaps undesirability of translating complex research findings into the brief sound bites preferred by media outlets, and unequal access to policy influence. Assessment exercises that take place every few years or more frequently are particularly disadvantageous to historical research whose impact may be more long-term, perhaps stretching over decades. Another concern about these types of assessments is that some scholars and institutions have greater access to resources that can enhance impact. One report has noted that, in recent research assessments in the UK, ‘it is already clear that universities that have traditionally excelled in the audit of academic output – Oxford, Cambridge and Imperial College London – also score highly on impact’.51 Inequality of resources, prestige and power shapes the ability of scholars to achieve impact. Perhaps an even greater concern than unequal opportunities is the imposition of standards from outside and from above. Assessment requirements often use definitions and measures of impact that are drawn from the hard sciences, inadequate instruments to apply to social science and humanities publications, and measures based on quantity may disadvantage historical scholarship in particular. At Rutgers University (United States), the faculty union has campaigned against the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

82

Communicating the history of medicine

university’s use of a private firm, Academic Analytics, which provides quantitative data on faculty research productivity. A 2016 statement from the American Association of University Professors notes, ‘While such services promise “objective” data about faculty productivity, some of the firm’s metrics lack any qualitative dimension’.52 Scholars’ objection to assessment by outside firms is an important step in building a larger movement against privatization and the imposition of business standards on higher education.53 Finally, while historians of medicine have many opportunities to pursue public impact beyond the academy, we must continue to insist on the intrinsic value of academic research, including on specialized topics. Exploring questions and generating new knowledge is necessary in itself, even if the results may not have quantifiable ‘impact’. A focus on assessment can also detract from universities’ central missions. As one UK scholar commented, ‘I have a concern that I may be stuck spending more time evaluating the impact of what I do and this will take me away from actually doing it’.54 Historians need to remind those who assess us – including ‘the public’ – of the crucially important ‘impact’ of not just our research but also our teaching mission, and the benefit to students of being taught by active scholars. Notes 1 Allen Mikaelien, email to author, 22 June 2012. 2 The Court struck down the Act’s crucial provision that states be required to expand Medicaid coverage for low-income workers. 3 ‘AHA Roundtable: Historians’ Perspectives on the Supreme Court Health Care Ruling’, 29 June 2012, http://blog.historians.org/2012/06/aharoundtable-historians-perspectives-on-the-supreme-court-health-careruling/#sthash.ynkGCJrM.dpuf (accessed 16 December 2016). 4 J. Champagne, ‘Teaching in the Corporate University: Assessment as a Labor Issue’, Journal of Academic Freedom, 2 (2011), 3. See also, e.g., F. Donoghue, The Last Professors: The Corporate University and the Fate of the Humanities (New York: Fordham University Press, 2008); E. Schrecker, The Lost Soul of Higher Education: Corporatization, the Assault on Academic Freedom, and the End of the American University (New York: New Press, 2010); S. Aronowitz, The Knowledge Factory: Dismantling the Corporate University and Creating True Higher Learning (Boston: Beacon Press, 2001).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

83

5 Z-A. Lum, ‘Donald Trump Slams Canada’s Health-Care System as “Catastrophic”’, Huffington Post Canada, 10 October 2016, http://www. huffingtonpost.ca/2016/10/09/donald-trump-canada_n_12423178. html. See also T. Lieberman, ‘Comparing the U.S. and Canadian Health Systems’, Covering Health International blog, 13 January 2014, http:// healthjournalism.org/blog/2014/01/comparing-u-s-canadian-healthcare-systems/ (accessed 16 December 2016). 6 Commonwealth Fund, ‘US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives’, 16 June 2014, http://www.commonwealthfund.org/publications/ press-releases/2014/jun/us-health-system-ranks-last (accessed 16 December 2016). 7 E.g. T. Miller, ‘Universal Health Care Means Rationing’, Crisis Magazine, 26 September 2011, http://www.crisismagazine.com/2011/universalhealth-care-means-rationing (accessed 8 August 2019). 8 University of Chicago Press, 2012. 9 A. Drobnic Holan, ‘Politifact’s “Lie of the Year”’, 18 December 2009, http://www.politifact.com/truth-o-meter/article/2009/dec/18/ politifact-lie-year-death-panels/ (accessed 16 December 2016). 10 Florida v. U.S. Dep’t Health & Human Servs., 648 F.3d 1235, 1306 (11th Cir. 2011). 11 AFL-CIO Department for Professional Employees, ‘The U.S. Health Care System: An International Perspective’, 2016, http://dpeaflcio.org/ programs-publications/issue-fact-sheets/the-u-s-health-care-system-aninternational-perspective/; Physicians for a National Health Program, ‘Government Funds Nearly Two-Thirds of U.S. Health Care Costs’, 21 January 2016, http://www.pnhp.org/news/2016/january/governmentfunds-nearly-two-thirds-of-us-health-care-costs-american-journal-of-pub (all accessed 16 December 2016); C. E. Rosenberg, ‘Anticipated Consequences: Historians, History, and Health Policy’, in R. A. Stevens, C. E. Rosenberg and Lawton R. Burns (eds), History and Health Policy in the United States: Putting the Past Back In (New Brunswick, NJ: Rutgers University Press, 2006), p. 14. 12 ‘Brief of Health Care Policy History Scholars as Amici Curiae in Support of Petitioners (Minimum Coverage Provision)’; Timothy Jost, email to author, 13 January 2015. The co-authors were Jost, Judy Feder and Jonathan Oberlander, with assistance from Stuart Altman, David Shactman and Harold Pollack. See also R. R. Weiner, ‘Much Ado: The Potential Impact of the Supreme Court Decision Upholding the Affordable Care Act’, in N. Persily, G. E. Metzger and T. W. Morrison (eds), The Health Care Case: The Supreme Court’s Decision and its Implications (New York: Oxford University Press, 2013).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

84

Communicating the history of medicine

13 Timothy Jost, email to author, 24 March 2014; NFIB v. Sebelius, Concurrence, Ginsburg. 14 In 2015, there are 14 state-based marketplaces; 3 federally supported marketplaces; 7 state-partnership marketplaces; and 27 federally facilitated marketplaces. Kaiser Family Foundation, ‘State Health Insurance Marketplace Types, 2015’, http://kff.org/health-reform/state-indicator/statehealth-insurance-marketplace-types/ (accessed 16 December 2016). This variety attests to the continuing fragmentation and complexity of the US health system under the Affordable Care Act. 15 Timothy Jost, email to author, 21 January 2015. 16 King v. Burwell, ‘Brief of Health Care Policy History Scholars as Amici Curiae Supporting Respondents’. 17 J. Quadagno, ‘Right Wing Conspiracy? Socialist Plot? The Origins of the Patient Protection and Affordable Care Act’, Journal of Health Care Politics, Policy, and Law, 35 (2014); Starr, Remedy and Reaction. It is worth noting that these scholars are sociologists, not historians. One possible explanation for the paucity of ‘real’ historians quoted in the brief is the publication cycles of different disciplines; few historians produce publications analysing recent events, as sociologists and political scientists do; the publication time frame for historical books and articles is often measured in years, not months or weeks (or days or hours). 18 A victory about which some of us have mixed feelings. I signed both amicus briefs because I stood by the history in them; I do not agree that the Affordable Care Act represents a solution to the problems of health-care access and affordability in the United States. See Hoffman, Health Care for Some, epilogue. 19 E.g. D. Rosner and G. Markowitz, ‘Getting the Lead Out’, The Nation, 23 April 2007; L. M. Kyriakoudes, ‘Historians’ Testimony on “Common Knowledge” of the Risks of Tobacco Use: A Review and Analysis of Experts Testifying on Behalf of Cigarette Manufacturers in Civil Litigation’, Tobacco Control, 15 December 2006 (Suppl. 4), iv107–iv116. 20 Obergefell v. Hodges, 26 June 2015; ‘Brief of Historians of Marriage and the American Historical Association as Amici Curiae in Support of Petitioners’; J. Mapes, ‘In Gay Marriage Decision, the Supreme Court Turns to Historians for Insight’, The Oregonian, 26 June 2015. 21 S. Reverby, ‘“Normal Exposure” and Inoculation Syphilis: A PHS “Tuskegee” Doctor in Guatemala’, Journal of Policy History, 23:1 (2011), 6–28; S. Smith, ‘Wellesley Professor Unearths a Horror: Syphilis Experiments in Guatemala’, Boston Globe, 2 October 2010. Reverby is also the author of highly regarded historical works on the nursing profession and on the Tuskegee syphilis study.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

85

22 D. G. McNeil Jr, ‘U.S. Apologizes for Syphilis Tests in Guatemala’, New York Times, 1 October 2010; S. M. Reverby, ‘Enemy of the People/Enemy of the State: Two Great(ly Infamous) Doctors, Passions, and the Judgment of History’, Bulletin of the History of Medicine, 88:3 (2014), 403–430, fn. 15, p. 407. 23 R. Levitt et al., ‘Assessing the Impact of Arts and Humanities Research at the University of Cambridge’, p. xiv, http://www.rand.org/pubs/ technical_reports/TR816.html (accessed 16 December 2016). 24 Not to mention a hugely successful Broadway musical about a Founding Father (‘Hamilton’). 25 J. Gruber and N. Schreiber, Health Care Reform: What It Is, Why It’s Necessary, How It Works (New York: Hill and Wang, 2011). 26 E.g. L. Yagoda, N. Durtiz and J. Freedman, Affordable Care Act for Dummies ( John Wiley and Sons, 2014); R. S. Roberts, The Obamacare Train Wreck: How Every American Will Be Affected (CreateSpace Independent Publishing Platform, 2014). Gruber’s 2013 comments on the role of United States voters’ ‘stupidity’ in the passage of the Affordable Care Act were widely circulated by conservative media in 2014–2015; S. Armour, ‘MIT Economist Jonathan Gruber Had Bigger Role in Health Law, Emails Show’, Wall Street Journal, 21 June 2015, http://www.wsj.com/articles/mit-economistjonathan-gruber-had-bigger-role-in-health-law-emails-show-1434910195 (accessed 16 December 2016). 27 G. Habash, ‘How Many Copies Does It Take to Be an Amazon Bestseller?’, Publishers Weekly, 10 March 2013, http://www.publishersweekly.com/ pw/by-topic/industry-news/bookselling/article/56284-how-manycopies-does-it-take-to-be-an-amazon-bestseller.html; R. Nightingale, ‘8 Things You May Not Know About Amazon’s Bestsellers Rank’, http:// www.makeuseof.com/tag/8-things-people-dont-know-amazonsbestsellers-rank-sales-rank/ (accessed 16 December 2016). 28 N. Berlatsky, ‘What is the Point of Academic Books?’, Pacific Standard, 16 December 2014, http://www.psmag.com/books-and-culture/pointacademic-books-publishing-writing-literature-96610; C. Gasson, ‘The Economics of Academic Publishing’, Royal Economic Society Newsletter, http://www.res.org.uk/view/art2Apr04Features2.html (accessed 16 December 2016). 29 Jon Stewart of the hugely popular The Daily Show on United States cable’s Comedy Central would sometimes interview academic authors; I hoped for that call, but it never came. Because C-Span does not use Nielsen viewership ratings, only estimates are available. A. Weprin, ‘C-Span: 47 Million Watch Us Every Week’, 19 March 2013, Adweek.com. On European television venues for scholars, see E. Sciolino, ‘The Chic, Lethal

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

86

Communicating the history of medicine

Salons on the Screens of France’, New York Times, 13 April 2012. Numerous radio and television series of the British Broadcasting Corporation have also featured academic authors over the years (e.g. BBC2’s ‘The Late Show’; Radio 4’s ‘In Our Time’). 30 Starr, Remedy and Reaction, pp. 32–34; T. Daschle, Critical: What We Can Do About the Health-Care Crisis (New York: Thomas Dunne, 2008), Part Two, ‘The History of Health Care Reform’. 31 Y. Nizayov et al., ‘Open Access Meets Discoverability: Citations to Articles Posted in Academia.edu’, https://www.academia.edu/12297791/Open_ Access_Meets_Discoverability_Citations_to_Articles_Posted_to_ Academia.edu (accessed 16 December 2016). Of course, independent studies are needed to confirm and supplement such claims. 32 J. E. Zelizer, ‘How Medicare was Made’, The New Yorker, 15 February 2015, http://www.newyorker.com/news/news-desk/medicare-made (accessed 8 August 2019). 33 E.g. K. Leonard, ‘Shifting Opinions: Medicare and Medicaid, Just Like Obamacare, Were Very Controversial at the Outset’, U.S. News and World Report, 30 July 2015, http://www.usnews.com/news/the-report/ articles/2015/07/30/obamacare-and-the-50th-anniversary-of-medicareand-medicaid (accessed 16 December 2016). 34 T. Hall, ‘Op-Ed and You’, 13 October 2013, http://www.nytimes.com/ 2013/10/14/opinion/op-ed-and-you.html?_r=1. According to the Times guidelines, ‘Unfortunately, because the number of submissions is so large, we have to pass on much material of value and interest, and cannot reply to all submissions. If you do not hear from us within three business days, please assume that we will not be able to use your article’. http:// www.nytimes.com/content/help/site/editorial/op-ed/op-ed.html (accessed 16 December 2016). 35 E. Boris and J. Klein, ‘Home Care Workers Aren’t Just “Companions”’, New York Times, 1 July 2012; Boris and Klein, Caring for America: Home Care Workers in the Shadow of the Welfare State (Oxford: Oxford University Press, 2012). 36 E.g. H. Markel, ‘The D.S.M. Gets Addiction Right’, New York Times, 5 June 2012; B. H. Lerner, ‘The Right to Choose Your Cancer Treatment’, New York Times, 13 June 2012. 37 http://historynewsnetwork.org/search?q=%22affordable+care+act%22 &start=21 (accessed 16 December 2016). 38 E.g. https://www.google.com/analytics/. For more detailed discussions of scholarly uses of social media, see ‘The Impact Blog’ of the London School of Economics and Political Science, http://blogs.lse.ac.uk/ impactofsocialsciences/ (accessed 16 December 2016).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Writing history as it happens

87

39 B. Obama, ‘Remarks by the President to a Joint Session of Congress on Health Care’, 9 September 2009. 40 K. P. Donnelly and D. A. Rochefort, ‘The Lessons of “Lesson Drawing”: How the Obama Administration Attempted to Learn from Failure of the Clinton Health Plan’, Journal of Policy History, 24:2 (2012), 184–223. 41 Ibid., p. 184. 42 On Obama’s pragmatism, see J. T. Kloppenberg, Reading Obama: Dreams, Hope, and the American Political Tradition (Princeton and Oxford: Princeton University Press, 2010). 43 V. Berridge, ‘Thinking in Time: Does Health Policy Need History as Evidence?’ The Lancet, 375:9717 (6 March 2010), 798–799. 44 E.g. P. Novick, That Noble Dream: The Objectivity Question and the American Historical Profession (Cambridge: Cambridge University Press, 1988). 45 E.g. K. Jellison, ‘History in the Courtroom: The Sears Case in Perspective’, The Public Historian, 9:4 (Autumn 1987), 9–19; Kyriakoudes, ‘Historians’ Testimony on “Common Knowledge” of the Risks of Tobacco Use’, 107–116. 46 T. L. Haskell, Objectivity is Not Neutrality: Explanatory Schemes in History (Baltimore: Johns Hopkins University Press, 2000), p. 155. 47 American Press Institute, ‘The Lost Meaning of Objectivity’, http:// www.americanpressinstitute.org/journalism-essentials/bias-objectivity/ lost-meaning-objectivity/ (accessed 16 December 2016). See also B. Kovach and T. Rosenstiel, The Elements of Journalism: What Newspeople Should Know and What the Public Should Expect (New York: Three Rivers Press, 2007). 48 C. N. Degler, ‘Remaking American History’, Journal of American History, 67:1 ( June 1980), 7–25. It should be noted that Degler’s piece includes an attack on Marxist interpretations of history and on Howard Zinn in particular. For Zinn’s rejoinder, see H. Zinn, Letter to the Editor, Journal of American History, 68:1 ( June 1981), 211–213. 49 Reverby, ‘Enemy of the People/Enemy of the State’, p. 403. 50 E.g. J. T. Lindgren, ‘Fall from Grace: Arming America and the Bellesiles Scandal’ (March 2005), Law and Economics Papers, http://law.bepress. com/nwwps-lep/art9 (accessed 16 December 2016). 51 R. Van Noorden, ‘Impact of UK Research Revealed in 7,000 Case Studies’, Nature, 518 (12 February 2015), 150–151, http://www.nature.com/news/ impact-of-uk-research-revealed-in-7–000-case-studies-1.16898 (accessed 16 December 2016). 52 American Association of University Professors, ‘Statement Urges Caution on Academic Analytics’, 28 March 2016. https://www.aaup.org/news/

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

88

Communicating the history of medicine

statement-urges-caution-toward-academic-analytics#.XRIo1i2ZPOQ (accessed 25 June 2019). 53 E.g. M. Eve, ‘Open Access, the Impact Agenda and Resistance to the Neoliberal Paradigm’, The Impact Blog, London School of Economics and Political Science, 19 March 2013, http://blogs.lse.ac.uk/impactofsocialscience s/2013/03/19/open-access-neoliberalism-impact/ (accessed 16 December 2016). 54 Van Noorden, ‘Impact of UK Research Revealed’. Assessment requirements ‘can also deflect from core university goals, as staff are required to respond to audit exercises that divert time and attention away from teaching and research’. R. Watermeyer and M. Olssen, ‘“Excellence” and Exclusion: The Individual Costs of Institutional Competitiveness’, Minerva, 54:2 ( June 2016), 201–218. This article also points to how impact assessment enforces inequality and hierarchy among individual academics, as well as among institutions.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

5

The audiences of eugenics: historiographical and research political reflections Lene Koch

Being a historian of eugenics in Denmark, I have never been in want of an audience.1 Writing in the 1990s, it seemed that the mere mention of the concept of eugenics was enough to create a strong interest in what I had to say about this – at the time – forgotten chapter of Danish history. German Rassenhygiene and its relationship to the Holocaust were well known, but it was a surprise to most people that Denmark and other North European countries such as, e.g., Sweden had a eugenic past as well. Newspapers, radio stations, TV, magazines and academic conferences were continuously asking for interviews and comments and seemed ready to publish almost anything I had to say about the issue. The interest in eugenics in this period was prompted by the heavy public and private investments in the mapping of the human genome in Europe and the United States, and associated ethical, social and legal implications. A more distant but no less sombre reason was the potential link between eugenics and the new genetics. If a historical link between the crimes of racial hygiene and modern genetic selection (prenatal diagnosis, genetic testing, cloning, etc.) could be established, the new genetics would have serious explanatory problems. Being a historian juggling with the huge archival material of Danish eugenic practice in the first part of the twentieth century, and working also on in vitro fertilization and genetic testing, gave me a unique platform for engaging with the public in a way that may be seen as an exercise in ‘audiencing’.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

90

Communicating the history of medicine

By ‘audiencing’ I mean the practice of establishing a formative reciprocal relationship between, in this case, researcher and audience. Thus, general or specific groups to whom a researcher’s results are directed – and who may also help in shaping the researcher’s work – may be considered his or her audience. I gladly contributed critical views to the general debate on the risks associated with new biotechnologies.2 The media always suspected that I would provide them with one specific kind of viewpoint, i.e. that despite assurances that everything was voluntary and safe, deep down the new genetics was eugenic and eugenics was bad. Initially, I was happy to follow this line of interpretation. I felt pampered by the media, and a little flattered that my views were so easily communicated. Gradually, however, my research led me to revise my initial viewpoints concerning Danish eugenics. I understood that, at the time, the alternative to sterilization was indefinite internment. If a mentally disabled person was left to his or her own devices it was thought this might lead to sexual abuse, illegitimate childbirths, the birth of more mentally disabled children who would grow up under very poor circumstances – and possibly to a compulsory removal of such children from their mothers at the cost of the local community. At the time, the economic argument for sterilization, I understood, was taken very seriously. The emerging welfare state, it was argued, had to carefully balance its concerns. If the healthy workers were to receive support from the state in times of need, the number of the unhealthy had to be controlled. Today we would scoff at economic arguments when the selection of human beings is concerned, and at the worry that the mentally disabled and their children might constitute a threat to civilization – but it is a historical fact that at the time these worries were seen as valid and requiring political action. As I began to promote such views – not as my own, but as views of the past that had to be taken seriously if we wanted to understand the past on its own terms – my work began to lose some of its media attraction. The fact that I could no longer appeal to the simple indignation of the public, and its direct moral concerns and emotional identification with the poor and unfortunate victims of sterilization, weakened my chances of gaining a large and supportive audience. As I tried to appeal to a more intellectual response – stating that we must understand the difference between us and them, that the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

91

historical context was different, as were moral norms, etc. − I realized that I was often seen as a defender of eugenics, rather than a critic. I had rejected the simple dualism of being either for or against – my audience had not. Moving between studies in modern biotechnology and the history of eugenics I realized that the modern norms of bioethics and individual rights were often transferred to the historical study of eugenics – and that the application of these modern norms almost automatically led to a problematization of compulsory sterilization in the past. I realized that the norms in Danish society in the first half of the twentieth century differed substantially from those dominating our present society, as they gave social and communal interest a much greater priority than that of the individual. Actually, the eugenic mind-set presumed that the interests of society and of coming generations should override those of the individual. In contrast to this, and in order to create a distance from the activities of its eugenic past, modern genetics associated itself intimately with modern bioethics and its ideals of voluntary choice and individual self-determination. Increasingly – through my studies of patient files, and the professionals’ arguments used to justify sterilization – I realized that there were huge methodological and historiographical difficulties in applying modern norms to the past and that I could not assume that the violation of such norms automatically implied that eugenics was morally bad. Reading my way through the eugenicists’ arguments for compulsory sterilization and later studying thousands (11,000, to be precise) of patient files of the people who had been sterilized, I gained an insight into a social and moral culture that differed from our own in important ways. And I began to understand how eugenics could make sense to those who advocated it at the time and that simply condemning it as unethical and reactionary would be bad history-writing. And perhaps that was my primary concern. I wanted to be a serious historian and understand how the past and the present could hold such different views on basic moral issues. I therefore had to respect the fact that moral culture in the past was quite different from that of the present. As the relationship with my audience became more and more difficult, I found more often than not that I was factually misunderstood

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

92

Communicating the history of medicine

when I presented my new findings. I tried hard to distinguish between eugenics as a politically legitimate policy on the one hand and the many mistakes and abuses that took place (misjudgements of people’s IQ, wrong diagnoses, mistaking poverty or illiteracy for mental retardation, etc.) on the other. But the view that compulsory sterilization might be seen as a legitimate step for the authorities at the time seemed incomprehensible to a modern audience. I was struggling to find a balance between my criticism of eugenics and my interest in trying to understand it on its own premises – and to communicate this search for a balance to my audience. I am not sure that I succeeded, and I sometimes think that people wanted to see eugenics as an offence and were unable to separate it from Nazism. To this day, serious political and intellectual commentators still speak of the compulsory sterilization of the mentally ill in Denmark as comparable with Nazism. The effects of this are difficult to estimate, but one possible consequence is that the historical lessons offered by eugenics may not be well understood. In the following I present a narrative, which puts the difficulties of finding a suitable balance between present-day criticism of eugenics and a more understanding hermeneutic historiographical approach into perspective. I decided to take a closer look at the way the eugenicists related to their audience in the past. I believe that this story may teach us a lesson about ‘audiencing’ as well as about the historicity of the moral appropriateness of eugenics, and lastly a lesson on the role of the historian when studying and presenting morally and politically controversial research. In this way I hope to do two things. One is to demonstrate my respect for the ethical and social norms of the past, without accepting them uncritically. Second, I want to show the historicity of the norms of our own time and illustrate how they contributed to shaping the view of eugenics as morally dubious. With this ambition, I shall introduce the world of the professional geneticists employed at the Institute of Human Genetics and Eugenics, established in 1938 at the University of Copenhagen. These scientists were eager to gain social and scientific impact, improve public health and, not least, serve society. It is a story about the way professional academics in the 1930s and 1940s related to their major audience, the Danish Parliament who had passed eugenic legislation. With this case study I discuss the problems that may occur when medical science allies itself closely with current political objectives – and the risks that

The audiences of eugenics

93

sciences of all sorts run, be they social, medical or other, when giving in to uncritical ‘audiencing’.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The political impact of eugenics: a historical case of ‘audiencing’

As suggested above, the perceived relationship with eugenic practice has given human genetics a bad image. To throw light on this controversial history and look at it as a case of ‘audiencing’, I have found it productive to look at this history through the lens of a concept that is currently dominating European research policy, i.e. ‘grand challenges’. This concept, introduced in the ongoing EU research-funding programme Horizon 2020, refers to such societal problems as the energy crisis, the climate threat and chronic diseases. These issues have been highlighted as problem areas where abundant funding will be supplied to scientific efforts to provide solutions. Most researchers are happy if others can use their work, but the conditions and requirements attached to the funding of research on grand challenges remains a contested issue. The Magistra Vitae tradition represents the ambition to produce useful knowledge in history. The question, however, is whether it is at all possible to learn anything from historical experience. Reinhart Koselleck quoted the German Count Reinhard, who was prompted by Goethe to make the following remark: ‘Experience […] arrives for individuals always too late, while for governments and peoples it is never available’.3 Such a pessimistic view on the utility of historical research would perhaps not impress governments or funding agencies. Koselleck, however, could inspire a more limited ambition, to constantly problematize received truths, problems or solutions, to turn them upside-down and see what secrets they yield, which alternative narratives they may hold. The decision to point out certain issues as grand challenges of our time and – by implication – to designate other issues as being of less societal importance may be seen as a case for such problematization. In the following, I shall discuss grand challenges as important societal ‘problems’, the chosen proposals to remedy these problems as ‘solutions’ and associated research results as ‘truths’. I will discuss where such a categorization might lead us when applied to the history of eugenics. Such a concern with the present may be a task for social

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

94

Communicating the history of medicine

science rather than for historians – but it may also be seen as way of acting as a contemporarily engaged critical historian of science and medicine. After all, Nikolas Rose has, following Foucault, proposed that social scientists should be ‘historians of the present’.4 At any rate, it requires that the historian is able to move between his or her engagement with the present and his or her critical immersion in sources of the past. The relationship between science, politics and state

The current focus on how science relates to its audiences and handles social responsibility, often defined in terms of ‘impact’, is often seen as an indication of a new ‘contract’ between science and politics that demands that researchers are more attentive to society’s interests and current political requirements. The classic statement on the relationship between state and science is the new deal proposed by Vannevar Bush in his famous presidential report on ‘Science – the Endless Frontier’ (1945), where he claimed that basic research was not only important in itself but was a pacesetter for economic and technological development.5 According to Bush, useful research did not emerge from the pipeline readymade, but was based on new thoughts and concepts, which originated in ‘pure’ science. Bush’s model for a ‘social contract for science’, with government funding basic research and scientists defining the tasks of research, led to a situation where politicians de facto left much policy-making in the hands of researchers. The lack of requirements for short-term impact established a different relationship between research and its political beneficiaries, and a different form of audiencing, than the ones we know today. This system was exported to many European countries, including Denmark: during the first four post-war decades or so, science was seen as self-regulating; demands of short-term utility were not prominent; a golden age of research freedom followed. Asilomar and the end of scientific self-regulation in medical science and genetics

Social scientific responsibility in medical science has become a hotly debated issue in the EU as well as the United States. This trend is often

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

95

dated to the famous Asilomar conference, which took place in California in 1975. At this meeting geneticists brought the issue of scientific self-regulation to the fore by discussing a moratorium on certain kinds of genetic research. This reflected a moral concern that scientists should again transgress ethical limits, as in Nazi Germany or with the development of nuclear arms. At Asilomar the issue was not human genetics, but the biohazards associated with the uses of and experiments with recombinant DNA. Guidelines were drawn up to ensure the safety of the public and researchers would continue reflecting on and debate dangerous implications of revolutionary new technologies, or perhaps even refrain from developing them. The implications of Asilomar have been discussed intensely by historians and social scientists, and, although many different interpretations of its decisions have been aired, a certain consensus has emerged around the view that it was the last futile attempt of the self-regulating scientific community to maintain its independence.6 Subsequent developments in biomedicine, such as in vitro fertilization, genetic manipulation or cloning, brought to an end to the belief that autonomous researchers could regulate themselves in a way satisfactory for politicians and the general public. From the start of the 1970s and intensifying in the early 1980s, a popular demand emerged that lay people and politicians should work hand in hand to limit and regulate transgressive research. It seemed as if the public and not least the politicians had lost faith in researchers’ ability to control and regulate taboo-breaking or unethical research. The time was ripe for renegotiating the contract between government and science. Grand challenges today and in the past

Today, politicians nationally and internationally (e.g. in the EU) increasingly demand detailed control of public research funds and require close collaboration between public and private partners in science. This system is believed to stimulate accountability and social responsibility from researchers, who are now expected – at the peril of losing research freedom – to demonstrate their readiness to assist in finding solutions to urgent societal problems. Although it is often claimed that this way of organizing and financing research is new, several authors have argued that private-public

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

96

Communicating the history of medicine

partnerships are neither new nor a guarantee of socially useful results.7 Rather, as the history of eugenics illustrates, already in the early twentieth century scientists worked closely with private investors and public procurers to counter one of the grand challenges of the time, i.e. the perceived dramatic increase in the number of mentally ‘retarded’ individuals.8 Today, no one worries much about this problem as the occurrence of serious inherited mental disability has been greatly reduced following the introduction of voluntary prenatal diagnosis and free abortion. The perceived magnitude of this challenge in the early decades of the twentieth century should not, however, be underestimated and may be seen as the product of a historically specific moral panic orchestrated by politicians, asylum staff and scientists, further encouraged by popular movements such as sexual liberation and feminism. In hindsight, the proposed solution, to track down, diagnose and sterilize individuals thought to carry undesirable genetic traits, has been considered a moral and political disaster, and created for human genetics a bad reputation that it has struggled with ever since.9 From this we may learn that grand challenges are social and historical constructs and not necessarily everlasting truths. Eugenics and the challenge of mental retardation: the case of Denmark

In 1912, world-renowned Danish plant physiologist and geneticist Wilhelm Johannsen became a member of a small private organization, the Anthropological Committee, whose members included prominent civil servants, politicians, statisticians and scientists. The committee lobbied politicians to take measures to improve the health quality of the Danish population, providing data of ‘national scientific interest’ concerning the population’s racial biology. It initiated the registration of mentally disabled individuals and argued for the advantages of legalizing their sterilization. When the University of Copenhagen would not establish institutional space for the study of heredity, members of the committee were instrumental in making Parliament earmark funds to further ‘racial hygienic teaching and research at the University of Copenhagen’.10 The appropriation was listed in the national budget for

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

97

1919–1920, and Wilhelm Johannsen was appointed its administrator. From this point on, things went smoothly for the genetic-eugenics lobby in Denmark.11 Academic research in racial biology (later named human genetics) was closely connected with the development of the eugenics movement, which was led by a variety of actors: physicians, geneticists, politicians, writers and so on. Eugenics as a philosophical idea came from the UK and quickly spread around the world. The technology of sterilization was extensively used in the United States, from where experiences were communicated to European asylums and hospitals. The United States was the first country to pass eugenic sterilization laws, and Denmark – rather than Germany – was the European pioneer. As a consequence of the events outlined above, Denmark passed the first national sterilization law in 1929 with a large parliamentary majority. From 1934, compulsory sterilization of the mentally ‘retarded’ was legalized, an act that remained in force until 1967. The close collaboration between eugenically informed and concerned politicians such as the Social Democrat Karl Kristian Steincke (three times Minister of Justice and once Minister of Social Affairs) and internationally oriented asylum physicians such as Christian Keller spearheaded a strong alliance in support of the eugenics project. The widespread fear that mentally disabled individuals would procreate uncontrollably, with serious consequences for societal norms and the national economy, has been described as a moral panic. It may also be described as one of the grand challenges of the time. Although the time seemed ripe for eugenics, the obstacles to legalization of compulsory sterilization were considerable: physicians worried about implications for the doctor-patient relationship, liberals disliked the idea of compulsion, Christians disliked the idea of intervening in God’s creation and conservatives feared indecency and the spread of contagious sexual disease if sterilization was allowed. The scale of the obstacles to be overcome influenced the need to stoke the moral panic. Stories about the disastrous social, moral and economic consequences of asylum care and the success of the American pioneers in the eugenics movement proliferated in the media and in parliamentary debates. Sterilization, according to the American model, was introduced as the solution. It was science-based and for that reason considered appropriately

98

Communicating the history of medicine

modern: compulsion might be resorted to in cases where voluntary means were insufficient.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

A private-public partnership

The institutionalization of the scientific study of human genetics developed in close association with the political process pushing for eugenic population control. The Rockefeller Foundation provided a large sum of money to establish an Institute for Human Genetics and Eugenics in 1938, while the reluctant University of Copenhagen eventually agreed to pay the running costs. This is a classic example of a private-public partnership, demonstrating that Mode 2 research is far from being a recent invention. The partnership was not established to produce or market profitable products, as is often the case today, but was a rather utopian attempt to save human civilization using scientific means – though economic considerations were certainly decisive for the interest of the Danish state.12 A reduction in the number of ‘unfit’ citizens would help finance the impending social reforms that K. K. Steincke was eager to pass in the interest of the socially responsible working man, reforms that were to become the basis for a Danish welfare state. Scientific innovation was, however, a necessity, and studies to determine the mode of heredity for relevant conditions were thought necessary. This was the rationale behind the desire to create an academic institution, and the existence of a vibrant scientific community of geneticists was an important factor for Rockefeller’s choice of Denmark. Another major reason why the Rockefeller Foundation selected Denmark was the close collaboration between science and the state in social and legislative affairs. The foundational work of the Anthropological Committee had not been in vain. The establishment of an academic institution based at the University of Copenhagen was expected to produce a major social impact precisely because of its legal context as well as the internationally unique registry of the Danish population. The combination of these factors was expected to enable groundbreaking research of societal interest, thereby promoting the overall mission of the Rockefeller Foundation. In 1933 this mission was articulated by the foundation’s representative in Denmark, who stated: ‘What the human race needs and needs desperately is a science of genetics, which would ultimately be used to produce a better race’.13

The audiences of eugenics

99

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Co-production of genetics, eugenics and health politics

The new institute was a research institution, which took its social responsibility and participation in social challenges very seriously, without ever neglecting its duty to perform basic research. The institute issued one doctoral thesis after another at a speed that would make any modern Research Assessment Exerciser happy. The institute’s external activities serving public authorities were similarly intensive. Taking the Anthropological Committee’s registry of hereditary diseases (comprising about one-tenth of the Danish population) as its starting point, the institute was able to provide estimates as to whether individuals proposed for sterilization were actually hereditarily ‘tainted’. The head of the institute, Professor Tage Kemp, worked as genetic advisor for the Organization for Mothers’ Aid,14 the Medico-Legal Council and the Sterilization Board, and signed hundreds of recommendations to sterilize. Such recommendations provided scientific support for the Danish sterilization system. Looking at this huge set up from a present-day perspective, the case was not one in which science, located in its ivory tower, invented dangerous innovations that people did not understand until it was too late – the worries articulated at Asilomar – and which was feared in the case of in vitro fertilization, embryo research and cloning. Audiences as we know them today did not yet exist. In Denmark, sterilization and eugenics were rarely debated in the media and information about eugenic practice was to a great extent kept out of the public eye. Controversies on the issue of eugenics and sterilization were negotiated in narrow circles of politicians and scientific and clinical experts. As a matter of fact, science was enrolled in a political project orchestrated by national politicians wanting to improve public health and the competitiveness of the nation. Eugenics hence developed as a scientifically based practice supported by political ambitions to govern the population. The audience for genetic expertise in this case consisted of the political elite. It is impossible to imagine the development of the Institute of Human Genetics and Eugenics without its specific social and political context and vice versa. Science and society were co-produced, to use an expression from the American sociologist and STS scholar Sheila Jasanoff.15 The understanding of heredity as ‘hard’ and unchangeable

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

100

Communicating the history of medicine

from generation to generation originated in Mendel’s theory of heredity, and is often considered the reason why eugenics gained traction in the early twentieth century. Similarly, the development of human genetics can only with difficulty be extracted from the development of eugenics, as the Rockefeller financing demonstrates. One result of this co-production was the sterilization (voluntary or not) of around 11,000 Danish citizens between 1929 and 1967. During the legislative process critics were often brushed aside with arrogant comments and the administration of the sterilization laws, like decisions to sterilize, took place out of the public eye. The Board of Sterilization did not issue any reports to the public, and no one knew who or how many were sterilized in accordance with the eugenic laws until 2000.16 Hence eugenic practices developed without any audience other that its own narrow circle. Critical comments therefore influenced the practice of compulsory sterilization only very slowly. They emerged gradually, and as the new, human-rights-oriented ideological climate of the post-war period gained ground, eugenics in its original form was eventually abandoned. The historicity of truths and moral rightness

One can discuss whether eugenic sterilization in Denmark and the other Scandinavian countries was morally wrong or a case of appropriate social responsibility. It would be a mistake trying to answer this question from a modern point of view. From a scientific perspective and according to contemporary norms, eugenic sterilization was responsible and morally acceptable, and it was therefore supported by parliamentary majorities. Sterilization was broadly recognized as the right solution to a grand challenge of the era. It is important to stress that what is deemed politically expedient and what is seen as a grand challenge are historical products. Huge sums were invested to solve the problem of hereditary disease, as the Rockefeller Foundation’s support of genetics shows; far-reaching interventions into the reproductive lives of citizens were considered justified, and traditional religious views on the regulation of sexuality were overridden. We may compare this to contemporary grand challenges. An example is the obesity epidemic, which has led health services to organize

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

101

campaigns justifying extensive interventions into people’s social and private lives by economic and biomedical arguments. Today, overweight individuals protest the victimization of the obese, ‘Fat is Beautiful’ organizations pop up and a range of claims made concerning the detrimental effects of obesity have been challenged by scientists.17 Another illustrative case is the climate threat. So-called climate sceptics have been more or less silenced, demonstrating how difficult it is to take an alternative view once problems that are granted the status of grand challenges have established themselves as ‘true’. The lesson of history

What can we learn from this narrative of a group of eugenicists whose research had implications for a whole nation and formed the basis for population policy and legislation affecting thousands of people’s lives? The international community of eugenicists was admired as a daring group of scientific pioneers, at least for a few decades. They assisted democratically elected politicians and authorities with scientific recommendations and evaluations, and gave credibility to a political project that later became highly disputed. Whether it was the politicians who led the researchers or vice versa is difficult to determine. Though matters having to do with sterilization practices were only rarely discussed publicly before the war, and if at all only in very narrow circles, a number of social and political actors promoting eugenics, sexual reform, welfare reform and so on helped make the passing of sterilization laws socially and politically acceptable. We may again speak of co-production or the mutual shaping of views. Social scientific responsibility is about ‘activities, which try to hold science accountable to those values which are broadly accepted in society’.18 This quote comes from two well-known Danish students of the emergence of Social Scientific Responsibility. In this sense, eugenics was indeed highly responsible in relation to the values of contemporary society, even though we do not agree with those values today. The fact that eugenics was democratically acknowledged in Scandinavia in the 1930s and 1940s presents a constant moral challenge for us. The story told above is not just a product of historical research, but also of academic collaboration with and observation of those

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

102

Communicating the history of medicine

professional geneticists who are the descendants of the eugenicists of the 1930s and 1940s. Many years of collaboration with human geneticists made me realize the complexities of practising medical genetics, balancing between responsibility towards the body social and the body individual in a bio-political climate where the effects of the history of eugenics were a constant presence. These modern geneticists were, as their eugenic predecessors had been, eager to employ all the possibilities of new reproductive and genetic technologies in order to help humankind. But they also – though sometimes reluctantly – succumbed to the requirements of society, in their case as they were articulated by the bioethical movement. This was largely a result of the continuing awareness of their tragic disciplinary history. So, in one sense they did learn from history. But at the same time they ran the risk of adapting too much to utilitarian demands in producing repro-genetic or genomic solutions for all sorts of human ailments. Historians and medical scientists alike have a hard time finding positions from which to discuss problematic historical issues respectfully as well as critically. It is extremely difficult for researchers to imagine what could have been right in the past, what is right today and what may be right in the future. The few physicians who criticized the proposed eugenic sterilization laws in 1929 out of fear of undermining the Hippocratic Oath and transforming the trust-based relationship between patient and doctor, appeared as traditionalists without any understanding of the urgency of the overwhelming grand challenges of the times. Today we may see them as heroes, then they were old-fashioned. What we may learn from this narrative is to be more humble and self-reflective as to our ability to produce the right solutions – even in the face of overwhelming crises and overwhelming technological possibilities. Critical positions are often only accessible in retrospect. Today, it has become a human right to procreate – partly as a result of the effective history of eugenics. The view that IVF may not be a sustainable solution and that immigration of young people from overpopulated countries would be a better solution to the challenge of a dwindling Western population will probably not find a very large audience. So, what can the history of medicine teach us about ‘audiencing’? How do we determine which challenges are truly and lastingly grand and which techno-scientific solutions will be truly and lastingly acknowledged as right? It is not the task of the historian to determine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

103

what is scientifically true, what social actors should do or which understandings prevalent in other historical periods are more or less true or right than others. Instead, I would propose that the job of the historian is to examine – after emphasizing that truths are historically specific – the effects of these truths in their specific historical contexts and into the present. The perceived truth of the heredity of mental ‘retardation’, combined with a social and moral obligation of science to counter it, turned out to have had problematic effects. From a strong consensus among the Danish social and political elites the ideas and methods of eugenics gradually met with popular resistance as a new, more critical audience emerged. Simultaneously, the original problem was redefined: concern for the collective population quality receded, and individual reproductive concerns moved into focus. The original goal of eugenic sterilization was to reduce the number of mentally dis­abled individuals. However, by the time we reach the decline of eugenics in the Scandinavian countries around 1950, sterilization had primarily become a method to help worn-out and socially underprivileged mothers avoid further reproduction at a time when abortion was not yet widely available.19 Thus a liberalization of individual reproductive control paradoxically became an effect of eugenics – and today seems to be the ethical norm. Another lesson from the history of eugenics is that notions of what is morally right and socially responsible are perpetually changing and that social problems, scientific truths as well as views on the utility of techno-science are always historically specific, situated and partial – always related to the space and time in which they are articulated and given meaning. This is true for the historical experiences that shape our current perspectives, as it is for the imaginaries of our future. In this space between experience and expectation, there is a vital need for critical thought and reflection, not least on the historian’s relationship to his or her audiences. This requires that she engages deeply with the empirical specificities of another era and at the same time adopts a critical view of the grand challenges of his or her time as historical products. The case of eugenics is undoubtedly one where it is more than normally difficult for the historian to manoeuvre vis-à-vis an audience that strongly endorses the opposite view. It is necessary to reflect on the effects of the truths about history that one tries to communicate when addressing one’s audience. The particular field of the history of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

104

Communicating the history of medicine

eugenics is highly charged emotionally and ethically, and its results are actively shaping the contemporary reception of, e.g., reproductive and genetic technology. The easiest thing is, of course, not to address the public at all, to contain the debate within academic media and thus limit one’s audience to a narrow circle of insiders – as did the leading Danish eugenicists, who preferred to limit the public’s knowledge of eugenic practice.20 This option seems outdated and unrealistic today. But if the historian chooses to communicate his or her findings and relate to potential broader audiences he or she seems to have at least two epistemological choices. One may be called the hermeneutic choice, implying an attempt to understand the views and actions of past societies. This historicizing position is, however, easily misunderstood as an attempt to relativize moral and political norms and cynically accept all encroachments and abuses in the past. I chose the hermeneutic position, which complicated my relationship with a large part of my audience – which followed the trend to absolutize their moral norms. The other we may call the modernist approach, adopting contemporary moral and political standards to characterize past societies. This choice easily leads to an arrogant, all-round condemnation of the past as viewed from a morally and scientifically superior present. This view has a huge and devoted audience. ‘Audiencing’ at its best must take the historian herself as its starting point. The personally lived and argued moral viewpoint implicitly represents some measure of relativism – but its advantage is that its normativity is made transparent and that it does not parade as ‘the one and only truth’. Acknowledgements

Thanks to Heine Andersen, Mette Nordahl Svendsen and Signild Vallgårda for their generous comments on the manuscript. Notes 1 Parts of this chapter have previously been published in L. Koch, ‘The History of Eugenics and the Social Responsibility of Science’, in A. Blok and P. Gundelach (eds), The Elementary Forms of Sociological Knowledge: Essays in Honor of Margareta Bertilsson (Copenhagen: Institute of Sociology, 2014).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

The audiences of eugenics

105

2 L. Koch, ‘Fosterdiagnostik og risikotænkning’, in B. Rosenbeck and R. M. Schott (eds), Forplantning, køn og teknologi (København: Museum Tusculanums Forlag, 1995), pp. 90–105; L. Koch, ‘Individuel selvbestemmelse og statslig styring i den molekylære medicin’, in H. P. Hansen and P. Ramhøj (eds), Tværvidenskabelige perspektiver på sundhed og sygdom (København: Akademisk Forlag, 1996), pp. 131–146; L. Koch, ‘Two Decades of IVF: A Critical Appraisal’, in E. Hildt and D. Mieth (eds), In Vitro Fertilisation in the 1990’s: Towards a Medical, Social and Ethical Evaluation (Aldershot: Ashgate, 1998), pp. 19–28. 3 R. Koselleck, Futures Past: On the Semantics of Historical Time (New York: Columbia University Press, 2004), p. 38. 4 N. Rose, ‘Writing the History of the Present’, in J. Joseph (ed.), Social Theory: A Reader (Edinburgh: Edinburgh University Press, 2005), pp. 269–280. 5 V. Bush, Science – the Endless Frontier (Washington: Office of Scientific Research and Development, 1945; reprinted by the National Science Foundation, 1990). 6 P. Berg and M. F. Singer, ‘The Recombinant DNA Controversy: Twenty Years Later’, Proceedings of the National Academy of Sciences of the United States of America, 92:20 (1995), 9011–9013; C. Glerup and M. Horst, ‘Mapping “Social Responsibility” in Science’, Journal of Responsible Innovation, 1:1 (2014), 31–50. 7 M. Gibbons et al., The New Production of Knowledge: The Dynamics of Science and Research in Contemporary Societies (London: SAGE Publications, 1994); S. Steven, The Scientific Life: A Moral History of a Late Modern Vocation (Chicago: University of Chicago Press, 2008). 8 R. Kohler, Partners in Science: Foundations and Natural Scientists, 1900–1945 (Chicago: University of Chicago Press, 1991); L. Koch, Racehygiejne i Danmark 1920–56 (København: Gyldendal, 1996). 9 L. Koch, ‘En ny fremtid? Om bioteknologi, begrebshistorie og betydningstilskrivninger’, in U. Görman, C-G. Andrén and G. Hermerén (eds), Att forma vår framtid: Bioteknikens möjligheter och problem (Lund: Nordic Academic Press, 2007), pp. 46–55. 10 Koch, Racehygiejne i Danmark 1920–56, p. 142. 11 Ibid., p. 136. 12 R. Griffin, Modernism and Fascism (London: Palgrave Macmillan, 2007). 13 Koch, Racehygiejne i Danmark 1920–56, p. 150. 14 Danish original: Mødrehjælpen. 15 S. Jasanoff, States of Knowledge: The Co-production of Science and the Social Order (London: Routledge, 2004). 16 L. Koch, Tvangssterilisation i Danmark 1929–67 (København: Gyldendal, 2000).

106

Communicating the history of medicine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

17 It should be noted, though, that the relationship between these factors is not wholly understood. 18 Horst and Glerup, ‘Mapping “Social Responsibility” in Science’, 31–50. 19 Koch, Tvangssterilisation i Danmark 1929–67. 20 Koch, Racehygiejne i Danmark 1920–56, pp. 74, 116–118.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

6

Striking a chord: physician-publics, citizen-audiences and a half-century of health-care debates in Canada Sasha Mullally and Greg Marchildon

In 2006, the Canadian Broadcasting Corporation (CBC) aired a madefor-television movie, Prairie Giant, celebrating the career of Tommy Douglas, a fiery and well-remembered political figure voted the ‘greatest Canadian’ in recent national polls. Douglas was the eloquent and charismatic leader of a socialist party, the Cooperative Commonwealth Federation (CCF), which came to power in the province of Saskatchewan in 1944. The bio-pic focuses on efforts over two decades to implement universal health coverage in Saskatchewan, which provided a template for the emergent national Medicare system. Douglas’ final efforts to ensure doctors’ services met with fierce resistance from organized medicine that culminated in a 23-day doctors’ strike in July 1962. This provides a dramatic turning point in Prairie Giant, depicting mass demonstrations organized by physician supporters, and death threats levied at Douglas and his cabinet. Because of this doctor-led backlash, Douglas is ousted from power on the eve of the work stoppage. But, in Prairie Giant, Douglas’ electoral defeat is quickly overshadowed by his government’s more potent political victory over the doctors. Douglas and the Saskatchewan CCF persevere by recruiting foreign-trained physicians to care for emergency services. His government faces down the physicians, depicted as increasingly intransigent and arrogant as the strike drags on, public support wavers and physicians’ legal actions fail in the courts. Finally, in a dramatic scene, Douglas wearily returns home after a long day of politicking to find his wife hanging up the phone.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

108

Communicating the history of medicine

‘We won!’ she says. ‘The doctors caved!’ Douglas sinks to his knees with relief. The scene closes at a post-strike celebration, where Douglas waltzes with his wife to the party anthem, ‘CCF to victory’.1 Canadians, when they participate in patriotic displays, tend to lean toward expressions of welfare-state nationalism. The CBC production Prairie Giant aired 50 years after the passage of the 1966 Medical Care Act, federal legislation enabling the keystone component of Canada’s universal health-insurance system, otherwise known as ‘Medicare’. Over time, the represented tactics of the College of Physicians and Surgeons of Saskatchewan, their ideological conflict with Tommy Douglas and their collective attempt to subvert Medicare has largely been accepted as historical fact, both by the general public and most professional historians and social scientists. On the Digital Archives of the CBC, the 1962 doctors’ strike accounts for half of the footage offered up on the ‘Birth of Medicare’.2 Many recent post-secondary textbooks on Canadian history single out the 1962 Saskatchewan doctors’ strike for special study, as it encapsulates key debates around health care in mid-century Canada.3 Most depictions, like Prairie Giant, paint the medical profession in a poor light. Although Canadians have seen their share of physician protest and strike activity in the twentieth century,4 the 1962 Saskatchewan doctors’ strike played a pivotal role in determining the terms of physician remuneration under Canada’s Medicare plan. Striking physicians feared that their clinical autonomy might be compromised under ‘socialized medicine’. It represents a push back from the forces of ‘medical liberalism’ against a social democratic moment in mid-century Canada; doctors ‘won’ the right to continue charging on a fee for service basis.5 On the other hand, Douglas’ government ‘won’ the larger battle to implement universal health care. In this chapter, we trace the debates about the meaning, purpose and origins of the 1962 doctors’ strike. We begin with commentators who weighed in while the ink was still drying on the Saskatoon agreement that brought the job action to an end, to present-day writers who continue to revisit the strike as a historical event. Accounts of those on the so-called ‘front lines’ of 1962 were generally highly polarized, and spoke to a highly polarized public. A rebellious decade, the 1960s created a moment when citizen rights were at the forefront of the national agenda.6 Dissent and upheaval among trade unionists, youth, and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

109

Quebecois and First Nations over this decade shook off the last vestiges of colonial British identity, but replaced it with a new identity that was uncertain and contingent.7 In a context where Canadian nationalism found new strength and took on a new shape around independence – cultural, political and economic – from the United States, embrace of a welfare state, albeit a limited and liberal version, supported the ethos of a new nationalist moment.8 By engaging with the theme of audiences for the history of medicine, this chapter highlights the prominent role of a very few physicians in the shaping of debates about Medicare’s early history, ostensibly writing their books to convince the general public of their view, but very much with their own profession in mind as their implicit audience within the medical profession. In the process, they attempted to establish or fortify two conflicting narratives on the ‘origins’ of universal health care in Canada. In her recent work on the sociology of the public sphere, Sonia Livingstone recognizes that the boundaries between the definition of ‘an audience’ and ‘a public’ are difficult to discern, and that ‘the civic mediates between public and private, or public and audience’.9 Physicians, for, against and on the fence were both participants in and witnesses to the 1962 strike. They constitute an audience for the political rhetoric offered up during and after the event. Additionally, a very few of their number engaged actively to shape the discourses of the strike, eventually targeting the wider Canadian citizenry as an audience for their ideas, elaborating on various positions in historical analyses and memoirs, but always keeping in clear view the members of their own profession, in particular aiming their work at the group that they considered their confrères, for anti-Medicare authors, the rank and file of the profession, for pro-Medicare medical authors, the academic elite of the profession. It is important to emphasize that these author-doctors formed a major exception to the rule. The vast majority of doctors never entered the debate as writers trying to shape the perspectives of their audience. By training and inclination, they were not writers and could not conceive of playing such an activist role. The vast majority – like the general public – were consumers of what others wrote, prepared to be persuaded but never to persuade through the medium of producing such long, sustained causal narratives. In considering the physician’s role in the public sphere, we argue that the 1962 doctors’ strike produced two contrasting histories that

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

110

Communicating the history of medicine

continued over the next half-century to compete for the sympathies of the wider national, Canadian audience. While initially sympathetic to the position of physicians, over time the Canadian audience evolved to be less receptive to anti-government, pro-doctor, pro-market messaging that animated Saskatchewan physicians during the strike action. The Canadian Medical Association, which had invested in public relations throughout the post-war decades,10 came to understand this fundamental premise and tried to advance its liberal agenda within the confines of the expressed principles and preferences of the wider general Canadian audience. The profession quickly realized that all stories advanced about Medicare had to be framed around the notion that health care was a fundamental right of Canadian citizenship, as the values of the liberal ‘baby-boom’ generation became the consensus attitude by the 1970s and 1980s.11 The popularity of the programme inclined the citizen audience (and many members of the physician-audience) to be more sympathetic to the aims of the programme, and adopt a proMedicare historical lens. Before that happened, the 1960s division was both ideological and occupational, with the voice of the medical profession split between an academic elite and a professional elite. The former described themselves as progressive physicians who not only favoured collective financing of health care but major changes to the existing model of health service delivery. A minority, they occupied prominent positions in the public service or in academe, and some also had a background in general practice and community medicine. The latter comprised a professional elite who represented private practice, and held key positions in provincial and national medical associations. They supported private health insurance, but accepted state subsidy for the poor. Both the academic elite and the professional elite built their interpretive case about what the strike ‘meant’ for Saskatchewan, for Medicare and for the emerging system by making specific historical claims. The professional elite increasingly framed the strike a product of internal politics peculiar to Saskatchewan, whereas the academic elite emphasized external forces and influences from organized medicine and national party politics. The specific locality of Saskatchewan is a contested site for national health history, resonating into the twenty-first century. Adopting a chronological analysis of the formation and actions of this medical public, we offer a résumé of the strike and the Medicare

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

111

dispute, followed by a description of the emergence of a medical public as a result of the polarization of the early 1960s as reflected in televised debates, opinions pieces in newspapers and journals, as well as booklength treatments of the strike. From there, we trace the ongoing uses of historical narratives produced over the intervening decades by physicians and physician organizations. The doctors’ strike of 1962

The 1962 doctors’ strike occurred after over 15 years of CCF healthcare reforms, including implementation of a provincial-wide system of universal hospital coverage. During the 23-day strike, the CCF government had the support of a few doctor-academics whose collectivist ethos clashed with the majority of doctors who espoused medical liberalism. This majority opposed further incursions of the state into their ‘business’ because of a perceived threat to their financial and clinical autonomy, opposed any policy change that might alter the relationship between doctors and patients, including any infringement on doctorpatient confidentiality and freedom of clinician or patient ‘choice’. Neither should be mediated or regulated by the state.12 In contrast, the CCF cabinet emphasized collective rights, seeking a universal standard of financial protection against unexpected illness, and assured access to care. Conceding to the medical profession on clinical autonomy, and willing to compromise on professional autonomy and remuneration, Douglas and his cabinet colleagues were stymied by doctor intransigence on public payment. Professional elites’ anti-government rhetoric had been escalating since 1959 when Douglas first announced the plan to implement universal coverage for medical care (i.e. physician services).13 Professional elites in Saskatchewan had changed composition since the CCF first came to power. By the late 1950s, the College was under the control of young, urban specialists hostile to the idea of government-sponsored, universal coverage. Onethird of physicians were recent immigrants from Britain, and saw themselves as refugees from the National Health Service (NHS), and adamantly opposed any such system in Canada.14 The 1960 provincial election in Saskatchewan became a de facto referendum on Medicare.15 As the ‘front line’ in the battle against expanded government involvement in health care, organized medicine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

112

Communicating the history of medicine

in both Canada and the United States saw Saskatchewan as a bellwether; depending on what happened there, ‘socialized medicine’ might spread like a contagion through North America. Yet, when the CCF government was re-elected, Douglas felt he had a clear democratic mandate to proceed with the plan. As a nod to physician opposition, Douglas invited three representatives from the Saskatchewan College of Physicians and Surgeons (SCPS) to join an Advisory Planning Committee on Medicare to advise the Minister of Health and the government to implement details of the new plan. The three SCPS representatives delayed proceedings, worried that Douglas would insist on a universal government-sponsored plan, instead of their preferred scheme for needs-based private health insurance. Growing impatient, Douglas and his Minister of Health demanded a preliminary report, to mandate their moving forward. They received general (and favourable) recommendations from the Commission’s majority, but also a minority report from physician representatives, along with a representative of the business community, which, unsurprisingly, recommended a programme of targeted subsidies for private health insurance.16 In October 1961, within weeks of receiving both reports, the Douglas government introduced the Medical Care Insurance Act, based on the general recommendations of the Commission majority. Claiming bad faith, the SCPS rallied opposition. For weeks, Douglas led the debate on the bill in the Legislature, but left the province just before the bill’s passage to enter federal politics as first leader of the left-leaning New Democratic Party (NDP). The SCPS viewed his provincial replacement, Woodrow Lloyd, as weak. They even thought his government might fold when the provincial Minister of Health made a public departure from cabinet. This, and pressure from vocal anti-Medicare groups, encouraged provincial professional elites to push back. Lloyd’s government, on the other hand, thought doctors would acknowledge the CCF’s electoral mandate and seek compromise. To the surprise of the doctors, the government did not back down in the face of a provincewide doctors’ strike. And, to the surprise of the government, the doctors went through with it. Each side miscalculated the other. With a physician shortage, particularly in rural areas of Saskatchewan, physicians enjoyed a great deal of public support in the strike’s early days. Fearing the loss of health services, residents rallied around

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

113

well-organized Keep Our Doctors committees throughout Saskatchewan. But solidarity quickly weakened as emergency services outside of the city proved insufficient to care for the farming communities. The ethical quandary facing physicians during the work stoppage came into sharp focus when a sick infant from Yorkton died after the parents drove miles between three hospitals looking for medical care. A subsequent inquest found the baby suffered from fatal meningitis, but the incident drew criticism from across North America to the province’s striking doctors. Creating audiences and publics

The 1962 doctors’ strike came in the middle of a period of health-policy experimentation both inside and outside Saskatchewan, and as such has engaged historians’ attention since the 1980s. This historiography is dominated by public policy analyses, and is undeveloped insofar as social and cultural history is concerned. The interaction between the public and audiences over the 1962 strike illuminates the ways that cultural engagement through historical writing shaped debates about Medicare within the public sphere. For the focus, especially for physician writers, is almost always on the origins of the system, and interpretations of the strike. Thus, while historians and social scientists have examined the ways that physicians have attempted to influence individual and collective behaviours to advance public health and hygiene initiatives,17 we turn our attention from the ways physicians ‘produced health’ to how they attempted to ‘produce health policy’. In so doing we take up Livingstone and Lunt’s call to ‘engage theoretically, empirically and critically with the national and international management of powerful media and communications institutions and processes’.18 While our analysis does not evaluate media regulatory regimes, we do see physician involvement in debates about the 1962 strike as an attempt at regulation; the professional and the academic elites within medicine certainly attempted to shape the discourses surrounding the strike action, and hence its meanings for various audiences concerned with broader debates around health-care provision in Canada. The marriage of cultural history and policy analyses might seem like an odd pairing, but the media processes whereby physicians engage is of interest,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

114

Communicating the history of medicine

including how they framed and reframed the strike from different authors’ points of view. This divided ‘medical public’ displayed all the characteristics of a diverse, deliberative body, where individual members actively contest the meanings of the job action. Intellectual elites and professional elites on either side of this debate use professional media venues and academic publishing as ‘powerful communication institutions’, in an overt attempt to shape policy through audience engagement. All deliberation in the public sphere claimed to advance the public good, but some advanced the social, political and economic position of physicians, while others advanced the intellectual and political power of an academic ‘progressive’ group within medicine. This reflects the work of Nancy Fraser, who describes the public sphere as a site where such contestations are always an attempt at grasping power.19 And, as Richard Butsch observes, ‘as soon as we accept contestation, power and interests as legitimate in the public sphere, collective actions intended to register opinion with the state, in addition to deliberation, fall into the purview of the public sphere’.20 The doctors’ strike of 1962 garnered some rational deliberation, but also emotional engagement and counterengagement over the 50 years that followed. The contestation within the ‘public sphere’ of 1960s Saskatchewan unfolded in many venues. There were open meetings of the medical profession in the lead up to and during the strike action. There were protests, wherein physicians enjoyed the public support of the antiMedicare Keep Our Doctors (KOD) committee. There were televised debates. There were letters written to the editors of newspapers, and editorials in medical journals. But the media in which physicians most engaged in the long term was print publishing through historically focused monographs, most of these first-person accounts. All of this created a civic culture engaging the medical public, and their chosen audiences (other physicians, Canadian citizens, but particularly residents of Saskatchewan) were heavily informed by, and employed, historical contexts and arguments. These venues offered narrative accounts that delivered linear arguments. In addition, the line between audience and public is difficult to draw, and should be recognized as overlapping categories.21 It seems clear that the academic elite tried to reach out to practising physicians in Saskatchewan as a potential audience for their work; yet such practitioners were not passive recipients of these

Striking a chord

115

messages, evolving quickly into an engaged, fully constituted public by the time the strike broke out.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Fighting words: physicians and citizen audiences for the doctors’ strike

The 1962 strike situation in Saskatchewan attracted intense interest from the medical profession in North America, the Commonwealth and Europe.22 It unleashed a storm of media attention, both inside and outside Saskatchewan. Local and Canadian physicians tried to seize control of the public discourse by staging local media events and debates. Dr Efstathios ‘Staff ’ William Barootes emerged as a local spokesperson for the physicians’ position. A well-known specialist in Regina, Barootes was a popular professional, especially among new and junior physicians.23 President of the Saskatchewan Medical Association, he also served as Vice President of the provincial College of Physicians and Surgeons. Later on in his career, he would sit on the Medical Council of Canada over 1972–1973, serve as Treasurer of the Canadian Medical Association (CMA) and, briefly, as its deputy-President, earning him a Medal of Service. A strong supporter of the Progressive Conservative Party, he was appointed to the Canadian Senate in 1984, holding the seat until 1993.24 Barootes was a quintessential example of the provincial and national professional elite. Barootes’ method of public engagement was, initially, direct and argumentative. He openly critiqued Tommy Douglas in a 1960 television debate on the merits of government-sponsored prepaid health care.25 In the lead up to the strike, Barootes also took on Douglas’ successor, Premier Lloyd, in another televised debate on how best to organize an ethical health system. During one particularly dry discussion of policy by the earnest but uncharismatic Lloyd, Barootes turned to soberly address the camera, and stated, with great emotion, how ‘you cannot order charity, you cannot order mercy, you cannot order good motives and good feeling toward your fellow man’. He swayed the public by observing how ‘sometimes by legislative order or decree you can destroy the best of human motives in good citizens. Quality of mercy should be enhanced and not destroyed by plotters and planners of government’.26 Most commentators agreed that Barootes dominated the anti-Medicare forces by his ability to insert a picture of ‘plotters and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

116

Communicating the history of medicine

planners’ undermining the ‘best of human motives’ that lay at the foundation of an idealized doctor-patient relationship. Such imagery, drawing upon people’s attachment to their physicians, created an early atmosphere of support for the striking physicians of Saskatchewan. According to almost all accounts of the strike, most physicians got behind Barootes and the rest of their professional elite, well prepared and organized in the strike’s early days. Coordinating their public messaging, the SCPS established five committees to reach out to community organizations, other members of the profession, and the local and national media. They created a separate group to troubleshoot the government’s arguments and a final committee to take on ‘special projects’ as they arose.27 While most physicians simply ‘took holidays’ in protest against the Medical Care Act, the professional elite mobilized to cover off all communications and manage messaging during the strike.28 Knowing that they could rely on the support of the provincial print media, the SCPS was unprepared for some of the criticism from across Canada and internationally. This criticism highlighted the intrinsic difficulties their job action posed for the province’s physicians. While Saskatchewan physicians refused to use the word ‘strike’, most commentators did not hesitate to use the term ‘withdrawal of services’.29 For instance, the editors of The Lancet and the British Medical Journal described the doctors’ strike as ‘unethical’.30 This assertion stung, prompting responses from local and national physician organizations, but gave the government an unanticipated advantage.31 Within Canada, provincial and federal medical associations quickly weighed in on the ethics of the strike action. Arthur D. Kelly, CMA secretary, delivered ‘One Man’s View’ on the strike to the Canada Club of Toronto.32 Kelly’s analysis highlights three sensitive points about the conduct of the doctors raised by some in the media. He took umbrage with the charge that the physicians were engaging in ‘illegal action’ by withdrawing services from the public: ‘The medical profession of this country has a long and proud record of cooperation with governments of every stripe of advancing improvements in the health services for our fellow citizens’, and he argued that ‘it is the right of all professionals to choose to work when and where they will’.33 Strategically avoiding the term ‘strike’,34 he instead made liberal use of war metaphors to frame the strike as a clash of ideologies. Saskatchewan became an ‘embattled province’ during the work stoppage, ending with an ‘uneasy truce’,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

117

brokered 23 days later.35 By characterizing the strike as a revolution, Kelly attempted to counter claims that the work stoppage was unethical. He described how well the ‘Emergency Medical Services’, staffed by 200 physician volunteers at 40 regional hospitals, functioned. If this was a ‘war’, then, according to Kelly, it was one limited to the government and physicians, with no intended patient casualties.36 While physicians were the first to weigh in on the strike, other voices soon followed. Senior public officials, journalists and physicians – most ‘on the ground’ during physicians’ collective withdrawal of services – began to shape public understandings of what the strike meant, both in terms of what role physicians crafted and negotiated for themselves in the early, malleable days of Medicare. The historical record has tended to privilege the participant narrative as the principle sources of information about the strike; only a limited secondary scholarly literature has emerged to analyse the strike in a detached, analytical fashion. Firstperson accounts shaped the narrative about heroes and villains, winners and losers, of the strike, including those in Prairie Giant. The importance of being historical

Arthur D. Kelly, the embattled secretary of the CMA, was among the first to plea for a consideration of context – the ‘background of politics and government’ – when assessing physicians’ decision to strike. In a lengthy treatment of the strike in the Canadian Medical Association Journal, he pointed out the long history of professional and governmental cooperation, highlighting how the medical profession has often ‘cooperated’ with the populist, socialist and other left-leaning administrations of Saskatchewan ‘in the promotion of measures for the improvement of the public health […] and for the provision of health insurance’.37 This included a regionally operated plan of rural medical services insurance centred in the Swift Current farming region of southwestern Saskatchewan.38 He framed the 1962 dispute between the SCPS and the CCF government as a historical break, one that, according to Kelly, was precipitated by the government, who had in the past shown a willingness to work as equal partners with health professionals in designing and administering health services. Accordingly, problems only arose because of the ambitions of Douglas, and his CCF government, desperate to leave a policy mark.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

118

Communicating the history of medicine

Kelly’s article was also the first of many attempts to use historical narratives to understand the strike, positioning striking doctors either in line with or as breaking tradition with cooperative communitarianism of Saskatchewan’s rural communities. Historical linkages to past programmes of service were seen as successes in contrast to the flawed programme of universal medical care coverage.39 Historical referents became entire narratives, increasingly used to frame the more lengthy and engaged book-length studies that emerged in the late 1960s and early 1970s. Two professors in the Department of Social and Preventive Medicine at the University of Saskatchewan, Robin Badgley and Sam Wolfe, produced the first such study in 1967 from the perspective of the academic elite who largely sided with Douglas. With the provocative title Doctors’ Strike, the book pulled no punches; the action undertaken by Saskatchewan’s doctors was, indeed, not merely a ‘withdrawal of services’ or just a mass holiday-taking, but a labour strike undertaken to prevent the government from introducing universal medical coverage. Badgley and Wolfe acknowledge that Saskatchewan physicians were not historically opposed to prepaid public health insurance, though many were opposed to a universal, tax-funded scheme and even more opposed to any change in health service delivery. They discuss organized medicine’s opposition to the community clinic movement in Saskatchewan, a movement thought to threaten the physician-patient relationship and, through group-based practice, change the dominant independent practice model. Both physicians, especially Wolfe, were actively involved in developing such community clinics, which were governed by boards including community members as well health practitioners. Taking the long view, Badgley and Wolfe looked back to 1939, when physicians successfully boycotted a new public cooperative medical-insurance programme. This, they pointed out, was part of a growing ‘entrepreneurial identity’ for the physicians living in the prairie province, and a growing inclination to be influenced by the national organization, the CMA. The boycott and the ‘entrepreneurial’ position reflected the orientation of organized medicine in Canada, which were increasingly critical of any framework of care where physicians were asked to share power with either the state or citizens. The CMA, for its part, favoured subsidized, but physician-run, health-insurance schemes.40 Observing this trend, Badgley and Wolfe note how such schemes served the interests

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

119

of urban specialists, who tended to be at the forefront of the move toward private, physician-run health-insurance schemes. Communityrun health clinics were fine, and often enjoyed physician endorsement, but only if they remained in rural areas. Badgley and Wolfe had long studied community health policy or worked in the field. Wolfe, though Toronto-born, came as a young physician to Saskatchewan to practise family medicine in Porcupine Plain, an agrarian municipality just east of Saskatoon, founded in the 1920s by veterans returning from the First World War.41 Badgley was the son of a physician, but trained in health policy.42 Both men were ideologically left-leaning and academically inclined. Wolfe received a doctorate in Public Health from Columbia University in 1961, attending on a Rockefeller Scholarship. Badgley earned his MA at McGill and doctorate at Yale, and would later move on to the Milbank Foundation to study health human resources in the global south, eventually becoming a professor of public health at the University of Toronto.43 Wolfe had the ear of Douglas and the CCF government and was actively engaged in brokering the Saskatoon Agreement. He was also one of two physicians on the Medical Care Insurance Commission established by the CCF government to implement their medical care bill.44 It was his idea to use strike-breaking physicians from the UK in the event of a withdrawal of services,45 an event that played a key role in bringing the conflict to an end.46 The positions Badgley and Wolfe iterated in Doctors’ Strike reflected political ideologies they developed in the years leading up to the conflict, and which they carried through for the rest of their careers. They were fierce proponents in favour of changing the delivery of medical care, especially primary care. For approximately a decade after the 1962 strike, both physicians dedicated a good portion of their professional time and energy to establishing and managing group medical practices based on cooperative principles, trying to keep the community health clinic movement alive in Saskatchewan.47 Wolfe’s motivation to write was fuelled in part by his concern for the future of such clinics in the province.48 According to one biography, he took pleasure in realizing the extent to which the presence of the community clinic irritated former striking physicians, ‘enjoying the defence against the harassment of the Clinic by the medical establishment’.49 The Saskatoon Community Clinic would be one of a handful of group practices to survive in

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

120

Communicating the history of medicine

the province in the aftermath of the strike.50 In fact, Badgley and Wolfe argue it survived because of the backlash from the professional elites in the province, stiffening the resolve of clinic physicians and underscoring the need to preserve such models of community care. Both Wolfe and Badgley should be seen as actively engaged members of a medical public in Canada, part of an academic elite who shaped an alternative historical narrative to one crafted by Kelly, and the CMA. But they would not have the last word on the matter. The rendition of events offered up of Doctors’ Strike did not go unnoticed by the professional elite, in Saskatchewan or nationally. Indeed, to mark the conflict’s 10th anniversary, the CMA sponsored a history published in serialized form in the pages of the Canadian Medical Association Journal (CMAJ), a series of articles that appeared over 1972. One year later, the material was compiled by the communications department of the CMA in book form.51 The author, Ken MacTaggart, was a journalist, and covered the 1962 strike as a staff reporter with the Toronto Telegram.52 However, in this case he stands in as the voice of the professional elite in a response to Badgley and Wolfe, whom he cites at length throughout his series. A vocal supporter of the Saskatchewan physicians during the lead up to and over the course of the strike action, the self-described ‘science writer’ and his CMA-endorsed rendition offers a version of events approved and advanced by the professional elite in Saskatchewan and their national counterparts. MacTaggart situates Saskatchewan history in a romanticized agrarian past, and a pioneer narrative. ‘Nowhere else in Canada’, he writes, ‘had there developed such a background of pioneering spirit both in the population and that population’s physicians, with the warmth of relationships and the joint sharing of joys and trials that such an environment generates’.53 Immigrants described as ‘sturdy seekers’ from the UK, Scandinavia and the Balkans, among other regions, took to farming and shaped the agrarian communities of the province in an environment that required them to be ‘solidly self-dependent’. MacTaggart wrote in great detail about physician-government collaborative programmes for tuberculosis, cancer and mental health care, as well as the municipal doctor plans that stretch back as early as 1919.54 Such initiatives, he explained, were limited to rural areas of Saskatchewan for ‘natural’ economic and community development. He noted the growth of group practices and physician-sponsored insurance schemes in the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

121

major towns and cities of the province took off at around the same time. While at the time the municipal doctor schemes were an ‘important accomplishment’, compared with medical services available to people in Saskatchewan in the early 1960s, ‘they would appear today as barely more than adequate’. He implied that modern city-dwellers would not tolerate second-class care, and a natural transition whereby rural residents were ‘pulled’ into the orbit of the more elaborate group practices in larger towns was underway in Saskatchewan by mid-century. Counter to this were the social democratic traditions of the country. The seeds of social reform were sown in the dustbowl conditions of the 1930s. And MacTaggart is careful to echo Kelly, whom he quotes at length, and reiterates the ways the medical profession cooperated with the government, meeting regularly with Premier Douglas and with the officials of the Department of Health.55 Also like Kelley, MacTaggart emphasizes how the provincial College did not oppose the earlier efforts of the CCF government to widen health-care access in the postwar years after the election of the CCF. In his rendition, the College even recommended implementing a hospital insurance plan two years before the government brought forth its own universal plan in 1947.56 Accordingly, the break between the profession and the government only came when the administration of the system threatened to exclude the medical elite from decision-making in the design and maintenance of medical-care insurance – glossing over the widening gulf that separated the two beginning in the 1950s.57 MacTaggart takes pains to present CCF health policy in what he considers a neutral light. While he notes that organized medicine in the province was critical of the operation of the community clinic at Swift Current, he admits that, generally, ‘the physicians in the regional plan were among the best paid in the province’.58 He also acknowledges the pressure and scrutiny under which Douglas and his CCF government operated. ‘[B]ecause the government was known and accepted as the first socialist administration in the country’, he writes, ‘what the government said and did was noted carefully by everyone, whether the listener was a supporter or a critic of socialism’.59 Public criticism and feedback swung between two extremes in mid-century Saskatchewan politics: ‘even minor government achievements were hailed as triumphs, and government failures were considered catastrophes’.60 While the municipal doctor plan worked to supply health services, it did not ensure

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

122

Communicating the history of medicine

continuity of care with the same practitioner. While this did not undermine the system per se, he notes how this programme changed the complement of physicians in the province in the lead up to the strike. High turnover meant that the health service complement in Saskatchewan, particularly in rural areas, was very young and mobile. Additionally, the influx of physicians escaping the NHS in Britain altered the rhetoric and dominant ideology within the SCPS away from support, no matter how tepid, of compulsory health-insurance schemes.61 And it marked and emphasized a break with the agrarian communitarian approach to health-service provision. While responsible for innovation in service provision under conditions of scarcity, in MacTaggart’s historical framework, the legacy of the dustbowl endured by the descendants of those ‘sturdy immigrants’ fosters an independence of spirit in Saskatchewan that will not tolerate state interference in medical affairs. According to MacTaggart, the Commission’s pledge to promote improvement in the quality of health care fell on deaf ears in the early days of the strike. How could it have ‘stir[red] joy and happy expectation in the hearts of the profession that had for more than a half century cared for thousands of patients through drought, crop failures and other periods of privation and shortages’.62 Thus, the edifices of a communitarian past become a hindrance for a province poised to enter a new era and create a new improved and sophisticated health-care system envisioned by the professional elites within Saskatchewan. Striking physicians were striking for the future; while the government and the academic elite at the University of Saskatchewan were mired in the past. Doctors check up on interpretations of Medicare

More than a decade would pass before the strike would see additional and renewed historical attention. By the 1980s, the Canadian citizen audience was not polarized on the issue of health care as in the 1960s, and a consensus had emerged about the need for, and value of, a universal public system. This is reflected in historical retrospectives at midcentury of the programme’s early years, where a new generation of writers interpreted early opposition to Medicare, including the doctors’ strike, as a narrative foil that reinforced audiences’ positive orientation to public health care. C. David Naylor, a medical doctor and scholar holding an Oxford PhD in social and administrative studies, renewed

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

123

interest in the topic with his well-received book, Private Practice, Public Payment, an examination of organized medicine’s rise to power in twentieth-century Canada. A celebrated member of Canada’s universitybased academic medical elite, Naylor’s message was similar to the narrative line taken by Badgley and Wolfe. Like them, he looked back to the inter-war and post-war period to place physician opposition to universal Medicare within a larger context. The 1962 strike was an important event in this longer history of professional political empowerment, with their success imposing collective will and vision onto health policy and health programmes, both within individual provinces and nationally. The Saskatchewan College of Physicians and Surgeons’ strike activities fitted within a lineage of activists attempting to advance liberal medicine, which is one reason, Naylor argued, that they were more influenced by political events outside Saskatchewan than previous writers cared to admit. Calling attention to how the SCPS deployed the rhetoric of ‘free enterprise’, which they juxtaposed against a spectre of ‘state-control’, Naylor shows how the College positioned itself very closely along the ideological spectrum to the physicians of British Columbia who resisted a similar plan a quarter of a century earlier.63 For Naylor, the SCPS critique of the universality principle reflects previous positions the organization took in 1940, a year when the federal government of Canada first considered sponsoring a health-care insurance scheme. Naylor writes, ‘As had been the case in Ottawa in the 1940s, something of a political tug of war took place with labour and agriculture pulling against the medical profession’.64 Taking issue with the depictions of ‘medical cooperation’ by writers like MacTaggart and Kelley, Naylor instead argues that organized medicine actively tried to manage federal and provincial governments intent on expanding state-sponsored health care. ‘It is perhaps best to view organized medicine as pursuing a loss-minimizing strategy between 1941 and 1944’, he argues.65 Like Badgley and Wolfe, Naylor recognizes a growing schism between rural and urban health-care providers as the century wore on, as well as during the strike. Acknowledging that a majority of physicians participated in the strike, he also noted how many began ‘trickling back to work’ a few weeks later.66 This might have been because a group called the Community Health Services Association (CHSA), comprised of representatives from labour and farm groups in association with CCF supporters, began

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

124

Communicating the history of medicine

advocating for community clinics as early as the first week of the strike. At the close of the conflict, five clinics operated round the clock, with plans in place for ten more should the strike drag on. Motivated by ‘a disenchantment’ with the job action, the clinics ‘provided premises where physicians willing to serve under the terms of the Medical Care Insurance Act as well as work in salaried group practices’.67 By adopting a national framework of analysis as he charts Medicare’s history, he is able to bring regional differences to the fore. There was a traditional split in the medical profession in eastern and western Canada before mid-century. Western provinces, with their dominant rural populations, were less hostile to state-sponsored health programmes overall. This would explain why a national agenda against compulsory health insurance seemed so contested in 1960s Saskatchewan.68 Over the long arc of health-policy history, the 1962 strike was a ‘crucible’ for shaping the system, and the reputation of organized medicine. The strike, he argued, ‘redounded to the profession’s discredit’ and proved to be a public relations disaster for organized medicine.69 Revisiting the strike in the twenty-first century

Naylor’s book was the definitive Medicare history for two decades and his take on the strike became canon. The academic elite seems to have successfully advanced a dominant narrative, a version of events sympathetic to social democratic politics and policies in line with those held by the public as well as most members of the profession in the 1980s and 1990s, who benefitted financially from the combination of private practice supported from the public purse. Some of the weaknesses of this uniquely Canadian policy combination began to challenge the system in the 1990s as health-system costs – first noticeable by the mid-1970s – began to escalate. This provided a revisionist moment for some doctors interested in challenging this orthodoxy, with new attacks on the design and operating principles of Medicare.70 At this moment, a Saskatchewan-based clinician-historian, C. Stuart Houston, offered a slightly revisionist view with Steps on the Road to Medicare: Why Saskatchewan Led the Way. Like Naylor, his contribution did not focus exclusively on the physicians’ 1962 strike; as his title suggests, there is an overarching triumphalism to his history, wherein

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

125

Houston not only celebrates the outcome of the 1962 conflicts, but writes physicians back into the narrative as policy innovators rather than reactionaries. Houston features research scientists, public health specialists and health bureaucrats, placing them on equal footing with Tommy Douglas as medical system pioneers and architects.71 As leaders, such physicians benefitted from the particular social and cultural history of Saskatchewan, which possessed a ‘unique community spirit’ that inspired universal health care. They were ‘[s]urvivors of the depression, severe drought, and dust storms (the “Dirty Thirties”)’. In contrast to several previous writers, but especially Naylor, Houston embraces the ‘great man’ view of history as part of a larger project to put physicians back into the centre of Medicare’s history. His book also underscores the importance of historical thinking and the usefulness of historical memory when developing good health systems and health policy: ‘Moving forward Medicare may ask, at each level, to learn from our history. Can we emulate the cooperative spirit, altruism, and ingenuity of the Saskatchewan pioneers?’.72 Houston’s narrative also expresses a sort of Saskatchewan exceptionalism when he lays emphasis on the hardscrabble, agrarian context that encouraged mutuality within communities. Indeed, for Houston, ‘the co-operative spirit of the predominantly rural Saskatchewan people, most of them immigrants from Europe, had been developed to a higher and more practical degree than in any other jurisdiction in North America’.73 In addition to this exceptionalism, Houston often essentializes rural values to offer additional insight into the ‘natural’ evolution of Medicare in the prairie province. He remarks, for instance, on how farm women easily supported such schemes because such citizens placed a high premium on health care for their families.74 ‘From a historical perspective’, he writes, ‘one can look back over the Saskatchewan events chronicled in this book and at least dream about returning to our roots. At the local level, think of the grassroots empowerment felt by the pioneers whose municipal taxes paid for innovative municipal doctors […]’.75 The approach is informed by filial pride; his father, C. J. Houston, featured in the book, was a senior member of the Saskatchewan profession when the strike broke out. The elder Houston was a senior but less visible member of the professional elite, and represents a mediator

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

126

Communicating the history of medicine

demographic within the professional elite active during the work stoppage. Steps on the Road to Medicare provides evidence of a generational divide in 1960s Saskatchewan medicine; those physicians who had worked with Douglas and his government on previous initiatives approached the negotiations in the 1960s with a greater degree of trust than others. For instance, the elder Houston had, according to his son, tabled a plan for compulsory, universal public health insurance in the 1943 meeting of the provincial College (even though he, along with his other College colleagues, opposed the provincial government’s universal medical care coverage plan in the early 1960s). Years later, as a practitioner from the north-eastern district of the province, C. J. Houston and his colleagues recommended a government-sponsored programme for comprehensive medical care to the SCPS. Although, as the younger Houston is careful to add, this programme was designed to be ‘free of political control’, it suggests a certain sympathy for universal health insurance among rural-based Saskatchewan physicians of a certain generation, acknowledging that the rural community clinics, when properly policed, worked well for both rural populations and physicians.76 Indeed, Steps on the Road to Medicare reflects Naylor’s observations about an emerging rural-urban split within the professional orientation to Medicare. At one point, Houston writes how ‘The Region’s doctors were aware that specialists in Regina and Saskatoon looked askance at this [Swift Current] experiment in “socialized medicine”’. He remarks how Swift Current doctors felt like ‘black sheep’ within the profession.77 He even goes so far as to recognize, towards the end, how rural physicians surveyed in Saskatchewan in 1941 expressed doubts about the viability of the private practice medical model in the future of the province.78 While not chronicling strike events directly, the 1962 conflict arose from a political situation in the province that Houston describes as ‘emotional and polarized’. The author dismisses the strike as unrepresentative of the profession’s role in health-care history. In fact, he implies that some physicians who wished to remain in service and remain neutral felt they had to comply with the work stoppage.79 It supports the observation made by others that the strike failed first in rural areas of the province. Indeed, the character and complement of Saskatchewan rural medicine was changing swiftly over mid-century. The 1948 Hospital Services Act created opportunities for work in the expanding community

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

127

hospital network of the province. While the medical school underwent expansion, many newly minted, foreign-trained physicians arrived to service communities throughout the province over this decade. These physicians played a role in shaping the public orientation of medicine in the province, and constituted a new public voice within the profession. These appeared to have acted as a counterpoint to the mediated position of elder physicians like C. J. Houston. While marginalized in public debates for most of their careers, by the 2000s, such positions found Canadian citizen audiences newly receptive to their position. As the twenty-first century unfolded, a new polarization about Medicare was beginning to emerge among the Canadian public, fuelled by dissatisfaction with health-care service access, a result of funding cuts in the early to mid-1990s. This change was a remarkable shift. Canadians’ faith in a universally accessible welfare state, dominant for two decades, was remarkably resilient. It weathered the panic over spiralling cost containment in the 1970s.80 And it largely survived the conservative turn in the 1980s, and the neo-liberal turn of the 1990s.81 More recent memoirs from doctors like Noel Doig, a British physician who came to Saskatchewan in 1958 from Essex, suddenly emerged in the public domain.82 These new critical accounts were offered as an attempt to ‘set the record straight’ on the physicians’ strike for twenty-first-century readers far removed from the event. Doig is aware of the blemish the strike left on the public face of organized medicine; the publication of his memoir is timed to coincide with its 50th anniversary. Unlike Houston, Doig does not identify as a ‘historian’ to this event, nor does he claim impartiality. Instead, his memoir is offered as a counterpoint to the rendition emerging from popularized histories of the event like Prairie Giant. He came to Canada largely as a consequence of his frustration with the NHS and writes as a member of the profession with important ties to the contemporary professional elite. He volunteered to work with the SCPS during the strike and was part of a three-member College delegation to the UK to present the College’s message to the media and to British doctors in the midst of the doctors’ strike.83 His book follows the tradition of fiery revisionism established by Arthur Kelly as early as 1963 and continued by MacTaggart in 1972. Setting the Record Straight is an unapologetic, root-and-branch attack on Medicare and the conduct of the Douglas-Lloyd government over 1960–1962. Unlike Naylor and Houston, there is little space and short

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

128

Communicating the history of medicine

shrift for the government side of the fateful negotiations. Indeed, he assumes most negotiators, especially Tommy Douglas, were insincere in their efforts and had intended to mislead the medical profession from the beginning. Indeed, Doig views Medicare as an effort to introduce NHS-style socialized medicine to Canada, though most recognize major differences in terms of organization and delivery. Both Medicare and the NHS are described in disastrous terms, and Doig makes general calls for a return to private fee for service practice. For this writer, the striking physicians of 1962 were acting with foresight to protect the practice of quality medicine that was lost with the introduction of Medicare. The academic elite is a special target here, and Doig’s memoir offers important insight into ‘town and gown’ conflict that lingered in the years following 1962. He is particularly hostile to three ‘salaried doctors employed by the university’s College of Medicine at Saskatoon, who differed strongly from most of their colleagues’ and who took a proMedicare stance early on.84 For Doig, academic medicine created a false division in the profession, guilty of ‘rank treachery’ 85 against not only fellow physicians but also against Saskatchewan residents, a majority of whom, he argues, opposed the legislation.86 Doig is opposed throughout the book to the term ‘strike’. Quoting the SCPS President Dalgleish, he argues that ‘a strike was a work stoppage, and the doctors did not stop work but made provision for the care of their patients’.87 He supports this claim in an entire chapter to describing how the strikers’ Emergency Service operated.88 Doig refers to the need of ‘law-abiding citizens’ to ‘defy bad legislation and the tyranny of governments’, and offers up the English Civil War, the French Revolution, the American War of Independence and the collapse of the Soviet Union as his historical examples.89 Doig’s retrospective signals a shift back toward a form of heightened medical liberal rhetoric that readers have not been exposed to since the period of the strike itself. It is a reminder that medical liberalism as ideology can put the profession of medicine on a road where it perceives the withdrawal of crucial services as a justifiable act of civil disobedience. And his book suggests that the public sphere remains a site of contestation as far as the policy history of Canada’s more important piece of social welfare legislation is concerned.

Striking a chord

129

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Conclusion

By the turn of the twenty-first century, individual physicians, including members of provincial and national medical associations, seem to have largely made peace with their role in the dispute. Staff Barootes admitted in a 1995 interview that he and the rest of the College were wrong about the possibility of government interference in medical practice.90 ‘We were clumsy, awkward, we were highly rhetorical, we used all the antics of bad politicians: exaggeration, dire threats of what might happen.’ 91 Historical memory is contingent and interpretations of the debates surrounding early Medicare can be expected to change over time. Yet the publication record here suggests an unsated appetite for policy history among audiences who engage at both a personal and political level in the history of medicine in Canada. These, in turn, illuminate the ways history can be used to support political ideologies about health policy. History has been a tool used to engage physicians as an audience for, and a public politicized by, the dramatic events surrounding the famous 1962 doctors’ strike in Saskatchewan. Physicians saw many advantages to engaging in historical analyses, debating with each other with differing bystander accounts and insider memoirs. In this way, the writers also constituted audiences for such works, but only in part. Both professional and academic elites used historical accounts to debate the merits and shortcomings of universal health care, writing to engage each other but also writing with the intent to reach other stakeholder audiences – such as policy-makers and members of the general public – and either support or complicate the emerging twentieth-century consensus about Medicare’s benefits. By surveying key monographs brought to press over the past 50 years, we have shown how physicians, journalists and academics acting as historical chroniclers fell on two sides of a very public debate. From Arthur Kelly to Noel Doig, a medical professional elite depicts the strike as an example of civil disobedience against an untrustworthy dictatorial regime. These tend to pay attention to the local debates and contexts within mid-century Saskatchewan to justify acts of ‘civil disobedience’ that led to the physician ‘insurrection’ that followed. Academic elites from Sam Wolfe and Robin Badgley to C. David Naylor interrogate and question the economic motives of organized

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

130

Communicating the history of medicine

medicine in such debates. Most such writers tend to lay emphasis on external agencies and organizations as providing support for the physician work stoppage, seeing the events of Saskatchewan in 1962 as part of a larger ideological debate about equitable health-service access. These public debates elicited both historical revisionism and counterrevisionism. Over this evolution, we highlight the demographic and occupational differences between the two medical publics dominant in historical-health politics. But Canadian physicians who questioned the merits of Medicare did not merely debate the issues within the ranks of the profession. Their contestations within the public sphere vied for the attention of audiences, including other physicians and members of the general public. Here, the history of medicine has provided the playing field upon which an ongoing debate over Medicare in Canadian society has played out over the last 50 years. Those writers with the greatest impact seek not so much to close debate, but use history to engage a wide range of audiences about healthpolicy formation and to actively and continually question the historical record. Notes 1 Prairie Giant, dir. J. N. Smith and K. De Walt (Canadian Broadcasting Corporation [CBC], 2006). 2 ‘The Birth of Medicare’, Canadian Broadcasting Corporation [CBC] Digital Archives (Canadian Broadcasting Corporation, 2015). Available online at: http://www.cbc.ca/archives/topic/the-birth-of-medicare (accessed 17 June 2015). 3 M. Lux, ‘Constructing a Canadian Icon: The Medicare Debate in the 1960s’, Visions: The Canadian History Modules Project (Toronto: Nelson Education Publishing, n.d.). Available online at: http://www.visions. nelson.com/module28.html (accessed 17 June 2015). 4 No doctors’ strikes in Canada approached the intensity of the Saskatchewan strike. The first protested municipal governments’ weak support of legislated Depression-era health care for poor relief recipients. See C. D. Naylor, ‘Canada’s First Doctors’ Strike: Medical Relief in Winnipeg, 1932–34’, Canadian Historical Review, 67:2 (1986), 151–180. The second was the 1970 Quebec specialists’ strike on Quebec’s implementation of universal medical care coverage. See S. S. Lee, Quebec’s Health System: A Decade of Change, 1967–77 (Toronto: Institute of Public Administration

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

131

of Canada, 1979). Two work stoppages in Ontario and British Columbia during the 1980s protested against what the new Canada Health Act terms the practice of extra-billing: see H. M. Stevenson, A. P. Williams and E. Vayda, ‘Medical Politics and Canadian Medicare: Professional Response to the Canada Health Act’, Milbank Quarterly, 66:1 (1988), 65–104; R. L. Kravitz, M. F. Shapiro, L. S. Linn and E. S. Froelicher, ‘Risk Factors Associated with Participation in the Ontario, Canada Doctors’ Strike’, American Journal of Public Health, 79:9 (1989), 1227–1233. 5 For an elaboration of ‘medical liberalism’, see G. P. Marchildon and K. Schrijvers, ‘Physician Resistance and the Forging of Public Healthcare: A Comparative Analysis of the Doctors’ Strikes in Canada and Belgium in the 1960s’, Medical History, 55:2 (2011), 203–222. 6 The theme of human rights in Canada as a backdrop to the idea of the welfare state, and health care as part of Canada’s ‘rights culture’ is explored in D. Clement, Canada’s Rights Revolution: Social Movements and Social Change, 1937–1982 (Vancouver: University of British Columbia Press, 2008), especially pp. 34–36. 7 For a discussion of how the 1960s acted as a turning point for the struggle over Canadian identity, see B. Palmer, Canada’s 1960s: The Ironies of Identity in a Rebellious Era (Toronto: University of Toronto Press, 2009). 8 S. Azzi, ‘The Nationalist Moment in English Canada’, in D. Clement, L. Campbell and G. S. Kealey (eds), Debating Dissent: Canada and the Sixties (Toronto: University of Toronto Press, 2012), pp. 213–228. 9 S. Livingstone, ‘Introduction’, in S. Livingstone (ed.), Audiences and Publics: When Cultural Engagement Matters for the Public Sphere (Bristol: Intellect Books, 2005), p. 15. 10 M. G. Taylor, ‘The Role of the Medical Profession in the Formulation and Execution of Public Policy’, Canadian Public Administration, 26:1 (1960), p. 113. 11 For a social and cultural history of this generational impact, see D. Owram, Born at the Right Time: A History of the Baby Boom Generation (Toronto: University of Toronto Press, 1996). 12 Marchildon and Schrijvers, ‘Physician Resistance’, p. 204. 13 A. W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–61 (Toronto: University of Toronto Press), passim. Douglas radio broadcast on Medicare, 16 December 1959, R33.1–575a, T. C. Douglas fonds, Saskatchewan Archives Board (Regina). 14 See D. Wright and S. Mullally, ‘“Worse than Being Married”: The Exodus of British Doctors from the National Health Service to Canada, c. 1955–1975’, Journal of the History of Medicine and Allied Sciences, 65:4 (2010), 546–575.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

132

Communicating the history of medicine

15 A. M. Brien, ‘The 1960 Saskatchewan Provincial Election’ (unpublished MA thesis, University of Saskatchewan, 2004). 16 Advisory Planning Committee on Medical Care, Interim Report of the Advisory Planning Committee on Medical Care to the Government of Saskatchewan: September 1961 (Regina: Queen’s Printer, 1962). W. P. Thompson, Medical Care: Programs and Issues (Toronto: Clarke, Irwin, 1964). 17 See, for instance, V. Berridge and K. Loughlin (eds), Medicine, the Market and Mass Media: Producing Health in the Twentieth Century (London: Routledge, 2005). 18 S. Livingstone and P. Lunt, ‘The Implied Audience of Communications Policy Making: Regulating Media in the Interests of Citizens and Consumers’, in V. Nightingale (ed.), Handbook of Media Audiences (Malden: WileyBlackwell, 2011), p. 170. 19 N. Fraser, ‘Rethinking the Public Sphere: A Contribution to the Critique of Actually Existing Democracy’, in C. Calhoun (ed.), Habermas and the Public Sphere (Cambridge, MA: MIT Press, 1992), pp. 109–122. 20 R. Butsch, ‘Introduction: How are Media Public Spheres?’, in Butsch (ed.), Media and Public Spheres (London: Palgrave Macmillan, 2007), pp. 6–17. 21 S. Livingstone, ‘Introduction’, in Livingstone (ed.), Audiences and Publics, pp. 11–12. 22 Interested commentators spoke up in national, regional and international medical journals. For Canada, see B. E. Freamo, ‘The Saskatchewan Situation’, Canadian Medical Association Journal, 87 (7 July 1962), 41–44. A US sampling includes C. W. Baugh, ‘The Saskatchewan Story’, Journal of the Iowa State Medical Society, 53 (1963), 535–543 and L. R. Hegland, ‘The Death of Free Enterprise in Saskatchewan’, Rocky Mountain Medical Journal, 60 (March 1963), 33–35. See also varying degrees of professional sympathy expressed from Sweden to the UK to Australia: N. R. Blume, ‘[Trial of Strength in Saskatchewan]’, Svenska Läkartidningen, 59 (20 September 1962), 2719–2720; Editorial, ‘Saskatchewan’, British Medical Journal, 5297:2 (14 July 1962), 106–107; Editorial, ‘Private Practice in Saskatchewan’, British Medical Journal, 5298:2 (21 July 1962), 174–175. 23 ‘Deaths: E. W. “Staff ” Barootes’, Canadian Medical Association Journal, 163:6 (19 September 2000), p. 795. 24 C. S. Houston, ‘Barootes, Efstathios William, 1918–2000’, The Encyclopedia of Saskatchewan (Regina: University of Regina and the Canadian Plains Research Centre, 2015). Available online at: http://esask.uregina.ca/ entry/barootes_efstathios_william_1918-_2000.html (accessed 9 July 2015).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

133

25 ‘Opinions Unlimited,’ CKCK-TV (20 March 1960). See SAB R-B2871–1, Saskatchewan Provincial Archives, Regina, Saskatchewan. See also references to same in N. Doig, Setting the Record Straight: A Doctor’s Memoir of the 1962 Medicare Crisis (Saskatoon: Indie Ink Publishing, 2012), p. 25. 26 ‘The Pros and Cons of Medicare’, Close-up, with Tom Koch, CBC Television (22 July 1962). Available online at: http://www.cbc.ca/archives/ entry/the-pros-and-cons-of-medicare (accessed 9 July 2015). 27 K. MacTaggart, ‘The First Decade (V)’, Canadian Medical Association Journal, 107:4 (19 August 1972), 337–338. 28 Naylor, Private Practice, Public Payment, passim. 29 E. A. Tollefson, a Saskatchewan-born but Oxford-trained lawyer and professor at the University of Saskatoon, observed both the medical profession and organized labour objected to the term ‘strike’ in the context of the Medicare dispute. He used ‘feud’. E. A. Tollefson, Bitter Medicine: The Saskatchewan Medicare Feud (Saskatoon: Modern Press, 1963), pp. 110–111. 30 See A. E. Blakeney, ‘Press Coverage of the Medicare Dispute in Saskatchewan: I’, Queen’s Quarterly, 70 (1964), 356. For a recent discussion, see S. L. Thompson and J. W. Salmon, ‘Strikes by Physicians: A Historical Perspective Toward an Ethical Evaluation’, International Journal of Health Services, 36:2 (2006), 331–354. 31 Examples of opprobrium in the international press are captured in M. G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions that Created the Health Insurance System and their Outcomes (Montreal and Kingston: McGill-Queen’s University Press, 2009), pp. 307–314. 32 A. D. Kelly, ‘The Saskatchewan Situation: One Man’s View’, Canadian Medical Association Journal, 87 (24 November 1962), 1113–1118. It was delivered several months after the strike ended, but the debate was still fresh in the public discourse. 33 Kelly, ‘The Saskatchewan Situation’, p. 1118. 34 Kelly instead depicted the warnings from the provincial society threatened to cease all functioning of ‘private practices’. On another occasion, he makes oblique reference to how ‘private practice was discontinued’. Kelly, ‘The Saskatchewan Situation’, pp. 1114–1115. 35 Ibid., p. 1117. 36 Ibid., p. 1115. See also A. D. Kelly, ‘Saskatchewan Medical Care Insurance Scheme: Appraisal of Current Position’, British Medical Journal, 5374:1 (4 January 1964), 49–50. 37 Kelly, ‘The Saskatchewan Situation’, p. 1113. 38 Working with local doctors, the health authority, Kelly pointed out, ‘provided the only Canadian example of a plan applicable to 50,000 residents

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

134

Communicating the history of medicine

of the region and financed principally from local taxation’. Ibid. See also J. Feather, ‘From Concept to Reality: Formation of the Swift Current Health Region 16’, Prairie Forum, 16:1 (1991), 59–80; J. Feather, ‘Impact of the Swift Current Health Region: Experiment or Model?’, Prairie Forum, 16:2 (1991), 225–248. 39 Kelly, rather unironically, engaged in a lengthy debate on a municipal doctor system adopted in ancient Greece, countering historical interpretations of Henry Sigerist. See A. D. Kelly, ‘Instant History’, Canadian Medical Association Journal, 94:17 (23 April 1966), 910–913. 40 R. F. Badgley and S. Wolfe, Doctors’ Strike: Medical Care and Conflict in Saskatchewan (New York: Atherton Press/MacMillan of Canada, 1967). 41 See ‘History: Town of Porcupine Plain’, website. Available online at: http://porcupineplain.com/visitors/history/ (accessed 8 June 2015). 42 ‘Obituary, Dr. Robin F. Badgley, 1921–2011’, The Globe and Mail, Saturday, 28 April 2012. Available online at: http://v1.theglobeandmail.com/ servlet/story/Deaths.20120428.93292655/BDAStory/BDA/deaths (accessed 24 September 2015). 43 Ibid. 44 The other physician-appointee was Dr Orville K. Hjertaas, practising in Prince Albert at the time. Taylor, Health Insurance, p. 289. See also S. Houston and B. Waiser, The People Behind the Douglas Years (Calgary: Fifth House, 2010), pp. 60–65. 45 Wolfe had flown to London before the strike to interview physicians to work in Saskatchewan to fill the gap that might be left by striking doctors. Teams of specialists in New York, Los Angeles and Detroit were also on ‘standby’ should their services be required. Taylor, Health Insurance, p. 298. 46 The house where Wolfe lived in Saskatoon is marked with a plaque commemorating this role, highlighting his efforts to bring in over 90 Britishtrained physicians to offer services for the duration of the conflict. J. Bury and B. Bury, Saskatoon: The Birthplace of Medicare, A Walking Tour of Downtown Saskatoon (Saskatoon: Saskatoon Community Clinic, [pamphlet] n.d.), p. 2. See also J. Bury, ‘Sam Wolfe, 1923–93’, Saskatchewan Encyclopedia (Regina: University of Regina and Canadian Plains Research Centre, 2007). Available online at: http://esask.uregina.ca/entry/wolfe_ sam_1923–93.html (accessed 8 June 2015). 47 Wolfe resigned his position at the University of Saskatchewan in protest at the university’s inability or unwillingness to take on a leadership role in studying the terms and causes of the strike. With Badgley, he lamented an opportunity lost ‘to assess the impact of the legislation critically and scientifically’. See ‘1962: The College of Medicine and the “Doctors’ Strike”’, website, Events in the History of the University of Saskatchewan (University

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

135

of Saskatchewan Archives, n.d.) Available online at: http://scaa.usask.ca/ gallery/uofs_events/articles/1962.php (accessed 8 June 2015). Also see S. Rands, Privilege and Policy: A History of Community Clinics in Saskatchewan, Revised Edition, G. P. Marchildon and C. Levington-Reid (eds), (Regina: CPRC Press, 2012). 48 S. Wolfe, ‘Saskatchewan’s Community Clinics’, Canadian Medical Association Journal, 94 (1 August 1964), 225–229. 49 Bury, ‘Sam Wolfe, 1923–93’. 50 D. Gruending, The First Ten Years (Saskatoon: Community Health Services Association, 1974). Also see G. Lawson and L. Theriault, ‘Saskatchewan’s Community Health Service Associations’, and C. Leviten-Reid, ‘Afterword to the 2012 Edition: Co-operatives and Consumer Control of Health Care Services: A Look 50 Years Later’, in Rands, Privilege and Policy, pp. 107–137. 51 K. MacTaggart, The First Decade: The Story of the Birth of Canadian Medicare in Saskatchewan and its Development during the Following Ten Years (Ottawa: The Canadian Medical Association, 1973). 52 See Doig, Setting the Record Straight, p. 179. 53 K. MacTaggart, ‘The First Decade (I)’, Canadian Medical Association Journal, 106:11 (10 June 1972), 1235. 54 In 1960, there were apparently 126 such plans in operation, covering 210,000 Saskatchewan residents. MacTaggart, ‘The First Decade (I)’, p. 1237. 55 K. MacTaggart, ‘The First Decade (II)’, Canadian Medical Association Journal, 107:1 (8 July 1972), 71. 56 MacTaggart, ‘The First Decade (I)’, p. 1234. 57 Naylor, Private Practice, Public Payment, pp. 168–174. 58 K. MacTaggart, ‘The First Decade (III)’, Canadian Medical Association Journal, 107:2 (22 July 1972), 162. 59 Ibid., p. 161. 60 Ibid. 61 Ibid., pp. 159–164. 62 K. MacTaggart, ‘The First Decade (VII)’, Canadian Medical Association Journal, 107 (23 September 1972), 555. 63 Naylor, Private Practice, Public Payment, p. 192. 64 Ibid., pp. 192–193. 65 Also, the period witnesses a certain degree of ‘wartime collectivism’ that encourages consideration wage-earners inability to pay for hospital and diagnostic services. Ibid., p. 247. 66 Ibid., p. 208. 67 Ibid.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

136

Communicating the history of medicine

68 Additionally, the ‘success of the Swift Current Health Region, social assistance Medicare plan, and hospital services program had helped ease government-SCPS tensions’. Naylor, Private Practice, Public Payment, p. 177. 69 Naylor, Private Practice, Public Payment, p. 253. 70 One notable Toronto-based physician, D. Gratzer, penned a book attacking Canadian Medicare at the age of 24, winning the Donner Policy Prize. D. Gratzer, Code Blue: Reviving Canada’s Health Care System (Toronto: ECW Press, 1999). Gratzer also edited Better Medicine: Reforming Canada’s Health Care (Toronto: ECW Press, 2002), which brought together scholars critical of Medicare. 71 Other writers have taken a more critical view of the same leaders. See M. Lux, ‘Care for the “Racially Careless”: Indian Hospitals in the Canadian West, 1920–1950s’, Canadian Historical Review, 91:3 (2010), 407–434. 72 C. S. Houston, Steps on the Road to Medicare: Why Saskatchewan Led the Way (Montreal and Kingston: McGill Queen’s University Press, 2002), p. 129. 73 Ibid., p. 126. 74 Ibid., p. 125. 75 Ibid., p. 127. 76 Ibid., pp. 76, 80, 86–87. This is also part of MacTaggart’s narrative in ‘The First Decade (III)’, p. 159. See also Feather, ‘Impact of the Swift Current Health Region’. 77 Houston, Steps on the Road to Medicare, p. 84. 78 Ibid., p. 36. 79 Ibid., p. 87. 80 See observations by T. R. Marmor, W. L. Hoffman and T. C. Heagy, ‘National Health Insurance: Some Lessons from the Canadian Experience’, Policy Sciences, 6:4 (1975), 447–466. 81 R. Johnston et al., ‘National Identity and Support for the Welfare State’, Canadian Journal of Political Science, 43:2 ( June 2010), 349–377. Canada had no equivalent to the Reagan or Thatcher Conservative backlash. The Prime Minister of the era, Progressive Conservative Brian Mulroney, is largely seen as conciliatory toward leftist politics, and protective overall of Medicare. See, for instance, M. A. O’Neill, D. McGuinty and B. Teskey, ‘Canadian Political Science and Medicare: Six Decades of Inquiry’, Health Care Policy, 6:4 (2011), 49–61. 82 Doig, Setting the Record Straight. 83 Ibid., p. 210. His daughter, Anne Doig, served as President of the CMA in recent years. Although she avoids taking a position on Medicare, she writes a glowing afterword on her father. Ibid., p. 287.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Striking a chord

137

84 These are Dr Frank Coburn, professor of psychiatry; Dr Alexander Robertson, professor of social and preventive medicine; and Dr J. Wendell MacLeod, the dean of the College of Medicine. Doig, Setting the Record Straight, pp. 33, 35. For further information about Macleod, see L. Horlick, J. Wendell MacLeod: Saskatchewan’s Red Dean (Montreal: McGill-Queen’s University Press, 2007). 85 Doig, Setting the Record Straight, p. 36. 86 He claims far more Saskatchewanians opposed Medicare than supported it, using the 1962 election results as evidence. Doig, Setting the Record Straight, p. 148. 87 Ibid., p. 178. 88 Ibid., pp. 159–179. 89 Ibid., p. 189. 90 In a 1995 interview with Steven Lyons, a journalist working for the US Organization Physicians For A National Health Program, Dr Barootes said he would have rather ‘cut his own arm off ’ during the 1962 Doctors’ Strike than admit government control of health care would not interfere in patient-doctor relationships. ‘That was our big fear, that they would be telling us what to do […] So we were wrong on that and I admit that.’ S. A. Lyons, ‘The Birth of the Canadian Health Care System: An Interview with Canadian Urologist Dr. E. W. Staff Barootes’, PNHP Newsletter ( July 1996), 21–24. 91 Ibid.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

7

Mansions in the Orchard: architecture, asylum and community in twentieth-century mental health care Sarah Chaney and Jennifer Walke

The Mansions in the Orchard project, funded by a Wellcome Trust People Award for Public Engagement, ran from September 2013 to March 2015. On behalf of the Bethlem Museum of the Mind, the authors carried out new historical research and documentation, alongside public engagement activities. The project addressed the largely undocumented twentieth-century history of inpatient mental health care in Britain through the Bethlem Royal Hospital’s current site, opened in south London in 1930. We worked with Bethlem site users (staff and patients), local residents and London-based mental health service users to expand and interpret the Bethlem Royal Hospital Archive through new photography of the site and its users, a collection of oral history interviews and donations of photographs and archive material. This informed four exhibitions, numerous talks and events and a month-long series of activities at the Dragon Café, a service user creative space in Southwark. In this chapter we explore the value and relevance of a combined academic and public engagement approach – to the Museum of the Mind and its users as well as to the history of medicine more generally. First, we consider the value of public engagement in the history of psychiatry, through discussion of the longer tradition and benefits of service user involvement in mental health research and public engagement in a museum setting. We then move on to explore the specific outcomes of the Mansions in the Orchard project, as part of a new

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 139

museum space on the site of a working hospital. The project’s approach, we argue, presented a unique opportunity for mental health education and the reduction of stigma. These elements of the project informed our historical focus, resulting in a more inclusive history than in many institutional histories of psychiatry, focusing on the importance of space, place and architecture in twentieth-century psychiatry. Finally, we conclude by arguing that community engagement within a museum setting enriches the history of medicine as a discipline and vice versa. Importantly, a historical project in a mental health setting enables audiences to challenge established norms, encouraging critical thinking and combatting stigma. Mansions in context: museums and public engagement in the history of psychiatry

In the Mansions in the Orchard project, oral histories, collected from those who worked and lived onsite, were used alongside textual research and photographic documentation of the hospital architecture to explore lived experiences of twentieth-century mental health care. By incorporating the ideas and expertise of practitioners and service users throughout, the research generated a space for collaboration between academic historians, current and former hospital staff, patients and local residents. This encouraged diverse and candid firsthand testimony, and presented a vital counterpoint to the traditional privileging of academic or medical ‘expert’ opinion within psychiatric historiography. Richard Butsch has highlighted a historical dichotomy in audience depictions in this vein; namely, the assumption of an educated and civic-minded ideal, versus the ‘ill-informed, pleasure-seeking, suggestible crowds or mass’. Such a view has traditionally negated the roles of community and culture; factors that Butsch believes are now achieving greater recognition, through ‘negotiated readings […] based upon incongruities between preferred readings and personal experience’.1 Similarly, according to Alessandro Portelli, written and oral sources are not mutually exclusive.2 Nicole Baur has also proposed that an emphasis on meaning can help to penetrate official or accepted accounts, facilitating exploration of the recent past and shaping the future of mental health care through a patient-centred approach.3 Furthermore, David Russell suggests that personal testimony holds an

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

140

Communicating the history of medicine

‘intrinsic value in giving some flavour of the basic day-to-day care in past times, through provision of historically minute detail […] The immediacy of the oral report gives an extra dimension […] is often highly graphic, and can provoke in practitioners’ minds comparisons and contrasts with present-day care’.4 All these factors are acutely significant in research with historically and socially marginalized populations. Service user participation in research can take many forms, on a continuum from consultation, to collaboration, to co-production. The latter approach is here employed primarily for its democratizing value, including varied and often marginalized perspectives throughout the project lifecycle, which can generate rich and representative data. Here we understand co-production as a form of research created jointly by academic researchers, artists and service users, as part of a project in which there was considerable overlap between these groups, with the intention of equal representation. This is a subtly different emphasis from Sheila Jasanoff ’s definition of co-production as ‘an idiom – a way of interpreting and accounting for complex phenomena so as to avoid the strategic deletions and omissions of most other approaches in the social sciences’.5 While Jasanoff ’s view is supported by this project, through this research we aimed to ensure equal representation of diverse groups through overlap between roles. Parallels and differences exist between two major models of research, Patient and Public Involvement (PPI) and Public Engagement in Science (PES).6 The specific involvement of mental health service users in research preceded that of many other medical specialties in Britain, and foreshadowed the 1996 creation of the UK Department of Health’s ‘Consumers in NHS Research’ unit (later renamed INVOLVE), which promotes patient and public involvement in research.7 Two usercontrolled research projects, ‘Strategies for Living’ and ‘User Focused Monitoring’ began in London in the 1990s, whilst the 2001 inception of the Service User Research Enterprise (SURE) at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, marked the transition of user-led research into academia. This university department operates on the premise that service user researchers have the advantage of ‘insider knowledge’ about mental distress, treatments and services, in addition to conventional academic training and qualifications.8

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 141

In this chapter, we highlight the ‘different truths’ that emerge from co-production, which represent a contrast to accepted psychiatric wisdom and hierarchies of evidence. A range of organizations and individuals have become engaged in mental health service user or survivor research on a national and international scale.9 These have heterogeneous theoretical agendas, aims and methods, as Jasna Russo relates: ‘Service user’ (Europe) or ‘consumer’ (Australia, New Zealand and USA), on the one hand, and ‘survivor of psychiatry’, on the other, are expressions of two different perspectives on psychiatry: the first one focuses on reforming the existing system, while the second puts the entire psychiatric system in question, including the very premise of mental illness.10

Peter Beresford has also cautioned that ‘recent interest in service user knowledge is part of broader pressure [from funding bodies] to increase user involvement’.11 This can be understood, on the one hand, as evidence of ‘impact’ – enabling research to reach a wider audience. On the other hand, however, it can be viewed as a tokenistic exercise, of more value as a tickbox process than for its content. In addition, it presents service users’ views as of value only where they intersect with the interests of medicine and health care, rather than of intrinsic value as research material: moreover, users in this model are presented as distinct from researchers. Thus, these ideas can be critiqued as merely another data source to inform and support a more ‘traditional’ research design, rather than as a way of enhancing democracy and empowerment. However, as a form of public engagement, mass media campaigns such as Time to Change in the UK and Mental Health Europe (MHE) have been found to support the long-term reduction of stigma and discrimination, especially in relation to prejudice and exclusion of people with mental health problems.12 Such initiatives can also promote helpseeking behaviour, social inclusion and the gradual dismantling of conventional hierarchies and illness stereotypes.13 In the Mansions project, a user-led research agenda benefitted from its location within a museum setting. Since at least the 1980s, nonspecialist education has been considered the primary purpose of most museums in the Western world, a focus that has encouraged a visitorcentric view of museum and gallery spaces. Previously regarded as repositories for research, exhibitions came to be seen primarily as

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

142

Communicating the history of medicine

‘visitor experiences’ and a huge body of literature has emerged on understanding audiences in museums and galleries in order to meet visitors’ needs.14 This emphasis on the visitor rather than the researcher has encouraged a bottom-up view of exhibition design and research. In the last five years in particular, the museum has come to be viewed as a ‘shared space representing multiple perspectives’.15 Civil or community engagement in museums has formed a central interest of funding bodies, such as the UK’s Heritage Lottery Fund (HLF), which promotes community-led historical projects.16 Both factors have led many museums to re-visit and interpret their collections and re-evaluate models of expertise within the institution, often leading to collaborative projects with under-represented groups and marginalized communities. These community groups are frequently ‘experts by experience’.17 Such projects have not been without their challenges, similar to those encountered in user-led research. In 2009, the UK charity Paul Hamlyn Foundation commissioned engagement specialist Bernadette Lynch to undertake a study of community engagement in British museums. The resulting report – Whose Cake Is It Anyway? – indicated that engagement activities were often marginalized, were not seen as a core function of museums and were generally dependent on shortterm project funding.18 One result of this ‘empowerment-lite’ (as Lynch termed it) was that projects sometimes had the opposite effect from that intended, leaving community groups feeling disempowered and further marginalized through their perception that they were simply rubber-stamping museum projects or being ‘used’ to access funding.19 It is vital that museum and heritage projects (and academic user-led enterprises) remain aware of this imbalance of power, and seek to redress this balance through the development of participatory practices, in which experts by education and by experience can deliver on genuine co-production, understood as supporting both parties to play an equally valued role in the research process and agenda.20 By promoting such a model, museums can enable discussion of difficult histories by openly acknowledging the varied perspectives of contributors as well as the ways in which dominant or normative views have been created and shaped for particular social and political purposes. The curator or archivist cannot be considered a ‘neutral’ force in such a setting.21 This approach has been taken up by heritage projects in the medical realm, such as the work of the Science Museum in London with marginalized community groups. One participant in

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 143

this programme reflected pertinently that ‘the curator’s voice is one version of reality. Visitors can create our own interpretation and displays. We [community groups] also have the power to do that, in our projects’.22 In a mental health context, the value of co-production as a means of empowerment in museums has been highlighted in the recent volume, Exhibiting Madness, which brought together case studies on mental health exhibitions and collections. As the editors noted, mental health collections have played a significant role in histories of twentieth-century psychiatry. Often put together by staff in an institutional setting, certain narratives within these collections have been highlighted or side-lined in the way objects are interpreted or displayed.23 Patients have often had little or no voice in the way collections were put together or represented over the years. Recent exhibitions have sought to redress this balance by actively seeking involvement from mental health service users past and present. These include the Willard Suitcase exhibit in New York (2004), ‘Remembering Goodna’ at the Museum of Brisbane, Australia (2007–2008) and the redisplay of both Bethlem Museum of the Mind and the Wakefield Mental Health Museum in the UK (2013–2015).24

Figure 7.1  Photograph of Bethlem Museum of the Mind foyer during redevelopment (Max Reeves, 2014).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

144

Communicating the history of medicine

Mansions in the Orchard emerged from this user-led approach to exploring and understanding the history of mental health care. We argue that community engagement within a museum setting enriches the history of medicine as a discipline and vice versa. For the Bethlem Museum of the Mind, this historical project provided a ‘safe’ space, in which challenging contemporary issues (such as restraint) could be explored by mental health staff and service users, enabling the sharing of varied perspectives. Conversely, the artistic elements of the project, bringing together a number of different audiences, shed new light on historical issues by moving beyond the archive to examine the significance of the landscape and architecture of the Bethlem site, outside a traditional academic framework. Before exploring these concerns in greater depth, we will first provide a brief outline of the Mansions in the Orchard project in the context of the history of the Bethlem Royal Hospital. Recollections of buildings: the Mansions in the Orchard project

The Bethlem Royal Hospital is believed to be the world’s oldest remaining psychiatric hospital. Founded in 1247 at Bishopsgate, just outside the City of London, Bethlem has moved three times over the centuries. In 1930, the hospital moved to its current location on the outskirts of London: the Monks Orchard estate, formerly a residential site. Bethlem’s chaplain, Edward O’Donoghue, made several visits to the site in the 1920s while the new hospital was being built. In Bethlem’s magazine, Under the Dome, he imagined the ‘mansions in the orchard’ that might remain in future years, when ‘a red brick palace may look down (with the recollection and wisdom of many centuries) upon the same landscape’.25 These ‘red brick palace[s]’ still remain today, surrounded by nearly 200 acres of the quiet woodlands described 90 years ago. Unusually in British psychiatry, Bethlem was built on the villa system, an architectural style of hospital popular in continental Europe and consisting of separate, self-contained units spaced out around the grounds. The hospital landscape features heavily in the memories of those who have used Bethlem since, as staff, service users or visitors. Taking a lead from O’Donoghue’s interest in the ‘recollections’ of historic buildings, the Mansions in the Orchard project sought to explore the neglected history

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 145

of Bethlem’s current site through its architecture.26 The project ran during the move of the Bethlem Royal Hospital Archives and Museum from a small temporary building into a new purpose-built exhibition space in the hospital’s Art Deco administration building. Public engagement was a key element of the project. In total, our activities reached over 8,000 people. Yet this wide audience also proved to be a challenge. All three researchers on the project – two historians and an artist – worked part-time to gather data, create artwork and coorganize public engagement activities. The equal valuing of traditional research and public engagement meant that there was sometimes a lack of time to complete either in as much depth as had been hoped. The initial target for oral histories, for example, was at least 25: time and staff constraints meant we recorded only 23. Additionally, the research questions generated by the project deserved greater attention than the temporary funding permitted, although many lessons learned were incorporated into the ongoing work of the Museum of the Mind. For the Museum of the Mind, Mansions in the Orchard offered a valuable opportunity to access existing and new audiences during the creation of the expanded museum. It helped to engage site users with plans for the museum and to encourage them to remain involved with the museum’s activities. The project indicated that there was a high level of interest in mental health history across the different audiences, through a sense that the history of psychiatry can offer valuable insight and lessons for contemporary health care. This interest will be expanded on in the museum’s future activities. Here, we explore the ways in which the project enabled mental health staff and service users to participate in gathering and understanding their own history, alongside opportunities for discussion and debate. This contributed to reducing the stigma of mental illness by addressing the ongoing reality of inpatient treatment in the ‘care in the community’ era.27 Public histories of psychiatry: the academic relevance of Mansions in the Orchard

Turning to the consideration of the key historical contributions of Mansions in the Orchard at a local and wider level, we begin by looking at the new historical material gathered through the project, and the ways in which the process of the project informed the historical interpretation.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

146

Communicating the history of medicine

Over 18 months, from autumn 2013 to spring 2015, we conducted 16 interviews and held focus groups with staff, service users and local residents. We also collated personal documents and artefacts donated by former staff members. A further five follow-up interviews with project participants were conducted in summer 2015, allowing these individuals to reflect on their involvement in the research, and their longer-term hopes for the museum. Additionally, the Bethlem blog has supported the ongoing collection of memories of the hospital following the completion of the project.28 Today, as part of the South London and Maudsley NHS Foundation Trust (SLaM), Bethlem is globally known for its role in treating and researching mental illness. Yet the alleged disorder and neglect associated with its earlier ‘Bedlam’ alter ego has endured in both academic discourse and the public imagination.29 Previous accounts of the hospital have drawn largely on internal records, without direct recourse to the experiences and opinions of the people at the very heart of the institution. By contrast, this project endeavoured to involve current and former service users, staff and local residents throughout all stages of conducting and disseminating the research. The research spoke to a number of macro-level issues and debates, such as those highlighted in two recent articles in the history of psychiatry. Rob Ellis reflected on the relationship between mental hospitals and the community through a case study of Epsom Hospital, addressing the localized implementation of national policy, the (unsung) benefits of the institution to its neighbourhood and the roles of the media and/or vocal critics in perpetuating stigma and stereotypes.30 This account resonates with stringent recent opposition to the development of a medium secure unit at Bethlem, but also with a more general ambivalence towards the hospital. It was very difficult throughout the project to engage local residents in conversation about the hospital. Thus, an attempt at conducting a focus group in a local library met with mixed success: despite widespread advertising of the event, very few people were willing to come inside to discuss their experiences of the hospital. However, over 20 people spoke to researchers outside the venue when approached directly. These included respondents whose family or friends had been treated or worked at Bethlem, as well as longstanding local residents with varied opinions, often based on hearsay, about what went on behind the hospital gates.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 147

Moreover, although details of the project and related events were posted online, in staff publications and at key points around the hospital, the majority of interviewees were recruited through ‘snowballing’ – i.e. on the personal recommendation of previous participants. Although convenient, this increased the risk of homogeneity within our sample and responses. In addition, some participants assumed that we were only interested in amassing positive accounts of the hospital – understandable amidst a tradition of hagiographic institutional histories – whilst others exaggerated the rates of criminal admissions to Bethlem, likely reflecting adverse media coverage of mental illness and its institutions.31 Such misgivings and misunderstandings will be further explored later in this chapter. In another historical article, Vicky Long has underscored the necessity of studying the evolution of inpatient psychiatric care during a period more commonly associated with institutional closures and community treatment. In particular, she identified a need for the scrutiny of long-term or chronic inpatient populations, and highlighted the risk of community care reinforcing the negative attitudes and stereotypes surrounding mental illness. Long ultimately posited a need to connect the medical and social dimensions of care, and to incorporate the voices of a wider variety of auxiliary and ancillary workers.32 This is something that we have incorporated throughout the Mansions in the Orchard project, and it is this diversity that has led to a themed history of the site and its users, broadly grouped into three overlapping categories: place and purpose, institution and identity, and community and communication. ‘Place and purpose’ looked at the historic relationship between the site and architecture of the Bethlem Royal Hospital and its therapeutic function. Specifically, we sought to examine how ideas of ‘asylum’ and ‘community care’ have shifted across the twentieth century, and how the physical and conceptual boundaries of the Bethlem site altered in relation to changes in these concepts. In light of the aforementioned shifts in models of expertise and audiences, we also considered the value of representing diverse accounts of ‘asylum’ and ‘community care’. The hospital’s verdant backdrop was widely deemed conducive to mental wellbeing, and not only for its patients. As a social worker put it: One of the things that I think is really important about the Bethlem site is that it is a place of asylum in the real positive sense of the word. People

148

Communicating the history of medicine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

can come here and they can have tranquillity and peace and get away from the city […] I think that that’s the true place for mental health to go and rest; to go and to have that space to just breakdown, so you can rebuild yourself.33

Other staff mourned the gradual loss of land and buildings over recent decades, while ruefully observing that they ‘couldn’t have expected us to remain in our own little bubble’.34 Echoing and extending this theme, Bethlem Gallery Director Beth Elliott felt that ‘the [Mansions in the Orchard] project has really highlighted what a rich canvas the grounds are’. She stressed the importance of not losing contact with the site and its users, adding that new premises would enable the gallery to ‘really retain an open, flexible, creative space’.35 This comment clearly connects the historical Mansions in the Orchard project with the contemporary work of the hospital and its occupational therapy department, through the unusual architecture and environment of the pastoral Bethlem landscape. The next area of our historical approach, ‘institution and identity’, explored how a hospital can offer an identity for those within it (staff and patients), and the ways in which this has changed or remained the same across the focal period. In particular, we considered the differences and similarities between actual or fabled Bethlem and other twentieth-century institutions. The stereotype of Bethlem as more relaxed than its partner institution, the Maudsley Hospital, was entrenched in different generations of staff testimony, but was discussed with humour and irony. We used to say ‘Oh, you are a Maudsley chap’. We would know the ones that had come from Maudsley; I think they were more forward-thinking than Bethlem. I always thought the Maudsley was ahead of us in terms of their outlook and things. I don’t know if they were really.36

Other respondents contrasted Bethlem’s atmosphere and working conditions with other institutions, and with present circumstances: We were all [aged] 18–20 and that was the beginning of our careers. We were put into a nurses’ home, into a uniform, we were given food […] there was nothing to think of about fending for ourselves. So that has changed tremendously with nurses today, who do degrees, they come, they live at home, they are married, they have got families […] The one thing they don’t have is the bond with the hospital that they train in, like we had. That’s a big loss I feel.37

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 149

Another staff member who contributed an oral history was interviewed again more recently, and described her personal and professional motivations for participating in the project. She and her family had lived in staff accommodation, and her first child was born there, growing up amid the scenic grounds and learning to swim in the onsite pool. She regarded the hospital as a formative influence on her nursing career, but was profoundly aware of remaining wider deficiencies in mental health care (especially community care), and a related need to help ‘normalize’ mental illness through the creation of ‘flagship’ initiatives such as the Museum of the Mind.38 These accounts reiterate the affinity participants felt with Bethlem, but also indicate some of the challenges faced by contemporary institutions where such connections are more fragmentary and fleeting than in previous decades. A third theme, ‘community and communication’, addressed Bethlem’s impact on the local community and the longer-term value of the history of psychiatry as a tool for community engagement (particularly in relation to the new Museum of the Mind). Some current and former staff members were also local residents. Their varying personal accounts of ‘community relations’ ranged from acceptance or complacency to fear and uncertainty and even outright hostility (the latter in the context of new forensic services). One nurse found herself at the forefront of communicating these plans to local residents: As soon as a whisper of this intention to develop a medium secure unit got outside of the hospital front gate, then there was this avalanche of objections. And it was relentless; it went on for at least three years. It was a really big campaign and it was led by I think probably quite a small group, but quite an energetic group, who really seemed to have very little else to do in their lives.39

Recent years have seen ongoing efforts to engage the public in the life of the hospital, and dispel some of the ‘tremendous misconceptions’ still clearly held about the hospital.40 The Mansions in the Orchard project focus on co-production and gathering of diverse perspectives served to challenge and extend existing historical narratives, shed light on beliefs surrounding mental illness and inform strategies for future engagement and educational activity. In particular, the use of oral history and creative media provided important conduits for articulating often sensitive personal experience, and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

150

Communicating the history of medicine

supported the emergence of the three broad themes outlined above. Mansions in the Orchard also enhanced site user involvement within the new museum, a key benefit recounted by Victoria Northwood, Head of the Museum of the Mind.41 Notably, this involvement was expanded in the design of the space, through the use of participants’ quotes in video installations, ongoing public consultation and a blog for the collection and dissemination of further memories after the formal completion of the project. Expanding engagement: Mansions in the Orchard and the public role of museums

The Mansions in the Orchard project ran alongside the development of the new Bethlem Museum of the Mind, which opened at the close of the project in February 2015. Situated within a working psychiatric hospital, the Museum of the Mind aims to benefit the wellbeing and educational and creative needs of site users (staff and patients), as well as contribute more generally to public understanding of mental health and illness, reducing the stigma often associated with it. The museum is now housed in the same building as the Bethlem Gallery, a contemporary gallery space connected to the hospital’s occupational therapy department. The gallery offers a professional platform for service user artists to display and develop their work and an ongoing series of creative workshops, such as the ground-breaking ‘Saturday Studio’, a yearlong professional development programme for artists who have left the inpatient care of South London and Maudsley NHS Foundation Trust (SLaM).42 Mansions in the Orchard contributed to the museum and gallery programmes through public engagement and involvement in historical research. Most of our engagement activities combined the artistic and historical elements of the project, which were most usefully used in combination. Activities fell into four main areas: talks and tours; focus groups and discussions; artistic and creative workshops; and interviews. Each of these encouraged a different type and level of engagement. Talks and tours are a standard museum intervention whereby attendees are primarily passive listeners to an expert speaker. Our activities encouraged discussion, however, which worked particularly well during a monthlong series of activities at the mental health service user led Dragon

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 151

Café. The Dragon Café, a project directed by Mental Fight Club, is a safe creative space that aims to be a force of positive change for mental health in Southwark, South London.43 The atmosphere of the cafe – a lively, non-hierarchical social space – meant that talks easily became discussion sessions, with contributions offered by a range of Dragon Café patrons. Drop-in activities and creative approaches, such as a participatory performance of historical ballads about Bethlem, offered a range of different methods of engagement. This enabled patrons to make a variety of parallels to current mental health concerns or draw attention to differences between historical and contemporary approaches. Most patrons have experience of the mental health system, and their way of thinking about history tended to be to seek answers to modernday concerns or to use history to challenge aspects of contemporary mental health care. The historical research, engagement opportunities and contemporary social and political questions became inextricably connected. This, indeed, is a key element of Mental Fight Club’s ethos: ‘We want all things to be considered, not just one version of reality, but all disciplines, all flavours of human thought’.44 The social and political value of mental health history – both as a set of data and a tool for critical thinking – is an important consideration for academic historians, who may lose sight of the contemporary relevance of their object of study. Throughout the project, we trialled different methods of gathering and showcasing user-generated content, including focus groups, discussion sessions, art interventions, interviews and blog posts. Usergenerated content is often regarded as a new and exciting development in the modern media world.45 In museums, it has been part of standard practice for at least a decade, but is now increasingly expected by audiences and often forms centre-stage in exhibitions.46 In this project, the user content was primarily focused on artistic practice, through the Bethlem Gallery and the employment of a service user artist, Max Reeves, who worked alongside the authors as the third member of the core project team. Reeves’ symbolic photographs were intended to depict the experience of mental illness through the landscape and buildings, and his style proved evocative to mental health service users in particular. Artist-led sessions in which participants drew, painted and wrote on the photographs were a useful means of incorporating a wide variety of personal responses from mental health service users. These

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

152

Communicating the history of medicine

Figure 7.2  Photograph of interior of abandoned ward (Max Reeves, 2014), with additions by anonymous artist.

were scanned and archived along with the original photographs. At a Saturday Studio session with Bethlem Gallery artists (most of whom had personal experience of mental ill-health), one artist customized a photograph of an abandoned ward to add a shadowy figure, reflecting a self-portrait she had previously painted (Figure 7.2). The photograph thus became a reminder of her experiences as a hospital inpatient but also her identity as an artist, and the method of engagement enabled her to combine the two approaches. These creative engagements helped us to gather a more nuanced history of the Bethlem site. In particular, the opportunity for anonymous intervention provided a counterpoint to some of the rose-tinted nostalgia presented in interviews and focus groups. More critical comments on the hospital were received in an anonymous photo collage in the gallery than in any other medium. This included photographs where staff faces had been scrawled out in red pen and comments like: ‘As if it was that easy …’ (written next to a sign saying ‘Press Intercom to Exit’). These responses indicate the importance of offering a variety of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 153

feedback and involvement methods in a mental health museum, to avoid further marginalizing those who do not share dominant views of the hospital. In addition, it provides an alternative means of gathering historical research material to that of traditional interviews; many of those who were happy to engage in an art project did not wish to take part in formal interviews. While of great importance, this material remains difficult to incorporate into standard academic histories, suggesting a wider need to re-evaluate the ways in which historians approach user stories and the frameworks they use to interpret them. The project was beneficial to participants in a number of important ways. There now exists a significant literature indicating the value of heritage, in particular object handling, to mental health and wellbeing. In particular, the ‘Heritage in Hospitals’ and ‘Museums on Prescription’ projects at University College London (UCL) have shown that museum objects can facilitate discussion and enable ‘emotional disclosure and communication’.47 Objects become ‘prompts for disclosure’ as well as opportunities for working collaboratively and sharing knowledge. In the ‘Remembering Goodna’ project in Australia, reminiscence itself was ‘of powerful therapeutic value’, improving the wellbeing of participants.48 In the Mansions in the Orchard focus groups we used collection items to open up discussions, encouraging shared reminiscence and breaking down boundaries of expertise between different types of staff and service users. When we discussed a 1950s hospital milk bottle, for example, curatorial staff ceased to be the experts, and instead reminiscences from those who had used these items in practice came to the fore. Other group members effectively interviewed their peers. This informal setting meant that the project was often valued by participants as a social activity. Those involved fed back positively on the ‘lively, friendly community involved in the project’ and rated their involvement as a beneficial social experience.49 Objects could also provide a ‘safe space’ for exploring challenging topics, such as restraint or ECT, which proved particularly emotive. Historical ‘distance’ enabled staff and service users to participate in mutual discussion, sharing views or experiences without either group feeling excessively challenged or becoming defensive. This creative approach to objects encouraged ‘a kind of openness because we’re all engaged in the object, a kind of freeness to the way people interact and talk to each other around them. It […] opens us all up to chat and to

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

154

Communicating the history of medicine

learn’.50 Hospital staff reflected on the enthusiasm of the service user community for the project and for the history of mental health generally; some felt that awareness of this interest would help them with person-centred care.51 This potential for interaction around emotive or painful topics also indicates the value of public history projects to empower marginalized groups. Besley and Low have suggested that museums have the potential for offering three stages needed to recover from trauma: a safe environment, a site of remembrance and an opportunity for reconnection.52 The last of these can be associated with empowerment: an opportunity for marginalized communities to shape the way they are presented and to reconnect with other social groups as a result. The active encouragement of user-generated stories, and the opportunity to tell multiple stories of the past, is an important element of this practice. These conflicting histories came into stark relief at the Dragon Café, where several patrons questioned the use of a theme of ‘sanctuary’ in relation to Bethlem. This ‘peaceful theme’ jarred with their experiences of Bethlem and all ‘the dreary, dehumanising horrors of your average psychiatric ward in this country’.53 By offering the opportunity to discuss and explore this topic within the safe space of the Dragon Café, as well as the creative responses outlined above, these distressing experiences could be legitimized, becoming just as much a part of the hospital’s history as the positive views often recorded in oral histories. The major impact on participants was in attitudes. Our evaluation showed that the project highlighted the importance of making mental health less of a taboo subject and normalizing experiences of mental illness.54 For some participants, particularly local residents, this has the potential to lead to a personal change in attitudes. As part of the project, we began to gather data in a questionnaire reviewing the stigma attached to mental health. This 20-question survey, with a mixture of tickbox and open-ended questions, was carried out with 36 participants: 20 on the local high street in West Wickham, and 16 people who came onsite to attend Mansions in the Orchard activities and events. While the small number of participants meant that it was not possible to draw any direct conclusions from this survey, questions concerning attitudes highlight areas for further research: in particular, assumptions about the relationship of mental illness to crime. The vast majority of respondents in West Wickham assumed that more than 20% of those detained in UK psychiatric hospitals have been committed through the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 155

criminal justice system; in reality, the figure is less than 4%. Onsite, a much lower figure was assumed by attendees; no one placed the real figure as more than 10%.55 While there was potential overlap between the two groups, the mixture of staff, service users and London-wide visitors meant that those completing the survey onsite formed a much more diverse audience than those on the local high street. This potential contrast in attitudes might be usefully explored by further activities at the Museum of the Mind. In our evaluation of the project, some participants also felt that their own insight into contemporary practice was directly enhanced by the historical approach to the Bethlem site. A historical approach provided lessons. These included avoiding the errors of the past, but also recovering valuable skills (for example, within nursing care). History, one staff member noted, ‘can provide a cautionary note about new therapies which are over-enthusiastically embraced’.56 Even more so, the project taught ‘humility’, for ‘science doesn’t – and shouldn’t – have all the answers’.57 A historical project helped to break down prejudices and expand thinking, managing fears born of stereotypes by providing awareness of the development of these stereotypes. One example that emerged from the project was the changing view of Bethlem held by some local residents as nearby county asylums began to close down; the negative associations applied to these institutions subsequently became transferred to Bethlem.58 By raising awareness of mental health history, some participants reported that they had developed better empathy with mental health service users today, viewing patients past and present as individuals. It also offered an opportunity for people to consider their own mental health, and to improve wellbeing, as well as generating support for the Museum of the Mind from site users, with an associated understanding of the museum’s purpose and value. Conclusion

The Mansions in the Orchard project at the Bethlem Museum of the Mind emerged from a background of service user involvement and public engagement within a museum setting. Both of these approaches contributed to the success of the project. In addition, they shaped the historical method, resulting in a very different project from academic histories of medicine. This non-hierarchical history was more subtle and nuanced than standard histories of psychiatry, which have tended

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

156

Communicating the history of medicine

to focus on institutional administration, rather than people and daily life within these settings.59 Our use of oral histories was an important element of this diversity. However, alongside this, public engagement activities resulted in additional historical material: in particular, artistic responses to the project incorporated a much wider array of responses from service user groups. This ensured that negative or critical reactions to the twentieth-century history of mental health care were incorporated throughout the project. Both the interviews and art materials have been added to the Museum of the Mind archive, forming part of the official history of Bethlem accessible to future generations. Time and funding were, however, a major challenge throughout. While new material was added to the archive, the project funding did not cover cataloguing this or making the oral histories and transcripts accessible to a wider audience. While it is hoped that this will be carried out subsequently, none of the project coordinators were directly employed by the Museum of the Mind, which risked an uncertain legacy. In similar projects, this might be addressed by ensuring that a named member of staff acted as liaison throughout. Despite this, the public engagement aspect of the project provided a valuable opportunity for mental health staff and service users to collaborate, recognized by core museum staff as well as workers from the wider hospital. In particular, focus groups offered a space for the exploration of difficult issues. A nuanced and critical approach to the past is a particularly important aspect of the historical method in mental health museums, to avoid further disempowering marginalized groups. In a mental health setting, creative and historical activities can promote wellbeing for participants: service users, certainly, but also staff, whose own mental health can be challenged by the stressful situations in which they find themselves. In a context of increasing financial threat to mental health services – an area of the NHS that has been particularly hit by UK government drives to austerity in recent years – both staff and patients are often left disempowered. Yet the museum and gallery could provide an alternative model, giving site users past and present a voice. I’ve been encouraged by how people have embraced and supported the work that we do, and realized that it’s a way of keeping this site in the picture, in profile, reminding the world at large that there’s extraordinary history and expertise within the Trust.60

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 157

Enabling these groups to write their own history offered them a space for reflection often neglected in daily work and lives, assisting with improved confidence or skills. Sessions at the Dragon Café with mental health service managers and trainee psychiatrists have indicated the immense value of such opportunities for both staff and service users.61 This will form an important element of the Museum of the Mind’s ongoing engagement programme. The public engagement activities of the Mansions in the Orchard project emphasized three key ways in which mental health history projects contribute to the history of medicine in practice. First, involvement in a creative and historical project contributed to the wellbeing of participants. Associated with this was the ability of the project to empower staff and service users to contribute to their own histories, providing them with the critical tools to challenge and improve services today. Finally, but perhaps most importantly, a heritage project can have a significant impact in helping to reduce the stigma associated with mental illness, particularly for a public audience. Since the Museum of the Mind opened in February 2015, increasing numbers of local residents have entered the Bethlem site, often surprised by the contrast with their expectations.62 Bringing residents together with staff and service user groups offers a social space for understanding and celebrating difference. Historical and art projects, in this context, can form a key means of reducing the stigma often associated with mental illness. Notes 1 R. Butsch, ‘Audiences and Publics, Media and Public Spheres’, in V. Nightingale (ed.), The Handbook of Media Audiences (Malden: Wiley-Blackwell, 2011), pp. 153, 164–165. 2 A. Portelli, ‘The Peculiarities of Oral History’, History Workshop Journal, 12:1 (1981), 96–107. 3 N. Baur, ‘Oral Testimonies in Mental Health History’, Social History of Medicine, 24:2 (2011), 484–487. 4 D. Russell, ‘An Oral History Project in Mental Health Nursing’, Journal of Advanced Nursing, 26:3 (1997), 489–495. 5 S. Jasanoff, ‘The Idiom of Co-Production’. Chapter 1 in S. Jasanoff (ed.), States of Knowledge: The Co-Production of Science and Social Order (London: Routledge, 2004), pp. 1–12.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

158

Communicating the history of medicine

6 C. Pinel outlined differences in the theory, objectives, methods and impacts of each model: PPI, as the newer approach, is more strongly linked to clinical research and measurable impacts; PES has roots in critical or philosophical thinking, employs more creativity in methods and is less constrained by regulatory bodies than PPI. C. Pinel, ‘The Art of Public Engagement in Science and Health Research’, Individual Presentation, Centre for Public Engagement Annual Conference 2015: Patient and Public Involvement in Research: The Art of Engagement, St George’s, University of London, 16 September 2015. 7 See: http://www.invo.org.uk/ (accessed 17 September 2015). 8 D. Rose, ‘“Having a Diagnosis is a Qualification for the Job”’, BMJ, 326:7402 (2003), 1331. 9 Internationally, service-user researchers are less likely to operate collectively. However, the Hearing Voices Network (http://www.hearingvoices.org) draws on pioneering German and Dutch activity, whilst G. A. Hornstein’s Agnes’s Jacket also considers the wider European terrain of lived experience: G. A. Hornstein, Agnes’s Jacket (New York: Rodale Press, 2009). 10 J. Russo, ‘Survivor-Controlled Research: A New Foundation for Thinking about Psychiatry and Mental Health’, Forum Qualitative Sozialforschung/ Forum: Qualitative Social Research, 13:1 (2012). 11 P. Beresford and K. Boxall, ‘Where Do Service Users’ Knowledges Sit in Relation to Professional and Academic Understandings of Knowledge?’, in P. Staddon (ed.), Mental Health Service Users in Research: Critical Sociological Perspectives (Bristol: Policy Press, 2015), pp. 69–86. See also M. Cresswell and H. Spandler, ‘The Engaged Academic: Academic Intellectuals and the Psychiatric Survivor Movement’, Social Movement Studies, 12:2 (2012), 1–17. 12 C. Henderson and G. Thornicroft, ‘Evaluation of the Time to Change Programme in England 2008–2011’, The British Journal of Psychiatry, 202 (2013), s45–s48. 13 S. Evans-Lacko et al., ‘Association between Public Views of Mental Illness and Self-Stigma among Individuals with Mental Illness in 14 European Countries’, Psychological Medicine, 42 (2012), 1741–1752. 14 R. Miles, ‘Museum Audiences’, Museum Management and Curatorship, 5:1 (March 1986), 73–80. For more recent works, see D. Chittenden, G. Farmelo and B. V. Lewenstein (eds), Creating Connections: Museums and the Public Understanding of Current Research (Oxford: Rowman & Littlefield, 2004). 15 G. Black, ‘Embedding Civil Engagement in Museums’, Museum Management and Curatorship, 25:2 (21 May 2010), 129–146, p. 129.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 159

16 From 2012–2014, for example, the HLF funded 542 community heritage projects to a total value of £4.5 million through the ‘All Our Stories’ grant scheme. For the full details and evaluation, see the HLF website: http:// www.hlf.org.uk/all-our-stories-evaluation (accessed 14 September 2015). 17 R. Sandell, J. Dodd, and R. Garland-Thomson (eds), Re-Presenting Disability: Activism and Agency in the Museum (Abingdon, Oxon: Routledge, 2010); S. Iervolino, Who Am I? Hacking into the Science Museum: A Gendered Intelligence Project Co-Produced with the Science Museum within the AHRC ‘All Our Stories’ Project (London, 2014); S. Chaney, There Are as Many Different Truths as There Are People: CoolTan Arts and the Science Museum in Partnership, unpublished report (London: Science Museum, 2014). 18 B. Lynch, Whose Cake Is It Anyway? A Collaborative Investigation into Engagement and Participation in 12 Museums and Galleries in the UK (London: Paul Hamlyn Foundation, 2011), https://www.phf.org.uk/publications/ whose-cake-anyway/ (accessed 25 June 2019). 19 Ibid., pp. 11–12. 20 A. Flinn and A. Sexton, ‘Research on Community Heritage: Moving from Collaborative Research to Participatory and Co-Designed Research Practice’, in CIRN Prato Community Informatics Conference 2013 (2013), pp. 1–14. 21 For a particularly pertinent challenge to the idea of archival neutrality, see T. Cook, ‘We Are What We Keep; We Keep What We Are: Archival Appraisal Past, Present and Future’, Journal of the Society of Archivists, 32:20 (2011), 173–189. 22 Chaney, There Are as Many Different Truths as There Are People, p. 12. See also S. Frampton and S. Chaney, Challenging the Normative View of Medical History: Report on ‘Whose Medical History Is It Anyway?’: A Workshop Exploring Diverse Interpretations of the Science Museum Medical Collections (London, 2014). 23 D. MacKinnon and C. Coleborne, ‘Seeing and Not Seeing Psychiatry’, in Coleborne and MacKinnon (eds), Exhibiting Madness in Museums: Remembering Psychiatry through Collections and Display (Abingdon, Oxon: Routledge, 2011), pp. 3–13. 24 J. Besley and M. Finnane, ‘Remembering Goodna: Stories from a Queensland Mental Hospital’, in Coleborne and MacKinnon, Exhibiting Madness in Museums, pp. 116–136; ‘The Willard Suitcase Exhibit Online’, http:// www.suitcaseexhibit.org/ (accessed 14 September 2015); S. Clarke, A. Elliott and F. Costain, Bethlem Royal Hospital Archives and Museum: Museum of the Mind Consultation Report (London, 2011); R. Ellis, “‘Without Decontextualisation”: The Stanley Royd Museum and the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

160

Communicating the history of medicine

Progressive History of Mental Health Care’, History of Psychiatry, 26:3 (2015), 332–347. 25 E. O’Donoghue, ‘Scraps from the Larder’, Under the Dome, 53:9 (1926), 55. 26 The main exception to the general lack of interest in twentieth-century Bethlem is the multi-authored ‘History of Bethlem’: however, the twentieth-century section focuses largely on administrative changes, and not users’ experiences of the hospital and site. J. Andrews et al., The History of Bethlem (London: Routledge, 1997). 27 For more on the project, see the final evaluation report. S. Chaney, Evaluation Report: Mansions in the Orchard (London: Bethlem Museum of the Mind, 2015). 28 See: http://museumofthemind.org.uk/blog (accessed 26 September 2015). 29 For example, Roy Porter’s assertion that, by the late eighteenth century, Bethlem had become ‘a byword for man’s inhumanity to man’. R. Porter, Mind-Forg’d Manacles: A History of Madness in England from the Restoration to the Regency (London: Penguin, 1987), p. 129. 30 R. Ellis, ‘“A Constant Irritation to the Townspeople”? Local, Regional and National Politics and London’s County Asylums at Epsom’, Social History of Medicine, 26 (2013), 653–671. 31 S. Chaney and J. Walke, ‘Life and Luxury in Monks Orchard: From Bethlem Hotel to Community Care, 1930–2000’, The Lancet Psychiatry, 2:3 (3 March 2015), 209–211. 32 V. Long, ‘Rethinking Post-War Mental Health Care: Industrial Therapy and the Chronic Mental Patient in Britain’, Social History of Medicine, 26 (2013), 738–758. 33 Wendy Whitaker, Interview with Jennifer Walke, 13 December 2013. 34 Peter Lambert, Interview with Jennifer Walke, 3 October 2013. 35 Beth Elliott, Interview with Jennifer Walke, 28 August 2015. 36 Mary Butler, Interview with Jennifer Walke, 29 September 2013. 37 Irene Heywood Jones, Staff Focus Group, Bethlem Royal Hospital, 18 November 2013. 38 Mary Chambers, Interview with Jennifer Walke, 28 August 2015. 39 Mary Yates, Interview with Jennifer Walke, 3 October 2013. 4 0 Brian Woollatt, Interview with Jennifer Walke, 13 December 2013. 41 Victoria Northwood, Interview with Sarah Chaney, 29 June 2015. 42 Bethlem Gallery, ‘Artists Survival Manual’ (2012): http://bethlemgallery. com/resources/Bethlem_Gallery-Artists survival_manual.pdf (accessed 26 September 2015). 43 See: http://dragoncafe.co.uk/ (accessed 26 September 2015).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Mansions in the Orchard 161

4 4 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015. 45 N. Carpentier, ‘New Configurations of the Audience? The Challenges of User-Generated Content for Audience Theory and Media Participation’, in V. Nightingale (ed.), The Handbook of Media Audiences (Malden: Blackwell, 2011), pp. 190–212. 4 6 See B. Adair, B. Filene and L. Koloski (eds), Letting Go?: Sharing Historical Authority in a User-Generated World (Philadelphia: Pew Center for Arts & Heritage, 2011). 47 R. Solway et al., ‘Museum Object Handling Groups in Older Adult Mental Health Inpatient Care’, International Journal of Mental Health Promotion, 17:4 (2015), 2. See also R. Lelchuk Staricoff, ‘Arts in Health: The Value of Evaluation’, The Journal of the Royal Society for the Promotion of Health, 126:3 (1 May 2006), 116–120; A. Lanceley et al., ‘Investigating the Therapeutic Potential of a Heritage-Object Focused Intervention: A Qualitative Study’, Journal of Health Psychology, 17:6 (21 November 2011), 809–820. 48 J. Besley and C. Low, ‘Hurting and Healing: Reflections on Representing Experiences of Mental Illness in Museums’, in Sandell et al. (eds), RePresenting Disability, p. 132. 49 Chaney, Evaluation Report, p. 10. 50 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015. 51 Other museum projects have looked at the value of creative and museum settings in breaking down stigma in the medical profession. J. L. Cutler et al., ‘Reducing Medical Students’ Stigmatization of People with Chronic Mental Illness: A Field Intervention at the “Living Museum” State Hospital Art Studio’, Academic Psychiatry, 36:3 (1 May 2012), 191–196. 52 Besley and Low, ‘Hurting and Healing’, p. 136. 53 Sarah and Thomas Tobias (Sarah Wheeler), Interview with Sarah Chaney, 2 August 2015. 54 Chaney, Evaluation Report, p. 10. 55 Chaney and Walke, ‘Life and Luxury in Monks Orchard’, p. 210. 56 Chaney, Evaluation Report, p. 7. 57 Ibid. 58 Chaney and Walke, ‘Life and Luxury in Monks Orchard’, p. 211. 59 As was the case with much of the material in Andrews et al., The History of Bethlem. For a lengthy critique of this approach, see A. Scull, ‘Bethlem Demystified?’, Medical History, 43 (1999), 248–255. 6 0 Beth Elliott, Interview with Jennifer Walke, 28 August 2015. 61 Sarah Wheeler, Interview with Sarah Chaney, 2 August 2015. 62 Victoria Northwood, Interview with Sarah Chaney, 29 June 2015.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

8

Swedish sex education films and their audiences: representations, address and assumptions about influence Elisabet Björklund

For sex educators, audiences are a central concern. This is obvious as the very purpose of sex education is to communicate knowledge about sexuality to people who, for various reasons, are considered in need of this knowledge. Through history, sex educators have striven to expand their audiences and increase the influence of their messages in different ways, not least by using mass media such as film, radio and television.1 However, due to the controversial character of the subject, these efforts have often involved certain obstacles, for example raised by legislation, censorship and different forms of protest, which are connected to concerns about the effects that sex education might have on its audiences. Fear of what an open discussion of sexuality might lead to in terms of behaviour has made sex education into ‘the most delicate subject’ – a subject perceived as risking influencing its audience in an undesired way if not treated with care.2 Moreover, the choice of medium is significant for the presumed effects of sex education. In my dissertation, I studied sex education in Sweden through the medium of film in the period until the late 1970s. During this time, sex educators saw many advantages in film, not least its pedagogical qualities as a visual medium. Furthermore, commercial cinema has the benefit of being able to communicate with large audiences, some of which might not have been reached by other forms of sex education. However, these advantages also raised concerns among many.3 From its inception, film in general – and commercial cinema in

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

163

particular – has had a low status as a medium for the masses. And despite being increasingly elevated as an art form during the course of the twentieth century, the history of cinema is filled with ideas around its assumed harmful influence on its audience – the reason why censorship of film has for a long time been considered acceptable even in democratic countries like Sweden, where the freedom of speech has otherwise been well protected.4 When combined with cinema, sex education thus became an even more delicate subject. The delicacy of sex education films is also something that I have become aware of when communicating the results of my research to different audiences, for example the media, students in different subjects, or associations and societies who have invited me to give popular lectures. When working on the dissertation, it was not hard to anticipate that the topic would attract interest. Not only can this be explained by the cliché that ‘sex sells’. For Swedes, the subject also creates associations with the widespread notion of Sweden as being a liberal (or ‘sinful’) country in sexual matters stemming from Sweden’s comparatively long history of compulsory school sex education and sexually explicit cinema – an idea that people in Sweden themselves have been eager to maintain.5 Most of the time, I have been happy about this interest, but it has also made me a bit uncomfortable. Finding a balance between a popular and an academic approach can be a difficult task for any scholar, but I have felt that my topic made this balancing act even more difficult. When interviewed, I have sometimes been annoyed by questions asked by journalists or by descriptions of my research when I have found these to be reproducing stereotypes or sensationalizing the content. Moreover, showing or not showing clips from films displaying sexual acts when lecturing needs consideration of context and audience. At times, I have also worried that my choice of topic – a genre that in Swedish cinema of the late 1960s and early 1970s was at the verge of crossing the border to pornography – would mean that I would not be taken seriously in certain environments. Because of this, I have occasionally felt a need to legitimize my work, for example by emphasizing the importance of sex education. However, this experience has also contributed to my interest in the social processes that produce the borders between acceptable and unacceptable ways of communicating information about sexuality to which sex educators have to relate. Here, medicine and its history have historically played an important part.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

164

Communicating the history of medicine

The medical perspective has had a great influence in the field of sexuality in general. From the end of the nineteenth century, a process started that has been called the modernization of sex, which entailed a secularization and medicalization of sexuality.6 Significant for this development was the fact that the authorities of the field changed: if sexuality had previously been an area in which the church had a great influence, it was now increasingly medical doctors who started to dominate the field.7 The concept of ‘sexuality’ itself arose during the second half of the nineteenth century, as the field of sexology – the scientific study of sexuality – developed in Europe.8 Around the same time, the first sex reform movements formed and sex education started to be advocated from different perspectives. Here, medical doctors were among the prominent voices. In Sweden, for example, the first Swedish woman physician, Karolina Widerström, was a pioneer in the field as she started to teach sexual hygiene to girls in Swedish schools as early as in the 1890s.9 And when journalist Elise Ottesen-Jensen started the RFSU – The Swedish Association for Sexuality Education – in 1933, this was done in collaboration with a group of medical experts associated with the left-wing journal Populär tidskrift för sexuell upplysning (‘Popular Journal for Sex Education’), that had been founded in 1932.10 When the perspective on sexuality started to change, it thus also became a topic of public discussion in an unprecedented way. This was, however, certainly not without opposition, and the controversial character of sex education has remained. To avoid censorship or accusations of immorality, sex educators have often emphasized a rational and scientific discourse on sex, especially by aligning themselves with medicine. Moreover, to underline the importance of its own project, sex educators have often used a rhetorical strategy in which a modern view of sexuality is contrasted with repressive ideas of the past, a rhetoric that often involved emphasizing progress made within medical research that has led to the current, more enlightened, situation. Assumptions about audiences have thus been a pivotal part of the discourse around sex education, and medicine and its history have been crucial when addressing these audiences. In this chapter, my aim is to explore these issues by highlighting some examples from the history of sex education films in Sweden. I do not intend to draw any conclusions

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

165

about how actual audiences of these films experienced them or interpreted their meanings. Nor is this a historical reception study in which I analyse, for example, discussions of the films in the public. Instead, I analyse efforts to create and control certain audiences and assumptions about them made by filmmakers, distributors, cinema-owners and censors through an analysis of marketing, censorship practices, representations and audience address. Hence, my focus is rather on ‘implied audiences’ than on real, historical ones.11 Sex education films have historically been shown in various contexts, such as in schools, at organized meetings and on television. My focus here, however, is on films screened in cinemas. This was the first screening context for sex education films and remained significant until the 1970s. Defined as public screenings in the law, films shown in cinemas were also the only films regulated by the National Board of Film Censors – Sweden’s governmental film censorship board – which had been established in 1911. As this type of sex education film is rare after the 1970s, the chapter is delimited to this time period. The chapter is divided into three sections and a conclusion. In the first section, I discuss the role of medicine in efforts to control the audiences for sex education films in the period until the mid-twentieth century. Through marketing and censorship negotiations, film distributors and censors sought to create a respectable viewing context, while not undermining the films’ commercial appeal. In the second and third section, I discuss the centrality of medicine in Swedish sex education films from the 1940s to the early 1970s, the way these films addressed their audiences and their use of medical images. The chapter demonstrates that a medical perspective was significant in the relationship between Swedish sex education films and their audiences, and that this pertained both to the context in which audiences viewed the films, and to the strategies of representation and educational address of the films. Centrally, the chapter shows that medicine and its history were used to legitimize the films on the commercial market. At the same time, this seems to have been a two-way process, as the films simultaneously participated in giving legitimacy to a certain category of medical doctor specializing in fields such as venereology and gynaecology. Although a controversial film genre, the sex education film of this period was thus intrinsically aligned with the medicalization of sexuality in the twentieth century.

166

Communicating the history of medicine

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Creating a respectable viewing context

Around the time of the First World War, governments and private actors in different parts of the Western world started to use the medium of film for the purpose of sex education. In many countries, however, films of the kind were highly controversial. The situation in the United States is illustrative. Here, sex education films have a long history. The first American sex education films produced were made by commercial companies, for example Damaged Goods (Thomas Ricketts, 1914) and Where Are My Children? (Louis Weber and Phillips Smalley, 1916), but government-sponsored films aimed at the American armed forces shortly followed, like Fit to Fight and Fit to Win (Edward H. Griffith, 1918, 1919).12 However, the genre quickly became contested. Eric Schaefer shows that the state-supported films became problematic when released on the commercial market after the war, among other things because of the way they dealt with the topic of venereal disease, and because they appeared at a time when Hollywood was stabilizing around the convention of narrative cinema and aimed to improve its public image. This had the result that the sex education film was suppressed by the major film companies, and instead the format started to be used by less respectable producers. Schaefer demonstrates how this gave rise to a new film industry by the end of the 1910s that existed parallel to the mainstream Hollywood cinema – exploitation cinema – a type of low-budget film that dealt with ‘forbidden’ topics and was shown in cinemas not belonging to the major film companies.13 Miriam Posner, who has studied the sex hygiene film The End of the Road (Edward H. Griffith, 1919), demonstrates that this development also had to do with anxiety about the connection between sex and money that was created when the state-supported films were released commercially.14 For a long time, sex education films in the US thus existed in two separate venues – in respectable screening contexts such as in the military or in schools, and in the exploitation cinema market.15 In Sweden, sex education films were not produced in greater numbers until the 1940s, but the genre became familiar in the market early on through imported films in the late 1910s and the 1920s. These films came from many different countries – for example, the United States, Austria, France, Switzerland and the Soviet Union.16 A substantial

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

167

number of the films were imported from Germany. Here, the so-called Aufklärungsfilm (‘enlightenment film’) and Sittenfilm (‘morality film’) emerged towards the end of the First World War and then became common film formats during the Weimar Republic, with Richard Oswald’s Es werde Licht! (Let There Be Light!; 1916/1917) being an important forerunner.17 These films dealt with a number of different subjects, but many were on the topic of sexuality. Like their counterparts in other countries, the films had an unstable status and existed on the border between educational and sensational discourses.18 As a genre, the sex education film thus clearly meant difficulties. On the one hand, the films purported to be educational and dealt with issues generally understood to be important by many people. On the other hand, as these issues had to do with a subject that was largely taboo and the films were aimed at a paying audience, the films were risqué. This was handled in different ways by film companies and censors, but a common effort was to try to counteract the controversial subject matter of the films by emphasizing their educational framework and medical discourse. It was, of course, of central importance for film distributors that their films passed inspection by the National Board of Film Censors. The board had to ensure that films followed general laws, were not offending to morality and were not ‘brutalizing, agitating, or confusing the concepts of justice’, as it was originally stated.19 They also judged whether a film could have a negative influence on children, and in those cases the film was given a 15-year age-limit.20 Sex education films, however, posed specific challenges. In the 1920s, when films of the type started to become common on the Swedish market, an unofficial censorship practice developed; censorship records from the period reveal that many films were only approved by the board if the film company had made assurances that the film would only be shown at gender-segregated screenings, or in connection with a lecture by a person trained in medicine. This implied a kind of negotiation between the board and the film companies in which film owners often had to legitimize the films in different ways in order to get them approved. For example, in 1923, when film distributor Oscar Rosenberg submitted the film Hygiene der Ehe (The Hygiene of Marriage; director unknown, 1922), he stated in his letter to the board that the film had been seen by no less than six physicians in Stockholm and that he would show it only to women.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

168

Communicating the history of medicine

Rosenberg also appended a statement by a Norwegian doctor who recommended the film and a Norwegian censorship card that showed that the film had been shown to segregated audiences in Norway.21 The film was eventually allowed in Sweden, but it was stated on the censorship card that the film owner had committed himself only to show the film to women.22 The board thus decided to approve the film, but this might not have been the case if the distributor had not been so careful in framing the film within a medical discourse and made the suggestion to limit the audience to one gender. In 1929, the censorship board officially gained the power to prescribe these kinds of restrictions in screenings, a right that remained until 1954.23 However, the practice continued even after this right had been rescinded, as film companies themselves sometimes decided to restrict their screenings in this way. The last film that I know of that the censorship board allowed for gender-segregated screenings only was the Austrian film Schleichendes Gift (Slow Poison; Hermann Wallbrück, 1946) that was imported to Sweden in 1947, but there are examples of films in the 1950s that were likewise only shown to men and women separately, for example, the Swedish film Möte med livet (‘Encounter with Life’; Gösta Werner, 1952). The practice of restricting the screenings in these ways can be interpreted in different ways, but it essentially has to do with assumptions about the influence of film on its audience. Here, it is clear that audience influence was not only understood to be something a film exerted by itself, but the viewing context was obviously seen as significant. For example, when the advertising manager at Svensk Filmindustri explained why the film company had chosen to restrict the screenings of Möte med livet, he stated that a number of people who had seen the film in advance had been ‘afraid that the message of the film would be shattered by embarrassed guffaws and giggles if young men and women sat on the same bench’.24 The gender-segregated screenings also suggest that there existed a fear over what could happen between men and women at the theatre if they saw the film together. As mentioned, the opinion that sex education can be destructive is common, but in the case of sex education films this might also have been enhanced by the fact that cinemas were part of the commercial entertainment industry, and were in themselves to some extent sexually charged places. Gendersegregated screenings and the accompanying lectures were thus aimed

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

169

at managing meaning and the behaviour of audiences by creating a more respectable viewing situation for the films. However, these efforts to create a legitimate framework for the films were actually interpreted in the exact opposite way by critics. Ever since the 1920s, gender-segregated screenings were not understood as making the films less sensational. Rather, they were interpreted as a commercial tactic to draw large audiences to the cinemas by suggesting that the films contained bold material.25 By the 1950s, this opinion had come to be shared also by people in positions of power over censorship, for example Gunnar Klackenberg, who was then deputy head of the National Board of Film Censors.26 Actually, that the restricted screenings counteracted their own purpose was also one argument of the film committee of 1949, which recommended that the addition about restricted screenings should be removed from the law that regulated film censorship.27 The tension between legitimizing and commercial strategies can also be noted if one examines the marketing of the films. Here, emphasis was often laid on creating respectability through the use of medical authorities, and sometimes the names of actual medical practitioners appeared in the advertisements. On the poster to the film Schleichendes Gift it was, for example, stated that the film had been edited by Dr Malcolm Tottie – an expert on venereal diseases at the Royal Medical Board. However, the main impression of this poster is its sensationalized character, as it displays a painted image of a pink naked woman caught by a long grey snake against a black background.28 And the fact that the film had been approved to gender-segregated audiences only was clearly stated on the poster, perhaps both as information and – as many critics suspected – to publicize the film. Bengt Bengtsson, who has studied Swedish so-called youth-going-astray films in the midtwentieth century, which also included sex education films, has noted the ‘two-faced’ character of their marketing – advertisements simultaneously emphasized earnestness and sensationalism.29 Film distributors thus strove to make the films legitimate, while at the same time working to attract a large audience. Theory of film reception emphasizes that meaning is not something that is inherent in a film, but that the meaning of a film can be different for different audiences, depending on, for example, the historical and social context of reception.30 Sex education films can be seen as a clear example of awareness

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

170

Communicating the history of medicine

about this. Regardless of how one chose to regard the restricted screenings – as a way to counter sensationalism or as something that created sensationalism – it is clear that both viewpoints understood the viewing context as significant for how the film would be interpreted. Comparing with many other genres of film one could, however, argue that the sex education film was seen as particularly unstable in this respect. It was a type of film whose meaning was at risk of being misinterpreted and whose influence on its audience was at risk of going in the wrong direction if it was not handled in a correct way. Heroic doctors and the attraction of medical images

As mentioned earlier, Swedish sex education films were not produced in greater numbers until the 1940s. The fact that they did emerge at this time has different explanations. Swedish film production boomed during the Second World War, and, as the production volume grew, the thematic content of the films also widened. From now on, issues such as sexuality and youth problems became more common on the cinema repertoire.31 The existence of the sex education film genre on the Swedish market since the late 1910s probably also influenced the readiness of film companies to invest in such productions. The sex education film was not a large genre, but approximately ten films of the kind were made in Sweden in the 1940s and 1950s. The genre can be described as a mix between commercial and public interests – the films were generally made by commercial companies and starred well-known Swedish actors, but medical doctors and other persons engaged in sex education were often part of the productions. A typical example here is the film Rätten att älska (‘The Right to Love’; Mimi Pollak, 1956). It is narrative and fictional in form, was produced by the major film company Europa film, and starred a number of familiar Swedish actors, such as the popular Stig Järrel. At the same time, it was based on an idea by schoolteacher and sex educator Torsten Wickbom, and Dr Malcolm Tottie of the Royal Medical Board had been an advisor on the production. Sex education films of this time period had a specific type of educational address. The films seldom used direct address as in traditional ‘expository’ documentaries.32 Instead, they generally spoke to their audiences in an indirect way. Annette Kuhn, who has studied propaganda films against venereal diseases in Great Britain during the First

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

171

World War, has demonstrated that these films addressed their viewers by positioning them as ‘moral subjects’. The films follow classical narrative conventions by focusing on characters and their actions through structures built around conflict and solution. However, rather than psychologically rounded individuals, the characters are better understood as representatives of different moral positions. Furthermore, Kuhn writes that the narratives of these films were often based on the acquisition of knowledge. The films focus on characters who, in the beginning of the film, are ignorant about sexuality. With the progression of the storyline, however, they gain knowledge and thus mature into informed and responsible persons, at the same time as the viewer is understood to go through a similar learning process.33 Distinguishing a number of stock characters in the classical American exploitation film, Schaefer has also noted that ‘[e]ducation is at the axis of character function in the sex hygiene exploitation film and provides the locus for the discourse on social issues under examination. Each character functions to either receive, promote, stifle, or create the need for education about sex and reproductive health’.34 This positioning of the implied audience in relation to the fictional characters is evident also in the Swedish films, as a recurrent narrative structure is that a character who has become pregnant or suspects a venereal disease visits a doctor and then receives sex education. In some cases, however, the narrative is instead organized around the story of a doctor as the main protagonist. This structure itself underlines a strong convention that can be seen in many Swedish films of this period: the representation of the medical doctor as the ultimate figure of authority and moral hero.35 A clear example is the film Kärlekslivets offer (‘Love’s Victims’; Gabriel Alw and Emil A. Lingheim, 1944), a film about venereal diseases. Here, the glorification of the doctor is quite explicit. In the opening scenes, a voice-over introduces the main protagonist, Dr Bernard, to the audience as the camera follows him when he is working in his laboratory and office. Bernard is said to belong to a group of hardworking and idealistic medical doctors who remain anonymous in the history of medicine, but whose work is just as important as the work of their more famous colleagues. The speaker continues by relating Bernard’s work to a longer medical history. On the wall behind Bernard’s desk are pictures of famous scientists, and as the camera cuts to

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

172

Communicating the history of medicine

close-ups of these pictures the speaker informs us about the accomplishments of the men portrayed. We are, for example, shown images of Antonie van Leeuwenhoek, Paul Ehrlich and Louis Pasteur. The speaker employs a language of military metaphors as he describes the work of Bernard and his antecedents as a ‘battle’ against the diseases and compares the type of scientist that Dr Bernard represents to the Unknown Soldier, a language common in the discourse around illness in general.36 The film reconnects to this narrative in the ending scenes. Having worked late into the night in his lab, Bernard finally seems to have reached a scientific breakthrough in a specimen labelled ‘B 43’. Realizing this, Bernard turns to look at the picture of Paul Ehrlich in his office, and, as he does so, the numbers ‘606’ shortly appear over the picture – the number of Paul Ehrlich’s famous compound that became the drug Salvarsan. Turning around and picking up the glass jar with his own specimen, the text ‘B 43’ appears in a similar way in the shot framing Bernard, suggesting that he has managed to create a drug of comparable importance as Ehrlich’s. Bernard then sits down by his desk, but, as he is about to continue working with his microscope, he suddenly puts his hand on his chest as if suffering a heart failure. He then turns his attention to a picture of a woman that he keeps on his desk – a woman who we later find out was the love of his youth. In a sequence of shots of mental subjectivity, the woman in the picture comes to life and speaks to Bernard, asking him if there is really no way of saving her. Bernard says that he would give his life to save her, whereupon he drops the picture and dies in his chair. In these scenes, Dr Bernard’s work is thus not only located within a longer medical history, but also put into historical context through his personal experience – medicine is understood to have come a long way since the woman in the picture died. That the implied audience was placed in a certain viewing position can also be noticed through the frequent use of medical images in the films. Robert Eberwein has identified a recurrent trait of many sex education films – ‘[…] the thematizing of vision and the dramatization of conditions of reception’.37 Sex education films tend to use visual means to influence their viewers, while at the same time featuring characters who are similarly influenced by these visuals, a strategy that also functions to validate the viewing experience for the audience.38 For

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

173

example, in Kärlekslivets offer, visual representations of the effects of syphilis are recurrently shown. In a lecture that Dr Bernard gives to a group of nurses, still images as well as a film demonstrating the different stages of syphilis are used. And in another scene, wax images of sores caused by syphilis are shown to a group of medical students. There are also microscopic shots of germs, as well as statistical charts of the number of cases of syphilis and gonorrhoea per year in Sweden. Similar images can be seen in other films of the time period, as well as other types of images with a shocking potential – for example, of childbirth. That images like these were used to influence the audience in different ways is clear. Most probably, images of venereal disease were used in an attempt to horrify audiences so that they would be more careful in their sexual behaviours. At the same time, the images were probably part of the attraction of the films. The practice was common also in films from other countries and has been discussed by different scholars. For example, Schaefer defined forbidden spectacle (like images of childbirth or venereal disease) as the most central stylistic characteristic of the classical exploitation film.39 And Christie Milliken has discussed the inclusion of horrifying images of venereal disease on the body into Second World War training films in relation to their assumed corporeal effect on the spectator, connecting the film type to Linda Williams’ influential discussion of ‘body genres’.40 Indeed, sex education films on the Swedish market fit into these analyses. The sensational content was, for example, often highlighted in advertisements and film posters in a way similar to how exploitation films were marketed.41 Moreover, the press often reported that people fainted or felt sick at the screenings.42 It is thus reasonable to conclude that the idea behind the imagery was a combination of educational and commercial rationales. Interesting in this context, however, is the view of the censorship authority. Film censorship as an institution relies on the assumption that moving images affect their audiences in a way that other media do not. That medical images of the kind often shown in sex education films were expected to have an influence on the audience of the film was probably obvious to the National Board of Film Censors. Scenes of the kind were thus sometimes cut, but the motivation behind these decisions was that one did not want to risk creating a fear of sex or a fear of giving birth.43 Rather than repressing sexuality as such, the National Board of Film Censors can, in these cases, be understood as

174

Communicating the history of medicine

an actor that wanted to diminish the presumed negative effects of certain films on people’s sex lives.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Medical science as a means of liberation

If the sex education films produced in Sweden during the 1940s and 1950s were characterized by certain narrative conventions and common types of educational address, the sex education films made in the 1960s and the 1970s looked quite different. From the late 1950s, sex education films had started to be more common in Swedish schools, and the number of films in the genre distributed to cinemas decreased. However, by the end of the 1960s, a series of films were made in Sweden, starting with the extremely successful Ur kärlekens språk (Language of Love; Torgny Wickman, 1969), which was followed by no less than three sequels in the early 1970s, as well as a number of films made from material from the original films. As might be expected, these films differed a lot from films made in earlier decades. The ‘sexual revolution’ of the 1960s and 1970s is quite manifest in these films, not least as they include a number of explicit and unsimulated scenes of different sexual acts. One continuity with earlier examples, however, is that the medical perspective is still central. In contrast to films of earlier decades, the Language of Love films were not fiction films, but instead employed more direct forms of audience address. The films were made in collaboration with well-known Scandinavian experts in the field of sexuality. In the first film, sexologist Maj-Briht Bergström-Walan, the Danish sex educators Inge and Sten Hegeler and gynaecologist Sture Cullhed participated. The film is structured around a sequence of discussions between these experts as they are seated in a living room while drinking tea. Between these scenes, the audience is shown different fictional and documentary sequences that are meant to illustrate the subjects dealt with by the experts. The sequels are structured in similar ways, but with a range of experts in the different films, most in only one film. The films in the Language of Love series have a completely different focus to earlier films of the genre. Instead of putting the negative consequences of sexuality at the centre, the films aim to help the audience to achieve a better sex life. The starting point of the film series is the assumption that people in general suffer from various problems caused

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

175

by repressive attitudes, taboos and ignorance, but that knowledge obtained from sex research can help people achieve a more satisfying sexual life – in short, science leads to liberation. This is made clear in the opening of the first film. The film starts with the credits shown over a series of images of Japanese erotic art from the twelfth century while a Swedish song with a sexual motif from the seventeenth century can be heard on the soundtrack. After this, there is a cut to the experts in the living room who begin to discuss views on sexuality in Europe over history. Here, the West is contrasted to the East, as Inge Hegeler comments on the Japanese art by saying that, at the same time as these images were given to brides, people in Europe used blood from pigeons to suggest that brides were virgins at their wedding nights. Different restrictions on sexuality in Europe are then discussed by the experts, and it is described how ‘a wave of taboo’ (Bergström-Walan) or ‘a whole complex of taboos’ (Inge Hegeler) have existed until the present day.44 After this, a number of stylized and fictional scenes of couples with various problems in their sexual lives are shown. The point of departure of the film is thus the claim that sexuality in the Western world has long been taboo, and that this still has consequences on many people’s sex lives today, a discourse quite clearly illustrating Michel Foucault’s famous notion of the ‘repressive hypothesis’ – the often-expressed claim that sexuality for long has been repressed and that we still live under the yoke of this repression.45 Later in the film, Cullhed reconnects to this view of history as he briefly explains the lack of knowledge about sexuality in past times and emphasizes the importance of recent sex research. He acknowledges that there have been important pioneers earlier on – Robert Dickinson, LeMon Clark and Theodor Van de Velde are mentioned as examples – but then goes on to say that it was not until Alfred C. Kinsey’s famous studies that the true breakthrough came. Kinsey, however, did not explain what happens in the body during sex, Cullhed says, and he then goes on to introduce the American sex researchers William H. Masters and Virginia E. Johnson, who in 1966 had published the results of their research on human reactions to sexual stimulation in the book Human Sexual Response.46 While talking about the earlier scientists, Cullhed has been facing the other experts in the group, but when starting to talk about Masters and Johnson, he suddenly turns and faces the camera, thus addressing the audience directly. This stylistic choice underlines

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

176

Communicating the history of medicine

the importance of what Cullhed is saying and signals to the viewer that he or she should pay attention. It thus places the research of Masters and Johnson in focus of the film. In the Language of Love films, the work of Masters and Johnson is the primary inspiration, and one aim of the first film is, in fact, to reconstruct Masters and Johnson’s studies in order to demonstrate their results to the viewers. This is done through two sex acts shown in different parts of the film – one of a masturbating woman and the other of a man and a woman having sexual intercourse. The scenes are both shot in a setting resembling a laboratory: the participants lie naked on a big, white, round, rotating bed without any pillows or blankets, and are shot with hidden cameras (the construction of the set is carefully explained by Cullhed early in the film). The scenes are also presented through the use of split-screen. As the acts are performed, smaller screens show close-ups of different body parts, animated cross-sections and a diagram indicating in which phase the participants are in their respective ‘sexual response cycles’ – the model created by Masters and Johnson to describe physiological reactions to sexual stimulation. Throughout the scenes, Cullhed also comments on what happens through a voice-over. This and other sex scenes in the films are part of the series’ pedagogical mission. Showing the audience explicit sex on screen, ‘reality as it is’, as Cullhed expresses it in one scene,47 was part of the aim to break down repressive taboos of the past and liberate the audience through the scientific ‘truth’. Language of Love was a unique film when it premiered. During the 1960s, a liberalization of film censorship took place in Sweden and increasingly explicit representations of sexual acts were, through the decade, approved by the National Board of Film Censors. Pornography was also debated, and was, as a consequence, legalized in 1971.48 Language of Love and its sequels were part of this process, and the films consequently became the object of much discussion on different levels, not least as censorship cases. A similarity with earlier films has to do with the use of medicine and a scientific discourse to legitimize content that would otherwise have been banned. Indeed, the big question around the films became whether they were to be considered sex education, or if they were rather pornography disguised as sex education. This was especially pertinent for the first two films in the series, as they were

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

177

made prior to the legalization of pornography, which meant that they would have been illegal if defined as pornography. After lengthy negotiations, the films were, however, released.49 Referring to sex research was not unusual during this era. In the US, a genre appeared during this time period often referred to as ‘marriage manual’ films, a type of film that purported to have scientific aims in order to get away with showing sexual acts on screen.50 Indeed, another name for this film type was ‘white-coater’, a term referring to the common use of people dressed as medical doctors or scientists in these films.51 Certainly, the genre identity of the Language of Love films is not at all clear, and the frequent suspicion that these films were an expression of commercial speculation that took advantage of the newly won freedom of the art form is not without reason. For example, the films were produced by the newly started company Swedish Film Production Investment AB, a small production company that in the 1970s would become one of the most successful producers of pornographic film in Sweden.52 On the other hand, the films are not really comparable to their United States counterparts, as they were clearly made in collaboration with a large group of established and respected experts in sexual issues during this time. Conclusion

This chapter has aimed to explore the role of medicine and its history in the relationship between Swedish sex education films and their audiences. Medicine was important in this relationship in two intertwined ways. First, medicine played an important role in assumptions about the influence of the films on their audiences. Through framing the films within a medical discourse – for example, through their content, their marketing and restricted exhibition contexts – film producers and distributors tried to manage audiences and their behaviour, thereby getting the films approved by censors and accepted on the commercial market. A medical framework was presumed to produce legitimate readings of the films, while the inclusion of medical images in the films was used both to affect the audience in different ways and to attract their interest. Second, medicine was part of the educational address of the films. Sex education films often represented medical doctors as heroic characters

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

178

Communicating the history of medicine

and used rhetorical strategies in which a repressive past was contrasted with the present-day situation, thereby positioning the implied audience in a certain relationship to medical knowledge. Overall, the films can be seen as an expression of the medicalization of sexuality that had occurred in the Western world since the late nineteenth century. In a national context, they can moreover be understood as reflecting a strong belief in rationality and progress that is often seen to characterize the Swedish welfare state during the twentieth century. But the films themselves also participated in this process. Portraying venereologists, gynaecologists and sex researchers as heroes and trustworthy authorities, and giving the real doctors that participated in the productions a public visibility and an arena to express themselves, it can be argued that not only did medicine legitimize the films – the films also helped legitimize the work of doctors within a particular subfield of medicine. Consequently, while the aim of the films was to create an enlightened or liberated audience, the implied audience was at the same time subordinated to a medical authority.53 However, the function of medicine and medical authorities in the films is ambiguous. Used to ensure the films passed censorship, the medical perspective meant that the films were judged as harmless for their spectators. Nevertheless, as discussed, medicine was also part of their commercial attractiveness – for example, through the use of medical images of venereal disease and childbirth or through the restaging of Masters and Johnson’s scientific experiments. Here, medicine was not seen as harmless. On the contrary, these images were often precisely what made the films controversial. This ambiguity characterizes the sex education film in general. Although many films were seen as reliable and important, there was at the same time scepticism to the genre as a whole, which I interpret as closely intertwined with the fact that the films were made for screenings in cinemas. If Sweden has historically been known as a progressive country when it comes to sex education, not least because Sweden was the first country in the world to make sex education mandatory in schools in 1955, it has at the same time been considered important that sex education is carried out by an official authority – not the family or the commercial market.54 However, it was not only the film companies who wanted the films to perform well at the box office – medical experts and sex educators involved in the productions had chosen the medium of commercial cinema for a reason.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

179

As many scholars who have studied the genre have discussed, the relationship between education and entertainment is thus quite complex.55 This complexity has not disappeared. At the beginning of this chapter, I briefly described some of my own experiences of talking about my research with different audiences as an example of how the delicate character of sex education films remains. Needless to say, my occasional uncertainty is nothing compared to the problems that sex educators of the past have struggled with, and teaching the results of my research or talking about it in more popularized form is obviously not the same type of education that sex educators engage in. Yet, sexuality is still a sensitive topic and the border between sex education films and pornography continues to be unstable, which is made clear by the fact that sex education films today also trigger protests.56 Accordingly, there are similarities between the difficulties that past sex educators encountered and the ones that I have come across. Just as sex education films were constantly at risk of being seen as speculative or crossing the border into the forbidden, which could undermine or completely halt their possibilities to make an impact, I have felt that my research similarly runs the risk of being sensationalized and consequently deemed unimportant. Furthermore, if assumptions about audiences and the influence of cinema affected how sex educators in the past constructed their educational rhetoric and how censors and film companies handled the screenings, awareness about possible reactions to my research likewise shapes the way in which I choose to present it to different audiences. Hence, although medicine in particular is no longer a necessary framework to create legitimacy, maintaining a balance between the acceptable and the unacceptable is still a complicated matter in the communication of knowledge about human sexuality. Notes 1 See, e.g., Manon Parry, Broadcasting Birth Control: Mass Media and Family Planning (New Brunswick, NJ, and London: Rutgers University Press, 2013). That the influence of film has for long been a topic of interest and debate among health educators is evident as there was audience research done on sexual health films already in the early 1920s. See Anja Laukötter, ‘Measuring Knowledge and Emotions: Audience Research in Educational

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

180

Communicating the history of medicine

Films at the Beginning of the Twentieth Century’, in C. Bonah, D. Cantor and A. Laukötter (eds), Health Education Films in the Twentieth Century (Rochester: University of Rochester Press, 2018), pp. 305–326. 2 This chapter is based on selected parts of my dissertation ‘The Most Delicate Subject: A History of Sex Education Films in Sweden’ (Lund: Lund University, 2012). The quote is from S. Karlung, ‘Det ömtåligaste ämnet’, Tidskrift för svensk skolfilm och bildningsfilm, 6 (1928). 3 Björklund, ‘The Most Delicate Subject’. 4 See M. Larsson, ‘“Vem behöver den här yttrandefriheten?” Om filmcensur och rörliga bilders farlighet’, in S. Johnsdotter and A. Carlbom, Goda sanningar? Debattklimatet och den kritiska forskningens villkor (Lund: Nordic Academic Press, 2010). 5 See, e.g., Nikolas Glover and Carl Marklund, ‘Arabian Nights in the Midnight Sun? Exploring the Temporal Structure of Sexual Geographies’, Historisk Tidskrift, 129:3 (2009), 487–510. 6 P. Robinson, The Modernization of Sex: Havelock Ellis, Alfred Kinsey, William Masters and Virginia Johnson (New York: Harper & Row, 1976). For the Swedish context, see C. Ekenstam, Kroppens idéhistoria: Discplinering och karaktärsdaning i Sverige 1700–1950 (Hedemora: Gidlunds Bokförlag, 1993), pp. 248–289. 7 Ekenstam, Kroppens idéhistoria, pp. 215–218, 252–255. 8 J. Weeks, Sexuality, 3rd edn (London and New York: Routledge, 2010 [1986]), pp. 5–6. 9 See L. Lennerhed, ‘Taking the Middle Way: Sex Education Debates in Sweden in the Early Twentieth Century’, in L. D. H. Sauerteug and R. Davidson (eds), Shaping Sexual Knowledge: A Cultural History of Sex Education in Twentieth Century Europe (London and New York: Routledge, 2009), pp. 55–57. 10 L. Lennerhed, ‘Sex Reform in the 1930’s and the 1940’s: RFSU: the Swedish Association for Sex Education’, in L.-G. Tedebrand (ed.), Sex, State, and Society: Comparative Perspectives on the History of Sexuality (Södertälje: Almkvist & Wiksell International, 2000), p. 391. 11 The concept of ‘implied audience’ derives from the concept of ‘implied reader’ in literary theory. See, e.g., S. Livingstone, ‘Media Audiences, Interpreters and Users’, in M. Gillespie (ed.), Media Audiences (Maidenhead: Open University Press, 2005), pp. 38–39. For a discussion of the various approaches to studying the audiences of health education films, see T. Boon, ‘Truffle Hunters and Parachutists: In Search of the Audience for British Health Education Films, 1919–45’, in Bonah et al. (eds), Health Education Films in the Twentieth Century, pp. 327–349. 12 R. Eberwein, Sex Ed: Film, Video, and the Framework of Desire (New Bruns­ wick, NJ, and London: Rutgers University Press, 1999), pp. 15–62;

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

181

C. Milliken, ‘Generation Sex: Reconfiguring Sexual Citizenship in Educational Film and Video’ (unpublished dissertation, University of Southern California, 2003), pp. 36–91. 13 E. Schaefer, ‘Bold! Daring! Shocking! True!’ A History of Exploitation Films, 1919–1959 (Durham and London: Duke University Press, 1999), pp. 17–41. 14 Miriam Posner, ‘Prostitutes, Charity Girls, and The End of the Road: Hostile Worlds of Sex and Commerce in an Early Sexual Hygiene Film’, in Bonah et al. (eds), Health Education Films in the Twentieth Century, pp. 174–187. 15 For the history of sex education films in the US, see Eberwein, Sex Ed, and Milliken, ‘Generation Sex’. 16 Examples include the Austrian film Hygiene der Ehe (The Hygiene of Marriage; 1922, imported in 1924), the French film La baiser qui tue (The Kiss that Kills; Jean Choux, 1927, imported in 1929), the Swiss film Frauennot – Frauenglück (Women’s Misery – Women’s Happiness; Eduard Tissé, 1930), and the Russian film Abort (Grigorij Lemberg and Noi Galkin, 1924, imported in 1936). 17 M. Hagener and J. Hans, ‘Von Wilhem zu Weimar: Der Aufklärungs- und Sittenfilm zwischen Zensur und Markt’, in M. Hagener (ed.), Geschlect in Fesseln: Sexualität zwischen Aufklärung und Ausbeutung in Weimarer Kino 1918–1933 (München: Edition Text + Kritik, 2000), p. 10. 18 Hagener (ed.), Geschlect in Fesseln. 19 In Swedish: ‘förråande, upphetsande eller till förvillande av rättsbegreppen’. E. Skoglund, Filmcensuren (Stockholm: Bokförlaget PAN/Norstedts, 1971), p. 18. 20 Skoglund, Filmcensuren, p. 18. 21 National Archives of Sweden, Arninge (hereafter RA), archive of Statens biografbyrå (hereafter SB), E 2: 147, 2155/23, Letter from Oscar Rosenberg, Norwegian censorship card and certification note by Dagny Bang. 22 RA, SB, D 1 A: 21, 32, 644. 23 Svensk författningssamling 1929: 305, § 6, and 1954: 512, § 6. 24 In Swedish: ‘rädda för att filmens budskap skulle slås sönder av generade flatskatt och fnissningar om ynglingar och flickor satt på samma bänk.’ Unsigned, ‘Vi diskuterar: “Kl. 7: damer, kl. 9: herrar”’, Expressen, 8 February 1952. 25 See, e.g., ‘“Endast för vuxna kvinnor”: En märklig stipulation till favör för reklamen’, Biografbladet, 5:2 (1924), 53–54; Berton (B. Onne), ‘Aveny’, part of the article ‘Din kropp är din’, Arbetaren, 5 April 1949; M. Edström, ‘Skandia: Möte med livet’, Arbetaren, 2 February 1952; Anon., ‘Filmcensuren’, Expressen, 8 February 1952. 26 G. Klackenberg, ‘Filmcensuren och sexualupplysningen’, Populär tidskrift för psykologi och sexualkunskap, 1:4 (1950), 7.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

182

Communicating the history of medicine

27 SOU 1951: 16, Filmcensuren – Betänkande I avgivet av 1949 års filmkommitté (Stockholm, 1951), p. 32. 28 Poster for Schleichendes Gift, private collection. 29 B. Bengtsson, ‘Ungdom i fara: Ungdomsproblem i svensk spelfilm 1942–62’ (unpublished dissertation, Stockholm University, 1998), p. 263. 30 J. Staiger, Media Reception Studies (New York and London: New York University Press, 2005), p. 2. 31 L. Furhammar, Filmen i Sverige: En historia i tio kapitel och en fortsättning, 3rd edn (Stockholm: Dialogos förlag, 2003), pp. 163, 171–177, 192; J. Olsson, Svensk spelfilm under andra världskriget (Lund: Liber läromedel, 1979), pp. 16–17, 100; Bengtsson, ‘Ungdom i fara’. 32 B. Nichols, Representing Reality: Issues and Concepts in Documentary (Bloomington and Indianapolis: Indiana University Press, 1991), pp. 34–38. 33 A. Kuhn, Cinema, Censorship and Sexuality, 1909–1925 (London and New York: Routledge, 1988), pp. 51, 53–56. 34 Schaefer, Bold!, p. 31. 35 In fact, in Swedish cinema in general, medical doctors are seldom portrayed as being ‘bad’. See G. Weiner, ‘Hjälte, bov eller förförare: Läkarens roller på bioduken stereotypa men fascinerande’, Läkartidningen, 98:15 (2001), 1816. 36 S. Sontag, Illness as Metaphor and AIDS and its Metaphors (New York: Picador, 2001 [1978, 1988]), pp. 64–67, 96–99. 37 Eberwein, Sex Ed, p. 4. 38 Ibid., pp. 4–6. 39 Schaefer, Bold!, pp. 75–95. 40 Milliken, ‘Generation Sex’, pp. 102–103; L. Williams, ‘Film Bodies: Gender, Genre, and Excess’, Film Quarterly, 44:4 (1991), 2–13. 41 See, e.g., advertisement for We Want a Child (Lau Lauritzen and Alice O’Fredricks, 1949), Biografägaren, 24:10 (1949), and poster to Schleichendes Gift. 42 E.g., Anon., ‘Herrar svimmar av Smygande gift: Dampubliken klarar sig bättre’, Afton-Tidningen, 21 October 1947; Anon., ‘För starkt för män’, Aftonbladet, 3 November 1949. 43 Klackenberg, ‘Filmcensuren’, pp. 6–7. 44 In Swedish: ‘en våg utav tabu’, and ‘ett helt komplex av tabu’. 45 M. Foucault, The History of Sexuality. Vol. 1, The Will to Knowledge, trans. R. Hurley (London: Penguin 1998 [1976]), pp. 3–35. 46 William H. Masters and Virginia E. Johnson, Human Sexual Response (London: J. & A. Churchill Ltd, 1966). 47 In Swedish: ‘verkligheten sådan den är’.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Swedish sex education films and their audiences

183

48 See E. Björklund, ‘The Limits of Sexual Depictions in the Late 1960s’, in E. Björklund and M. Larsson, Swedish Cinema and the Sexual Revolution: Critical Essays ( Jefferson, NC: McFarland, 2016), pp. 126–138. 49 The second film was, however, cut. See Björklund, ‘The Most Delicate Subject’, pp. 153–200, for a detailed account of the discussions around the films. 50 E. Johnson, ‘Sex Scenes and Naked Apes: Sexual-Technological Experimentation and the Sexual Revolution’ (unpublished dissertation, University of Texas, Austin, 1999), pp. 200–225. 51 Ibid., p. 219. 52 M. Larsson, ‘Practice Makes Perfect? The Production of the Swedish Sex Film in the 1970s’, Film International, 8:6 (2010), 40–49. 53 I am thankful to Sven Widmalm for pointing this out to me. 54 B. Sandström, Den välplanerade sexualiteten: Frihet och kontroll i 1970-talets svenska sexualpolitik (Stockholm: HLS Förlag, 2001), pp. 193–196. 55 See, e.g., A. Koivunen, ‘Syndens spår?: Om fördärvets spektakel i finländska syfilisfilmer 1945–1948’, Aura, 2:4 (1996), 53–55; Eberwein, Sex Ed, p. 36; Schaefer, Bold!, pp. 154–156. 56 See E. Björklund, ‘Statlig sexpropaganda? UR:s och RFSU:s sexualupplysningsfilm Sex på kartan’, in E. Hedling and A.-K. Wallengren, Den nya svenska filmen: Kultur, kriminalitet & kakofoni (Stockholm: Atlantis, 2014).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

9

On ‘the use and abuse’ of medical history ‘for life’: a disrupted digression on productive disorder, disorderly pleasure, allegorical properties and scatter Michael Sappol

For Elizabeth Fee (1946–2018), historian, activist, protector, friend

Walter Benjamin, in a notebook entry, muses that ‘a sort of productive disorder is the canon of the mémoire involontaire, as it is the canon of the collector …’.1 Which intrigues me, even if I am not sure how to take it. Benjamin was a restless thinker. He knew that, in collecting objects from different locations and periods, the collector makes a selection that brings some order to the indifferent scatter of things – makes a ‘canon’. But, like a plunderer of archaeological sites, the collector also disturbs an order, pulls things out of a remnant context. (Even the most abandoned and jumbled order is packed with reliquary evidence of events, traces.) In collecting objects and traces and stories, and narrating them, the historian does something similar. That could be a purposeful reconstruction of events based on trace evidence (the forensic principle), but Benjamin’s reference to mémoire involontaire (taken from Proust) excludes purposeful action and replaces it with an accidental effect that one may opportunistically exploit or not – a kind of secondary agency. I am a historian of sorts, an involuntary memoirist. In the course of an off-kilter career, I have worked/played with professors and graduate students outside the confines of an academic department, and at meetings and symposia and chance encounters in libraries and archives. No

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

185

students to teach or grade. I occasionally publish in journals, but mostly curate, edit and present (exhibitions, illustrated talks and websites). I address a tiny sliver of the general public, but mostly historians. And for many years I addressed and cultivated a special constituency: administrators of the National Library of Medicine (NLM) and the National Institutes of Health (NIH), who do not give much thought to historical artefacts and scholarship, things that are peripheral to their biomedical mission of understanding, curing and preventing disease. This scatter of thoughts, prompted by the unexpectedly challenging assignment of preparing this chapter, are a kind of disrupted mémoire involontaire (echoing my customary practice). We will attend to some work experiences shortly, but first consider this: ‘the person who collects … takes up the struggle against dispersion[,] … is struck by the confusion, by the scatter, in which the things of the world are found …’ (Walter Benjamin, The Arcades Project, 211; H4a). And this: ‘How the scatter of allegorical properties (the

Figure 9.1  ‘zero [0] vs the cooked’

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

186

Communicating the history of medicine

patchwork) relates to this creative disorder is a question calling for further study’ (The Arcades Project, 211; H5). Dear reader, please wonder along with me: what makes the scatter? Who encounters it? Who takes on the task of further study? Words on the page (and wall and screen), like the collectors and collections that Benjamin invokes, figure an audience and presenter. You, reading. Me, writing. A singular dyad, a chimera and also a division between you and me, within you and me, shared identifications, split personalities, mistaken identities. Word by word, phrase by phrase, paragraph by paragraph, yoked together, sitting together, generate chains of meaning or do not. Clouds of knowing and unknowing. And therefore politics. The dismal setting for our work

What is it that we perform in historicizing books and articles, historicizing exhibitions, websites, databases, historicizing comments and commentaries? How should we situate ourselves and regard our real and imaginary readers, listeners, viewers? Our work takes place in settings. There are expectations, realistic and unrealistic. For better or worse, things do not turn out the way we figure. An audience gathers – to enter into history, taste a small morsel of historicity. Small or large, it applauds, bridles, is moved to action – or dozes off or slips away – or never shows up in the first place. How dreary to contemplate ‘process’, ‘audience’, ‘reception’, ‘impact’. We fall into generic modes: demographics, assessment, memoir, metaphor, jeremiad, shop talk, prophesy, self-promotion, incantation, reportage. Inside and outside of our words, our books and articles and other work are subjected, by forces much bigger than we are, to a barren standard founded on ‘hard’ quantitative data, the prison house of numbers. Economists have a word for what happens outside the metrics, outside classical economics and free-market theory: externalities. Externalities: the results that quarterly and annual reports omit, the costs that have been pushed off onto other people, places and times. Global warming; the poisoning of workers and communities; the anxious burdens of consumer choice; the disorientation of accelerating information and objects; the proliferation of un- or under- or overregulated black-and-white markets; the trafficking of men and women and children (for all kinds of labour, not just sex work); the effects of the

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

187

lopsided distribution of wealth on electoral politics and public policy; the prison-industrial complex and every other hyphenated industrial complex. Externalities, then, deal with things that are not at all extraneous: the work of making and unmaking persons, the cultural and political costs of doing business, and the business costs of doing culture and politics. (And also, lest it slip away unnoticed: every random, unintended, unquantifiable benefit.) And consider this externality: the cost of making sense of it all, existential, phenomenological costs of accommodation, negotiation, resistance and so on. But we are already beginning to slip: cost implies a balance sheet, but these things cannot be tallied. Our political economies produce invisible unpriceable cognitive blow-back: philosophies, novels, paintings, sociological theories, ethnographies, histories, nonspecialist, extra-generic comment and commentary, partially articulated ‘feeling’. Not on the spreadsheet. Of course, those things also have externalities, some entirely detached, others loosely connected like flaps, others intersecting at rigid right angles or diametrically opposed negations. Invisible structures. We lose track of the political economy and poetics and dramaturgy of our scholarship and moods. Lose track of time, enduration, the history of our history.

Figure 9.2  ‘of “how” and “why,” for’

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

188

Communicating the history of medicine

We try to be vigilant, train ourselves to keep externalities in eyeshot. But mostly we are conditioned to see only what is right in front of us. We cannot keep our eyes off the numbers: we rise and fall with them. We are indoctrinated, even if we want to believe that our understanding and critique of the metric immunizes us. The figures tally up publications, citations, book sales, web and exhibition visits, ‘followers’, etc., and then determine tenure, salaries, funding, book contracts, invitations of all kinds. But even when not subject to the tallies, we are cognitively harnessed to the system of scorekeeping, habituated by the constant pressure of the algorithms that animate web searches, promotional ads, ‘likes’, ‘followers’, surveys, scores. That taxonomy, the demography and inventorying and analysis of audiences, is no idle exercise: it is the basis for generally accepted institutional, epistemological, aesthetic accounting principles. (Fuck that.) The library

In the spring of 1872, John Shaw Billings (1838–1913), the bibliophilic military surgeon turned military medical-librarian, sent a letter to Dr Henry S. Jewett of Dayton, Ohio. In the wake of the American Civil War, and with the full backing of his superiors, Billings had embarked on a quest to make ‘a great national medical library’, ‘as complete as possible in all publications relating to military organization, medicine, and the allied sciences’, a ‘universal library of references’. To do that, he pulled together an expansive postal and social network of like-minded physicians and bibliophiles, many of them former Civil War medical officers, and sent a circular letter asking for help in acquiring books, manuscripts, prints and medical journals. Henry Jewett passed on Billings’ request to his father, Dr Adams Jewett, also of Dayton, who (through the medium of a letter written by his son) offered Billings a variety of titles. The senior Dr Jewett touted one book in particular, John Snart’s Thesaurus of Horror; or, the Charnel-House Explored!! (London, 1817): ‘No Lib[rar]y is complete without the HORRORS!!’. Billings took up Jewett on his offer, a shared transaction that served as a small ritual of homosocial fellowship between medical men who were also bookmen. The library got its ‘Horrors’ (catalogued today as W 600 S669t 1817), a book that – in salacious, exclamatory, repetitious detail – made a ‘historical and philanthropical inquisition …

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

189

for the quondam-blood of its inhabitants’, into the ‘gothic barbarity’ and ‘extreme criminality’ of ‘hasty funerals’, ‘descent into the untimely grave’, and ‘premature interment’ (with an earnest discussion of the marvellous ‘re-animating power of fresh earth in cases of syncope’). ‘The Horrors’ added nothing to the stock of universal medical knowledge, the ostensible goal of creating a great medical library. But did add to Billings’ pleasure in the culling of quaintly vulgar works from the quaintly superseded medical past. And did add to the shared enterprise of quaint culling and collecting that bonded together likeminded cullers and collectors. And so ‘the Horrors’, and similarly eccentric works, came to be shelved on or near to shelves that held volumes by Andreas Vesalius and William Harvey – works of monumental historical significance (which, of course, had their own antiquarian quaintness) – shelved only a small distance away from works of au courant significance by Rudolf Virchow, Claude Bernard, Emil du Bois-Reymond, Gustaf Retzius and other nineteenth-century greats. The library started out, in 1836, as the quasi-personal ‘Library of the Surgeon-General’ of the US Army. After the Civil War, it acquired an additional name, the ‘Army Medical Library’, when it was planted alongside the Army Medical Museum in Ford’s Theatre (only a few years after Abraham Lincoln had been assassinated there). A bit later the library and museum were transplanted to a red brick building on the National Mall in Washington (in the spot currently occupied by the Smithsonian’s contemporary art museum, the Hirshhorn). That facility became a great and celebrated repository of printed materials, specimens and objects, historical and contemporary, relating to medicine, health, disease and the body. (But it only takes a few decades for contemporary medicine to descend into history and obsolescence.) In 1956, the Armed Forces Medical Library, as it was then called, was detached from the US military (which retained the museum) and given to the NIH. Pushed off the Mall and rebranded ‘the National Library of Medicine (NLM)’, it was transplanted to the NIH campus in Bethesda, to better serve scientists and health professionals – at the cost of becoming less accessible to the broader public and losing its vital connection to the museum’s object collections and research projects. It was then already an encyclopaedic collection of manuscripts, books, prints, photographs, slides and motion pictures. Today it

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

190

Communicating the history of medicine

Figure 9.3  ‘closeted. (And remains’

contains more than 17,000,000 items, gathered by Billings and successors who took on the unattainable mission of bringing to one building all of the earth’s medical knowledge and experience, from antiquity to the present. That was, and is, an amazing accomplishment, but the public is largely unaware of the NLM. Even medical professionals mostly only know it through its databases (PubMed, MedlinePlus, ClinicalTrials.gov, the Visible Human Project), and not as a great historical library.2 In 1998 I began working as curator-historian in the Exhibition Program of the NLM’s History of Medicine Division. (I later shifted out of the programme and took the double title of ‘historian/scholarin-residence’.) It was a time of ‘dot.com’ economic prosperity. Politicians of both parties, Democrats and Republicans, squabbling over budget cuts to social services for the poor, nonetheless competed to

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

191

throw money at the NIH. A small part of that came to rest at the NLM (at high water mark some $250 million per year); and a small fraction of that came to the History of Medicine Division (some of it squandered, some put to good use). The Great Recession of 2007–2009 ended the era of federal largesse. Since then, the NLM, and its History of Medicine Division, have had flat or declining budgets, and have been forced to make cuts in personnel, programmes and services. The library sits uncomfortably within the NIH, a vast agency dedicated to clinical medicine, public health and biomedical science. Its historical holdings do not make much sense within the NIH: history does not contribute to genomic medicine or neuroscience or wars against cancer or AIDS. NIH administrators, for the most part, do not feel any great affection for ‘the Horrors’ or for any other piece of historical flotsam. In the past, physicians (some of them bibliophiles) were the main, nearly sole, users of the library. But nowadays people in the health professions tend to get their information online. The users of the historical collection are mainly scholars and students in the humanities – various fields of history (including but not limited to the history of medicine and science), art history, cultural studies, feminist studies, print culture, film studies, urban studies, etc. – not a constituency that NIH administrators feel responsible to. In the age of the Great Recession and its aftermath, the collection has come to be regarded as something of a burden, a collection of relics that is itself a relic and a drain on the NIH purse (albeit a very minor drain in the grand scheme of things). For the most part, NIH administrators only muster enthusiasm for digitization projects and databases. They also approve of exhibitions that celebrate recent medical progress or that make a show of reaching out to historically mistreated groups. The administrators and staff of the History of Medicine Division try to cope. My work, as exhibition curator and then scholar-in-residence, sat oddly within the library and the division. For various reasons, I struggled in the Exhibition Program. After I left it, I was mostly permitted to do as I wanted. I wrote for print and web on mid-twentieth-century modernist medical illustration; obscure and eccentric mid-twentiethcentury medical films; a study of a late nineteenth-century cataleptic stage performer who was dissected; the silent medical cinema of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

192

Communicating the history of medicine

Figure 9.4  ‘mask? By’

suffering; an imaginary exhibition on anatomy’s photography; really anything that struck my fancy. In this kind of historical practice what counted for usefulness carried a strange epistemological, existential, almost anti-historical, odour. History historicizes, but in a way that explains nothing or the wrong thing, seems disconnected from its surroundings. Benjamin: ‘How the scatter of allegorical properties (the patchwork) relates to the creative disorder’ of historical objects, as collected and narrated, is ‘a question calling for further study’. Of course, scatter and disorder and patchworks go unacknowledged in NIH and NLM mission statements and budgets, where the History of Medicine Division is obliged to present a utilitarian rationale for its activities. My ‘further study’ dealt with the contingent ideological, political, economic, personal effects of things long past: the performance of medical science and technology as rhetoric, the uses and abuses of scientific medicine for identity formations and deformations and reformations. Not really part of the programme. Mostly history for history’s sake.

On ‘the use and abuse’ of medical history ‘for life’

193

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

My history

In a wild, contentious essay, ‘On the Use and Abuse of History for Life’, Nietzsche insists on the need for historical work and consciousness ‘for life and action’, and dismisses ‘jaded idlers in the garden of knowledge’ who study history ‘as a convenient way to avoid life and action’.3 That gives pause: my history? A narcotic. An evasion. A disorderly flight into the past. The present is past – the cumulative and only partly knowable effects of human actions and environmental changes over short terms and longue durées, effects that enchain or enchant or press us. The past gives us birth, then crushes us in the present, where we live. And then there is history, an ongoing (demystifying, edifying) collective project that produces epistemologically secure accounts of the past for the present. For use; ‘a usable past’.4 Historical consciousness – what historian Roger Cooter calls ‘a sense of historicity’ – is a necessity for progressive social and political movements, provides an antidote to the lies and mystifications of nationalists, free market ideologues, and apologists for all sorts of crimes of the powerful.5 Historians nurture the historical consciousness that serves to direct and give momentum to the arrow of progress, the emancipation of the oppressed. Knowledge is power. But my history of medicine is a lotus blossom, an indulgence. My history shirks political and moral obligations, makes no policy recommendations, contributes no solutions to present-day problems. Like many of my colleagues, I cannot cope with the present. Which conduces us to become historians. Knowledge is powerlessness. Unusable history: a sprezzatura of aesthetic effects, a texturing element of interior decoration and consciousness, a mood elevator or depressor, the secret knowledge possessed by social isolates and competing gangs of academic connoisseurs who narcissistically circle each other, alternately admiring or dismissing each other. Instead of a heroic journey to liberation and redemption, history goes in fits and starts, one step forward, one step backward, shuffles to the side where it serves as a ‘musty’ distraction, collapses, ends up in a closet. Instead of shapely meanings and happy endings, crumpled life, made shapeless over short and longue durées, by innumerable encounters and exchanges that lead off in multiple and ambiguous directions. Micro and macro. Blow and blow back.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

194

Communicating the history of medicine

Figure 9.5  ‘And yet: historical unattainable’

The truth, it turns out, will not set you free. (At least, not automatically.) Figuring it out, deploying it in rhetoric, getting anyone to listen, persuading anyone, getting anyone to act – that is hard and uncertain work. I only fitfully try. Nietzsche says … what? Dream anatomy

The NLM’s exhibition programme started in the mid-1990s. When she took the position of chief of the History of Medicine Division,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

195

Elizabeth Fee pitched the idea that the NLM should have historical exhibitions in its 5,000 square foot rotunda. At the time that space was occupied by the furniture of the library’s card catalogue, which held the records of millions of retrievable items in thousands of drawers. The cards had been entirely digitized and had lost their reason to live (outside cyberspace). So the physical space was up for grabs and the various divisions of the library competed for the real estate. Fee and the History of Medicine Division won, and got the right to use the rotunda as an exhibition space. Typically, libraries produce exhibitions (and publications, lectures and events) to promote their name and collections, attract visitors and direct public attention to some extraordinary, historically significant and/or visually compelling set of holdings. But NLM exhibitions usually made little use of library holdings. Topics were selected without taking into consideration the strengths and weaknesses of the collection. Which made for problems; the objects chosen for display often had to be borrowed from other institutions in bulk. But one accidental, opportunistic exhibition ran counter to the tendency. The Exhibition Program was preparing a show celebrating the achievements of American women physicians (nice idea, but very few interesting objects to display!). The curatorial team (of which I was not a part) was in disarray – there were personality clashes and conflicts over content – and could not meet its deadlines. The exhibition that currently filled the space, The Once and Future Web (a misplaced show on the Internet and telegraph as parallel technologies that transformed the world), had been up for over a year, and was mostly made up of objects on loan from the Smithsonian that were due to be returned. We held a meeting. For some reason, I was inspired to improvise a pitch for a ‘fast-and-dirty’ show on the history of anatomy – one of the strengths of the library collection – to plug the hole in the exhibition schedule, keep the space occupied and give the women physicians group a chance to regroup. Fee gave us the go-ahead, and a barebones exhibition team (me as curator, exhibition coordinator Beth Mullen, and Riggs Ward, a design firm) went to work. We had little supervision. Distracted by the crisis of salvaging the women physicians exhibition, the Exhibition Manager, who usually closely managed the exhibition process, had no time to attend to us. We were on our own – as we wanted to be.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

196

Communicating the history of medicine

We had six months to prepare: a short lead time. I had written on the history of anatomy and had a feel for it, though no great knowledge of early modern anatomy.6 So I crammed, gave myself a crash course: there was no time or money for outside consultation. The budget was around $160,000 – tight compared to the several millions budgeted for other shows. Most of that went to exhibition design and fabrication. By inclination and necessity, we featured what the library had, supplemented with a few spectacular art installations that were cheap and easy to acquire or borrow. We saved money and time by re-using the vitrines, walls and footprint of The Once and Future Web. If an object did not fit in the case or on the wall or floor, it could not be in the show. To save more time, we mostly skipped the protocols of NLM exhibitionmaking. We held no focus groups, made no presentations to the Director, put off the Educator (who customarily wanted exhibition scripts to be tailored to the level of the school groups that she brought in). And we only used a few computer interactives (off-the-shelf products from the Visible Human Project), just enough to satisfy the Director. (An imperative: exhibitions must have interactives.)

Figure 9.6  ‘gardens awkwardly exhibition’

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

197

The exhibition was named Dream Anatomy. (I wanted Visionary Anatomies, but did not prevail; and later gave the name to the National Academy of Sciences for an exhibition there.) The plan was to feature imaginative, evocative anatomical representations of the interior of the human body, from the fifteenth century to present. A baggy concept that gave us lots of wiggle-room: it is hard to find anatomical images that are not evocative. The main exhibition statement set out the theme: ‘Anatomy is our inner reality. Anatomy is us. Even if we haven’t formally studied it … don’t know all the details, we carry around with us an anatomical image of self … that divides us into regions and territories, with place names and borders and topographical features …’. Dream Anatomy would gesture substantively, pleasurably toward the fact that this anatomical self-image had a long and gnarly history of knowledge production mixed with fantasy, theatrics, aesthetics, politics and much unrespecting play with the bodies of the dead, a sociocultural dreamscape. And folded into that: a history of collaboration, and vexatious disagreement, among anatomists, artists, engravers, patrons, printers, authorities and readers. A history of mixed technologies of representation. And a history of professions and political economy and social transformation. All of that: mapped onto, embedded within, structuring, the human body, anatomy. Us. Or not. And a contrapuntal theme: even in death, the body is powerful, resists efforts at explanation and demonstration. Materially, legally, visually, pedagogically. The dead body is difficult to semiotically manage, is obdurate and alien. Opaque, cryptic, multivalent. Anatomy is a black box, a crystal ball, a mirror … We see double: self and other(s). Life and death. Beauty and ugliness. Objectivity and selectivity. And whatever else we do or do not want to see. A proliferating excess of meanings. And we historicize that for the present moment: anatomical mirroring has a temporal polarity (an alternating current): past and present oscillate, move in and out of phase, collapse and separate. Metaphors mixed. I had developed some of this in my previous scholarship. More came, almost unbidden, in the course of object research and the crafting of exhibition text. We improvised, throwing stuff in, taking it out, figuring out what it might mean as we went along. As we got in deeper, the show began to say something that medical professionals and historians rarely acknowledge (at least publicly), but that teenagers and hipsters

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

198

Communicating the history of medicine

celebrate: the science (and history!) of anatomy gives us licence to look at and enjoy the monstrosity and grotesquery of our inner construction, and to take pleasure in death and its relics and icons. The corruption and dissolution of the human form, the danse macabre, the anatomical horror show, the carnival of anatomical views. Anatomists and their audiences took pleasure in using bodies and body-parts. That pleasure occupied centre stage in the anatomy of earlier times, and is in plain sight now in contemporary presentations of human anatomy and its history. (Pay attention, historians!) For the entry into the exhibition, we recruited a bizarre image from Govard Bidloo’s late seventeenth-century Anatomy of the Human Body.7 A detached dissected arm that reaches out of a closed book, tendons and muscles streaming, entirely liberated from the obligation to function. Extraordinarily naturalistic, utterly fantastic. The illustration, by artist Gerard de Lairesse, lies on the cusp between the allegorical theatre of sixteenth- and seventeenth-century anatomy, and the harshly detailed realism of mid-eighteenth-century anatomy (the style that Bidloo and de Lairesse inaugurated). Our designers scaled up the illustration into a 4-metre-high introductory installation that mimicked a book opened up in the middle. It dwarfed our visitors and suggested that anatomical images, and the books in which they were printed, were totemically bigger than the people who read and viewed them. It was a perfect front door for an exhibition on the relation between two-dimensional anatomical images printed in books, three-dimensional embodied life and the imagination. The dissected hand comes out of a book, which comes out of a dissection, which comes out of a book … A loop. We did not know if it would work, but it did. We featured it on posters and in press coverage. Our visitors – health professionals, students, medico-legal researchers for hire, etc. – were drawn to the entrance, brought back friends, posed in front of it for selfies and group photos. As a prelude to the entrance installation, we hung from the ceiling painted slices that combined to create the illusion of a floating (sleeping?) life-size three-dimensional body composed of twodimensional anatomical sections (a piece by artist Carolyn Henne, based on the NLM’s Visible Human Project). The decision to float Henne’s illusionistic body in front of the Bidloo book was a happy accident. We pushed forward the Bidloo hand and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

199

Figure 9.7  ‘contrapuntal theme: Even in death’

Henne body before we had figured out what they were saying. The meanings came later, from repeated viewing and presentation when visitors showed up. Somehow, the exhibition mobilized the poetics that Bidloo and de Lairesse so artfully staged. Tendons streamed from the hand like a scatter of semantic properties. Bidloo’s desire to show anatomical objects exactly as the eye sees them – that Netherlandish aesthetic that makes his anatomy so shockingly original – was infused with the pleasure of mounting an allegorical show, the desire to make visual poetry that astonishes and pleasures an audience. De Lairesse was a history painter, art theorist and musician, not just a brilliant anatomical illustrator. Bidloo was a librettist, poet, playwright and politician-courtier, not just an anatomist. They were a pair of showmen; their anatomical atlas collaboration was their masterpiece.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

200

Communicating the history of medicine

The dissected hand reaching out of a book also alluded to the mysteriously ambivalent relation between the living body and the anatomical dead. The hand came vibrantly alive in its florid dissection, pointed to the hand of the artist and the hand of the anatomist that made the dissection, and, by coming out of a book, alluded to the entire genre of anatomical publication. And, for our purposes, also alluded to our visitors who made reference to their own hands and bodies as they encountered that illustration and to the genres of anatomical objects and illustrations displayed in the show. And so Bidloo’s late seventeenth-century anatomical poetics served as an anatomical poetics for the dawn of the twenty-first century, set loose a scatter of disparate ideological and moral meanings and uses. A patchwork of lessons on art and history and culture, a patchwork of lessons on science, technology and the human body. Dream Anatomy’s visitors took the scatter, joined themselves to the patchwork, but so what? We led tours of the exhibition where visitors mostly reported that they loved it. (What else would they say?) Comments in the guest-book were mainly appreciative, but there were also snide, obscene and defamatory remarks (which defile and mock every comment book and unmoderated blog). Some comments cheered on the exhibition for its freakiness (a response I approved), but many had a reverential tone that ran against the grain of the exhibition text: Dream Anatomy shows the wonders of the human body and the miracle of God’s creation; Dream Anatomy shows the inspiring progress of science over the centuries. (Sigh.) How, then, did we really do? We felt validated when the New York Times and Washington Post covered the exhibition. We took pleasure in our accomplishment: we believed we had made an intellectually and aesthetically satisfying historical show on a complex theme. But, asked to supply quantitative data, we had no good metrics. No one could truly say what Dream Anatomy’s impact on visitors was or even how many people visited. We made up a number, a semi-plausible guess, to use as a prop in the show about the show that we put on for NLM administrators. The only reliable count came from the exhibition educator’s tally of school groups and scheduled tours. More validation came from the exhibition’s sideshow and afterlife. We held a symposium on the history of anatomical illustration and imaging; had a contest of children’s anatomical drawing; screened a

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

201

Figure 9.8  ‘the physical space was up’

series of films with anatomical themes; made a website; published a book-length catalogue. Since 2002, the fast-and-dirty and not-so-wonderful Dream Anatomy website has had millions of visits. The catalogue has been distributed via sales and giveaways to thousands of people, and is sometimes used in university-level courses. A few years later it was posted online, where it has been downloaded by tens of thousands of people (no reliable metrics on that either).8 Use and uselessness and scatter

And so we tasted the innocent pleasures of putting on a medical library history show. Which was a grand pretext to troll the stacks, get dusted on old texts and images and objects, to ‘idle’ in the ‘garden of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

202

Communicating the history of medicine

knowledge’ with colleagues, friends, visitors, readers. But idling and gardens do not adequately describe our exhibition-making. Gathering, sorting, writing and planning Dream Anatomy was a deadline-driven project, not exactly idleness, and only partly derived from the idleness of others. The garden (collection) that I idled and toiled in existed because John Shaw Billings and his collaborators and successors spent many hours of hard work to enable their idling play. Nietzsche did not credit the fact that gentlemen-scholars laboriously cultivated beforehand the archives they idled in. But no need to make a sharp distinction between work and play. My work is my pleasure; idleness gives rise to obsession and compulsion, so that we pleasurably labour to construct the niches we idle in. As every collector knows. Curating, I became a collector of the second degree, drugged myself on the pleasures of collecting within the collection – not to personally possess anything, but to collect library objects and images for showing and telling. Junkies work hard to get the next fix. This jumble of mixed metaphors? Should we embrace it? Everything jumbled together inside and around us. Nietzsche says that ‘we must organize the chaos within us’. Must we? (He never did.) Or like Walter Benjamin, should we approve ‘the confusion, … the scatter, in which the things of the world are found …’? We are born from that, grow in that, are shaped and reshaped, formed and deformed. We live in the wreckage of unarticulated, unnarrated, incommensurable events and regimes and technologies, performed mostly by anonymous actors: mysteries. Which we unveil and collude with. We (specialists, historians, everyone) are moved to narrate. Make reassuring or infuriating or heartbreaking or revelatory or boring stories. Tales of heroes, victims, bystanders, obligations, institutions, technologies, laws and objects. Tales of redemption or meandering. We try to eke out a measure of clarity, meaning. Maybe that results in wisdom, maybe a productive mess. Maybe ennui or a frisson of tingles and chills. Our ‘data points’ have no metric, do not contribute to job placements, economic growth, diversity or any calculus of fundable projects or awards or research assessment exercises. Benjamin concludes a section of the Arcades Project with a working suggestion, a self-contradictory note: ‘How the scatter of allegorical properties (the patchwork) relates to this creative disorder is a question

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

203

Figure 9.9  ‘An evasion. A present is past’

calling for further study’. Dream Anatomy took advantage of the ‘properties’ that Bidloo and other anatomists, over many centuries, had patched together, and scattered. It was a patchwork (patched together by everyone who had a hand in it), and left its own scatter (including these very comments). Benjamin, enchanted with the era of the Baroque, when elaborate allegory flourished, confined his discussion of scatter to one figure of rhetoric, allegory, in which every element of a scene or story refers to some other specific external element or chain of elements. What I take from Benjamin is this: archives, libraries, museum collections, and the individual and groups of objects within them, even if no longer attached to the networks that made and operated them, generate meanings, throw off semantic properties, stand as metaphors, metonyms, analogues and every other figure, are the nutrient soil in which those things grow. The more you know, the more there is to be known. The more the scatter. The more contingent, unpredictable effects proceed. And the more you can mess with that, as Bidloo did.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

204

Communicating the history of medicine

In anatomy (as in history), there always was (still is) a scatter of idle pleasures. Incidental scatter, but also deliberately concocted for the amusement of the anatomist, his patrons, colleagues and students. Anatomy studies and educates, but anatomical representation mocks the living, stages a comédie humaine, puts on a Grand Guignol, acts out an epigram, narrates an epic of medical discovery, may even wander in a pastorale or dance a minuet at court or pose as a still-life or romantic ruin (an allegorical figure that echoes the ruin of the dead dissected body). In the present moment – even though anatomists and medical illustrators customarily try to suppress metaphor and allegory – anatomy shows us ecological systems, computer networks, architecture, machines and other tropes connected to our experience and imagination. The anatomical body can give rise to an extraterrestrial fantasia (e.g. the glass-enclosed brains of the Martians in Mars Attacks!), become a Halloween costume or the geography of a fantastic voyage. Or a taste: of the textures of technologies and conventions of imagemaking, the engraver’s burin, the decorative or allegorical background, the grain of half-tone, the affective power of colourization (by hand, then stencil, then 3- and 4-colour printing process, then kodachrome and computer). Things that are not incidental to the history of anatomical representation, but not solely confined to it. Useless and useful information. We cannot survive on a diet of purposelessness. Dedicated purpose yields anatomical knowledge and histories of consequence: Susan Reverby on US Public Health Service’s syphilis experiments in Central America, David Rosner on the criminal negligence of the American lead paint industry over a century and so on.9 Activist medical historians are heroic. But our world also deserves – needs? – unheroic historians who careen on, or stumble about, without external direction or mandates, led by obsessions, passions, accidental encounters, bad habits, inclinations. Which brings us back to ‘the Use and Abuse of History for Life’ and the despised figure of the jaded idler, who shares some of the qualities of the flaneur and the Proustian layabout. Idling, idleness, gives rise to the mémoire involontaire, obsessive collecting, voyeuristic peeking and peekaboo, storytelling, semantic drifting and a bunch of other supremely useless but delicious activities. I wonder though: what if we get through by harnessing all of this peeking and scattering and hoarding and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

205

scattering and hoarding? Even if that productive purpose is obscure to the reader or listener or visitor or the idler. Once made, the thing drifts about, maybe retaining its form, maybe breaking apart. And once collected it becomes available for use or abuse or further idling. (Like the debate over basic research vs. applied science.) The scatter of properties and uses and abuses is in the wayward eyes of the beholder and deft or clumsy hands of the collector. (Sorry, Nietzsche!) Historical work is a magnet that pulls (strongly or weakly). Escapism never entirely escapes … Use. (Sorry, Benjamin!) The humanities is our Locus Solus. Yet we must be estranged: too many horrors inflicted in the name of human exceptionalism. Humanity is a weed species, a plague on the planet and itself: we are all implicated. Humanism can only be tragic or comic, not heroic. Lest we romanticize: humanism always has prejudices and patrons, always serves masters. The cultural ideal of disinterested scholarship, artistry, refined connoisseurship, like the universal human and democracy, has always been a mirage. And yet universalism, disinterestedness: precious social historical moral accomplishments, even if always unattainable, unfinished, patchwork, a scatter, a travesty, a comedy of errors. The NLM exhibition programme was (is?) a scatter of gift and work exchanges, an offering to the public and a tool of internal institutional diplomacy. We made Dream Anatomy as courtiers in the court of the capricious Library Director, whose favour and patronage we sought for our exhibition and events, the Exhibition Program and the entire History of Medicine Division. He could be supportive or hostile: we pandered to him, and tried to avoid his fits of temper. He in turn was a courtier in the court of the NIH Director, and used NLM exhibitions and programmes as entertainment and promotional material for powerful congressional representatives, NIH administrators and visiting scientific notables and celebrities. Substantive or not, exhibitions served as window dressing, promotional material, props in his courtship of potential allies and superiors. We flew the flag of ship NLM of the NIH flotilla. (The Exhibition Program website touted Dream Anatomy as a ‘flagship exhibit’.) Further on down the food chain: Elizabeth Fee, Chief of the History of Medicine Division, was a courtier in the Director’s court. I owed my job to her, was a courtier in her court and was also a problematic courtier in the court of the Exhibition Program Manager (a problem because

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

206

Communicating the history of medicine

Figure 9.10  ‘usefulness carries a strange’

Fee hired me over the Manager’s head and gave me direct access, which the Manager understandably resented). Courts within courts within courts. All of us were implicated, used exhibitions to make alliances and advance careers. Fee, a valiant left-wing historian and editor at the American Journal of Public Health, was an assiduous network builder. She used exhibitions to recruit members to her network. And recruited members of her network to make exhibitions. (And to collaborate with her on books and articles, get publications, win grants, spread a kind of left political consciousness.) She wanted exhibitions that were progressive, critical and smart. But not too provocative. The NLM, a governmental entity in the nation’s capital region, was potentially

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

207

under the eyes of a right-leaning Congress and local and national media. I was a low-level employee, and therefore had some latitude. I pushed it … a little … I wanted to please Fee and did please her. Which was OK. I was (am) also of the left. And even the degenerate aristocratic idler-historians who Nietzsche denounced had to please or pander to someone: a sugar or bio-daddy, rare-book dealer, archivist, wealthy patron or publisher. And maybe Nietzche’s unidentified idlers felt tugs of allegiance to difficult political ideals or noble causes. Or sought refuge in the shade and coolness of the garden to escape political heat. As for me, after doing one more show (on the history of forensic medicine), I skipped out of the Exhibition Program, but stayed on in the History of Medicine Division as ‘historian’ and ‘scholar-in-residence’, devoting myself to editing publications, curating websites, giving talks and writing books and articles on topics of my own choosing, until I entirely left the library in 2016. The time of my history

That is a small discussion of my practice as a historian. Still, I cannot get my mind around ‘the practice of the history of medicine’. I could easily celebrate it as a tool for social, gender and environmental justice, celebrate the methodological and philosophical advances of the field, the extension of our discipline along its horizontal and vertical axis. And celebrate the centripetal forces reshaping current historical practice. Which is less Euro- and America-centric, less physician-centric, even less human-centric. The ‘circle of we’ widens socially and topographically and ethically.10 We are geographically, environmentally, socially, culturally enriched. We go deeper and shallower in time. We draw on a rich assortment of disciplinary methods borrowed from sociology, anthropology, philosophy, economics, psychology, neuroscience, computer analysis. Our subject matter takes in a lot. We know more, do more. But then drift: stagecraft … empathic identification … historicizing moods … aestheticizing reverie … estrangement … curiosity … boredom … study … casual looking … distracted browsing … obsessive gazing … ambient reception … unmanaged dialogue … unmanaged play …

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

208

Communicating the history of medicine

Figure 9.11  ‘touted one book in’

We use objects as props to tell stories that double and triple: narratives about past and present, to which we have no unmediated access, and know only as sequences of connected or unconnected disruptions. We narrate provisionally, under the constraints of whatever relics survive. Our histories are always stories about the present, a sequel to what went before and a prequel to what went after. Our narratives, already bent under the weight of that, carry an additional burden. Are always about the historian, a covert autobiography. A construction that misconstrues itself. A lie, even if scrupulously faithful to the sources and scholarship. A mask that hides and reveals. But why should time be that mask? By focusing on elapsed events and persons and conditions, the historian drags selected aspects of elapsed time into the present, evokes what has elapsed. To what end? We historians have a professional and temperamental bias. We reflexively approve history: it is good to historicize. We like to think on multiple tracks that we can only partly articulate and acknowledge. Our time: in part conscious, in part buried within us and only dimly sensed, if that. (Conditioned by …?) Blended seamlessly into anachronism, the past in the present, or more compounded, as Carolyn Dinshaw

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

209

nicely puts it, ‘an expanded now in which past, present and future coincide’.11 My history starts in childhood, when everything was present and nothing was historical. But even so, saturated with history, pressed into shape by the unacknowledged, unnarrated, unknowable past. My mother and father wanted to be moderns. They hoped that leaving behind their Jewish neighbourhood in Brooklyn for a newly built modern garden apartment in Queens, New York, and then a newly built modern house in a newly built modern housing development in suburban Long Island, would liberate them from history. They wanted to repeal the past, be newly born, free. For them, that meant being American and Communist and aesthetically modernist. Jewishness could never be disowned (that would be betrayal). But it had to be narrated just so: the Jews not as an ancient race but a redeemer people, leading humanity away from its horrific history into the emancipated future of science, reason, human rights, social justice. As for personal history, they reckoned that what they inherited was inconsequential or corrupted by contingency or desire: freshly concocted for the occasion at hand, even if it broadly corresponded to known facts. They had no nostalgia for the world we have lost. As for me, I was mystified: things had happened, preceded me. But what? My father refused to say: rarely spoke of his parents and childhood and young adulthood in Brooklyn and the Army in wartime, and what happened when the war was over. My mother did sometimes like to tell stories, but was a limited and unreliable narrator (as is everyone). Sex and desire went entirely unnarrated, nothing was ever said, but the air was thick. The past that made the present was the riddle of the Sphinx, impossible to figure, full of momentous, potentially terrible consequence, and none of us knew or could say why. Everyone and everything was closeted. (And now, long after their lives are over, remains so.) From an early age I was drawn to books that narrated origins, antiquity, prehistory: Sumerians, Hittites, Egyptians, Minoans, Greeks; dinosaurs, trilobites, pterodactyls, archaeopteryx, mastodons, etc. Renaissance, Bronze Age, Neolithic, Paleozoic, Permian, Triassic, Eocene. Ancient peoples and life forms. Lost texts and objects and architecture. Fossils, extinct species, evolutionary trees. Bullied at school, I lost myself in a reverie of deep and obscure pasts.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

210

Communicating the history of medicine

Figure 9.12  ‘dreary to “process”’

Later I came to historical scholarship as a reader, and then a historian. My article of faith was (is?) that richly descriptive, dialectically or dialogically interpretive, truthful historical narratives – based on epistemic protocols of research that excavated and explored primary sources, and that were subject to critical scrutiny by an engaged community of scholars – should play a vital role in political and everyday life. Historical narratives produced a sense of tragedy and farce, maybe redemption, and in any case reason and meaning (now I would add distraction). To the occluded jumble of existence. The time of history

Some recent scholars treat those assumptions with scepticism. Queer theorist Lee Edelman scoffs at ‘the motionless “movement” of historical

On ‘the use and abuse’ of medical history ‘for life’

211

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

procession obedient to origins, intentions, and ends whose authority rules over all’: And so we have the familiar demand for narrative accountings of ‘how and why,’ for self-conscious avowals of motivation, for strategic weighings of what’s opened up in relation to what’s shut down. Implicit throughout are two assumptions: time is historical by ‘nature’ and history demands to be understood in historicizing terms. But what if time’s collapse into history is symptomatic, not historical?12

Edelman warns against ‘the illusion of constant fluency’. Asks: ‘What if that very framing repeats the structuring of social reality that establishes heteronormativity as the guardian of temporal (re)production?’13 The problem, he argues, is ‘the turning or troping by which we’re obliged to keep turning time into history’: … history, thus ontologized, displaces the epistemological impasse, the aporia of relationality, the nonidentity of things, by offering the promise of a sequence as the royal road to consequence. Meaning thus hangs in the balance – a meaning that time, as the medium of its advent, defers while affirming its constant approach, but a meaning utterly undone by the queer who figures its refusal.14

Edelman then inserts a new protagonist into the historical narrative, ‘the queer’, who redeems us from history itself: This is the truth-event … that makes all subjects queer: that we aren’t in fact subjects of history constrained by the death-in-life of futurism and its illusion of productivity. We’re subjects, instead, of the real … of the encounter with futurism’s emptiness, with negativity’s life-indeath. The universality proclaimed by queerness lies in identifying the subject with just this repetitive performance of a death drive … and so in exploding the subject of knowledge immured in stone by ‘the turn toward time’.15

The rhetoric moves me, like an oracular poem, even if, again, I cannot say exactly how it predicts or describes anything (‘negativity’s lifein-death’?). Edelman’s critique is a strange kind of essentialist/antiessentialist identity/anti-identity theory of queer. He chafes against the idea of any kind of deep structure or rootedness compelled by the patriarchal ‘normativizing’ gravitational field of cultural/sexual policing. Queer wants sexuality and identity to be mutable and non-compliant,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

212

Communicating the history of medicine

Figure 9.13  ‘the indifferent makes a plunderer of ’

an act of the freest will, while at the same time surrendering to a contingently coerced erotic necessity – the inner self that is closeted until it comes out. The narrative of queer emergence requires that lesbian, gay, transgender desire is both forced and emancipatory, an inevitable surrender to structures of desire and personality (after it ceases being in denial and escapes the closet). Queer wants to be free of history, even while it wants to make a personal and movement and discursive history of queer.16 Set that against other contemporary critiques of history, historicity, historicism. A recent Sigmar Polke retrospective, at the Museum of Modern Art in New York, gestures toward a dismissal of historicity in its title: The Forever Now: Contemporary Painting in an Atemporal World

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

On ‘the use and abuse’ of medical history ‘for life’

213

(MOMA, 14 December 2014 to 5 April 2015). But why is the world now atemporal? On the web, things happen in near simultaneity, web time. The digital age with its celebrated 0/1 binary remakes the social, epistemological world into a structuralist mosaic, an infinite universe of algorithmic variations on the themes elaborated long ago in LéviStrauss: raw zero [0] vs. cooked one [1]. Pure structuralism fell out of fashion partly because it was unable to account for change over time and fissures within the binary: there was no meaning or movement outside the structured system of oppositions. But Marxians had no trouble annexing structuralism to their foundational metaphysic – the dialectic – and post-structuralists assimilated it into their universe of discursive instability, multivalence, incoherence by invoking the proliferation of signs … And that brings us back to mémoire involontaire. We can forget the past or never ever know it in the first place, just as we can refuse to acknowledge the present (and never really know that either). But past and present act on us nonetheless, with or without our knowledge or consent. We are haunted. We want to know who and what we are, but cannot without fixing our ghosts, knowing their history. And we historians – who make books or articles or exhibitions or motion pictures or websites or whatever – play that back to any real or fictive audience we can stir enough to pay attention… [Running out of steam … Can’t keep piling up words on idling and scattering and externalities and history. Still need to account for crowds of unaccounted idlers. Gardens of knowledge. Enchanted forests. Ghost sprawl: haunted houses, flying dutchmen, ghost factories, abattoirs, run-off, polluted ponds of toxic ectoplasm. Gravity-filled dark matter pulls on everything; wild unpassable thickets hem us in. Do not need to conduct a seance to know that history chokes and smothers, presses, weighs on us. History. Makes you cry. Gets you drunk. Gets you high. Makes you happy. Deludes, deceives. Study that. But no place to stand apart, stand outside. Can’t be a connoisseur of that. But that’s what idlers and collectors do. Drift away, dear reader …] Notes The images used in this piece derive from the collections of the National Library of Medicine, Bethesda, Maryland.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

214

Communicating the history of medicine

1 W. Benjamin, The Arcades Project, trans. H. Eiland and K. McLaughlin (Cambridge, MA: Harvard University Press, 1999), p. 211; H5,1. Subsequent references will be given in the body of the text. 2 For a detailed account, see W. D. Miles, A History of the National Library of Medicine: The Nation’s Treasure of Medical Knowledge (Bethesda, MD: US Dept. of Health and Human Services, Public Health Service, 1982). 3 F. Nietzsche, ‘On the Use and Abuse of History for Life’, trans. I. C. Johnston, amended in part by the Nietzsche channel, from Unzeitgemässe Betrachtungen [Untimely Meditations] (Leipzig, 1874). http://la.utexas.edu/ users/hcleaver/330T/350kPEENietzscheAbuseTableAll.pdf (accessed 16 June 2019). 4 W. J. Bouwsma, A Usable Past: Essays in European Cultural History (Berkeley, CA: University of California Press, 1990); C. N. Blake, ‘The Usable Past, the Comfortable Past, and the Civic Past: Memory in Contemporary America’, Cultural Anthropology, 14:3 (1999), 423–435. 5 R. Cooter, with C. Stein, Writing History in the Age of Biomedicine: Essays in the History of Medicine (New Haven: Yale University Press, 2013). 6 M. Sappol, A Traffic of Dead Bodies: Anatomy and Embodied Social Identity in 19th-Century America (Princeton: Princeton University Press, 2002). 7 G. Bidloo, Ontleding des menschelyken lichaams, illus. G. de Lairesse (Amsterdam, 1690). 8 M. Sappol, Dream Anatomy (Washington, DC: GPO, 2006). 9 For S. Reverby, see ‘Wellesley Professor Unearths a Horror: Syphilis Experiments in Guatemala’, Boston Globe, 1 October 2010; D. Rosner, Lead Wars: The Politics of Science and the Fate of America’s Children (Berkeley: University of California Press/Milbank Fund, 2013). 10 D. A. Hollinger, ‘How Wide the Circle of the “We”? American Intellectuals and the Problem of the Ethnos since World War II’, American Historical Review, 98:2 (April 1993), 317–337. 11 C. Dinshaw, ‘Theorizing Queer Temporalities: A Roundtable Discussion’, GLQ: A Journal of Lesbian and Gay Studies, 13:2 (2007), 191. 12 L. Edelman, ‘Theorizing Queer Temporalities: A Roundtable Discussion’, GLQ: A Journal of Lesbian and Gay Studies, 13:2 (2007), 180–181. 13 Ibid. 14 Ibid. 15 Ibid. 16 For a trenchant critique of queer theory from a queer theory perspective, see T. Dean, ‘No Sex Please, We’re American’, American Literary History, 27:3 (2015), 614–624.

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

10

Audiences and the history of medicine Ludmilla Jordanova

Audiences, we can readily agree, are difficult both to conceptualize and to study. There can be hardly any areas of humanities and social science research where they are not an issue. Or, to put it another way, thinking about audiences can be stimulating and can bring a fresh perspective to forms of scholarship that tend to be dominated by a concern with production, whether of knowledge, artefacts, ideas or imagery. There are fields that have taken the lead when it comes to reflecting upon audiences; they include market research, reception studies and media studies. In recent times museums have been actively developing audience research, because it can be used to show funders how accessible and effective they are and to inform decision-making.1 In this volume historians of medicine grapple with audiences for their field in a range of settings from medical schools to sex education films, from exhibitions to debates about health policy. They show that, however difficult it is to define the term ‘audience’, it remains a crucial, flexible, even indispensable term. Many of the chapters acknowledge that the very term ‘audience’ is a problem; well suited to research into performances in designated spaces, but perhaps not so apt for reflecting on the history of medicine with its diverse interest groups, stakeholders, consumers and publics. How does ‘audience’ help us to probe the experiences of reading, viewing art or walking through a building – all activities that are relevant to the history of medicine and amenable to forms of analysis that give due weight to

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

216

Communicating the history of medicine

reception, that is, to participants’ reactions? Perhaps it is best to treat ‘audience’ as a holding term that helps scholars to open up diverse types of response.2 It also helps us to imagine the dynamic interactions between stimulus and reaction, and hence to see audiences as active participants, not merely passive sponges. The idea that a work of art is completed by spectators expresses precisely a sense of audiences’ agency. We experience this agency when clapping and showing appreciation followed by performers doing an encore, which would be inappropriate if the reaction had been less than enthusiastic or downright hostile. Performers themselves often speak about how they are affected by their audiences and the kinds of attention they manifest. There is currently widespread interest in performance, but in its most literal sense of many people in the same space listening and looking at the same time, it refers to only a tiny proportion of the phenomena we want to consider using the term ‘audience’. It is necessary to go beyond its narrow meaning and explore the precise circumstances in which audiences come into being and the contexts in which they are constituted. This volume is concerned with audiences in relation to the history of medicine, which might sound quite specific, but, as the chapters reveal, there are many ways in which we can probe a subject that has been neglected hitherto. Doing so requires us to grapple not only with the concept of ‘audience’, but with the nature of the history of medicine, indeed with ‘medicine’ itself. One way of doing so is hinted at in Mike Sappol’s chapter. He describes an exhibition, Dream Anatomy, how it was put together and reactions to it. The poetry of his writing makes us aware of our intimate and complicated connections with anatomy – a centrepiece of medicine for many centuries. The exhibition was a brilliant venture, and its success owed much to its capacity to engage visitors in a subject that interests them more than any other – themselves. People’s curiosity about their bodies, illness, suffering and death is, it seems, inexhaustible. Together, these subjects make up much of ‘medicine’. Histories, no matter in what genre or medium, that touch on sexuality, reproduction, threats to health care and therapies for the mentally ill are likely to find audiences that may be eager and curious, but also, as several of the chapters show, to provoke controversy from a range of constituencies. As historians, we bring a sense of temporal change to our understanding of audiences. The arrival of the Internet, for example, has

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Audiences and the history of medicine

217

transformed, and continues to alter, our sense of what an audience is. Tweets are a good example, as are YouTube films, blogs, vlogs and so on. Significant shifts can take many forms, and as several contributors point out, the exercises of the Research Excellence Framework in the UK, with their demand that some researchers demonstrate measurable impact deriving from their research, pose challenges every bit as demanding as comprehending a digitally connected world. There is a clear contrast here with a play or concert in the past, experienced simultaneously by a limited number of people, and leaving few or even no traces. So performances in past times might seem to provide little guidance when it comes to medicine, but I am struck that an opera written nearly 200 years ago explores the theme of audiences for medicine, and hence could be used now to stimulate reflection on the history of medicine. Donizetti’s comedy, L’elisir d’amore, premiered in 1832, provides a vivid sense of quackery as performance and of audience reactions to and participation in popular medicine. We apprehend our own reactions as members of the opera’s audience and in the process we observe the behaviour of the villagers to whom the travelling quack doctor sells his cure-all. The work’s success suggests that nineteenth-century audiences recognized the ways in which simple folk could become customers and dupes by virtue of a quasi-medical performance.3 So there are clues here about the nature of medicine and its audiences in the past, if, that is, we associate medicine with the search for health and wellbeing, rather than more narrowly with learned physic, systematized knowledge, formal training and certain kinds of status. Thus it is always worth asking whether ‘medicine’ refers to everything to do with health, or is that too broad? Does the term risk marginalizing nursing, for example, as well as traditions of healing that are less institutionalized and recognized in the modern developed world? By posing such questions, another issue comes to the fore. If we define ‘medicine’ in its broadest sense, it is simply everywhere in most societies, and that makes it a diffuse object of study for historians. By that token everyone, in one way or another, is a member of medicine’s audiences – making the historian’s job even harder, but it does reveal how extensive the audiences for the history of medicine can be. Furthermore, as Mullally and Marchildon point out, accounts of medicine past contain deep assumptions about progressive, desirable change, future medical arrangements and about who may occupy the medical

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

218

Communicating the history of medicine

high ground. We can appreciate that medical practitioners form a highly interested audience for such accounts, but virtually everything to do with medicine touches large swathes of the population. It is these very properties that make the history of medicine of the most general interest. The huge success of Roy Porter’s books, Huisman notes, was rooted in his ability to show in lively, even subversive terms, how medicine was integral to life, how people in earlier times were preoccupied with bodily phenomena, and hence that medical history was central to understanding the past as a whole, rather than a specialized domain with limited appeal.4 It is vital that medical students are exposed to such work, not just to short, unreflective articles written for medical journals to shore up the careers of historians who feel vulnerable within medical schools. Söderfeldt and Krischel decry this situation, which has given the history of medicine the status of an ‘ancillary discipline’ in Germany, and which in effect undermines the generous remit of the field, and limits potential audiences. If we interpret medicine in the capacious manner Roy Porter did, it becomes clear that novels and poetry, historical fiction and biopics of famous healers from the past bring the history of medicine to large and diverse audiences. I might invoke here the writings of Francis Brett Young, the medically trained novelist, who painted vivid word pictures of medical practice.5 Fiction, poetry, and film, along with other cultural products, are now a staple of the medical humanities; it would be interesting to approach them with audiences for the history of medicine specifically in mind. In interpreting ‘medicine’ as widely as possible, there are numerous places where audiences for its history can be examined.6 As several papers in this collection show, there are also significant audiences within medicine for historical representations, which vary markedly according to national context. The door is thus wide open for comparative projects. These might build, for example, on work on scientific and medical institutions, which shows how national, economic, social and political contexts shape scientific and medical research and practice. It is a matter of great importance how all those who work in the health sector are trained, and the kinds of exposure they have to a sophisticated historical understanding of medicine. The flowering of interest in the history of nursing and projects to expose trainee nurses to it are especially striking.7 Education and training are

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Audiences and the history of medicine

219

generally followed by many years of actual practice, shaped as it necessarily is by the exigencies of routines. How might the history of medicine reach medical audiences once they have completed their training? One answer is through professional institutions, many of which have long pasts upon which to draw. They contain historical deposits of many kinds – medals, portraits, silver, furniture, prints, stained-glass windows, coats of arms and more. Such artefacts prompt a sense of the past, but are not themselves ‘history’, since they require interpretation, narrative, contextualization in order to be activated. Nonetheless, they are rich materials for those who interact with them routinely as they are for historians seeking to explore how medical professionals acquire and sustain a lively sense of their pasts.8 Lectures, conferences, orations and rituals in medical institutions are more overtly ‘historical’. Each year the Royal College of Physicians in London, founded in 1518, hosts an oration and dinner in honour of William Harvey. The oration itself may have little to do with their august forebear, who is known worldwide for his discovery of the circulation of the blood. But there is a narrative here, and in honouring him while portraits of him are in full view, a specific history of medicine is being recounted, some of it implicitly, since Harvey’s discovery is simply assumed to be world-changing, indicative of the close alliance between experimental science and medicine. Also taken as read is Harvey’s status as a learned physician. It was precisely men like him who started writing histories of physic.9 The history of the history of medicine helps us to appreciate the nature of its audiences. When books dedicated to the subject began to be published in the seventeenth and eighteenth centuries, their authors – mostly learned physicians – were writing for other well-educated people, who had received a classical training, had wide intellectual interests, including in natural philosophy, and were frequently collectors, connoisseurs and antiquarians. Early works in the history of medicine were not only for professional peers, although they certainly read them along with original texts by Galen, Hippocrates and Celsus, for example. Membership of medical institutions reinforced the historical sensibilities of such men, who were typically friendly with artists and writers, historians and archaeologists, classicists and members of the gentry and aristocracy. Thus networks existed in which histories of medicine could be read and debated as extensions of intellectual and

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

220

Communicating the history of medicine

cultural interests that were fairly widespread among those with some education – the very same people who took a keen interest in their own health and medical care, including the welfare of their families and servants. They were well aware of the myriad ‘traditional’ remedies and the practitioners among them may well have used them on occasion.10 Despite the big changes in the theory and practice of medicine over the long nineteenth century, we find just these features persisting into the early twentieth century. They are clear in the figure of William Osler, who combined clinical work with a deep knowledge and love for the history of medicine, which he brought to wide audiences, and not only to fellow physicians, since his scholarship was of interest to classicists, literary historians and bibliographers as well as other scholars in the humanities.11 Similarly, the surgeon Geoffrey Keynes brought the history of medicine to many readers through his publications, including an award-winning biography of William Harvey, and works on figures who combined medicine and literature. He also found fresh audiences through his work on portraits and for the National Portrait Gallery in London.12 Osler and Keynes were by no means typical practitioners, but they belonged to organizations that contained many medical professionals, who were aware of their historical contributions, their publications were widely read and they enjoyed high reputations. To be known is to have audiences. If we think holistically about audiences for the history of medicine, they include anyone who visits and works in institutions where portraits are arrayed, and mementoes displayed, practitioners who frequent such places in order to take exams and for professional development, those who listen to orations in the name of a historical figure, who go to galleries in museums or venues that offer a glimpse into past medical practice as the Old Operating Theatre at St Thomas’ in London does. And they take in the history in many different ways, by reading labels and panels, for example, as well as by looking at displays and absorbing substantial texts. Thus reading published histories of medicine is only one way in which diverse groups over many centuries have engaged with past understandings of the body and health care. The effects of repeated exposure to a range of historical prompts are likely to be cumulative, producing a form of historical consciousness. Audiences for the history of medicine include art lovers and gallerygoers. There is a well-established appetite for displays that present

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Audiences and the history of medicine

221

anything to do with anatomy in the past. Illustrated books and models are perhaps the best examples. Anatomical tables, such as we find in the Royal Colleges of the Physicians and Surgeons in London, are also appealing. There is indeed a special kind of curiosity about human bodies and their insides above all, of which writers such as Roy Porter were well aware. It is directed at contemporary as well as historical phenomena. It is difficult to draw a firm line between past and present when it comes to medicine, since visual artists, for instance, are eclectic in drawing on historical materials as well as in generating their own. Feminist artists in particular have been drawn to explore questions around reproduction and menstruation among other bodily functions. Yet the degree to which exhibitions touching on anatomical and physiological themes are understood by visitors as giving access to historical understanding and insights into ‘medicine’ is difficult to determine precisely. Nonetheless, high-profile art exhibitions – Spectacular Bodies and Anatomy Acts spring to mind – have generated broad interest in the history of medicine.13 Similarly, the success of the Wellcome Collection in London, with its temporary exhibitions, well-stocked bookshop and cool café, reveals not just the appeal of topics connected with medicine and its past, but the fluid, flexible ways in which this area has entered public culture. Even in more staid academic settings it is possible to discern related phenomena. Anecdotal evidence suggests that history students are keen to take courses that draw on medical and health-related materials. These are likely to touch on questions about bodies, identity, sexuality, gender and so on, with which they can readily connect. In teaching this way we are generating audiences for the history of medicine who are already sensitized, through social media, for example, to many of the key issues. Since universities are sensitive to student demand, it is reasonable to assume that such options will continue to proliferate, and it is already evident that the medical humanities have been expanding at a considerable rate over the last 10 to 15 years. One way of interpreting this growth is that non-medical groups want to be a recognized part of medical communities, and that by undertaking research and teaching they are bringing in new audiences, who vividly appreciate how matters relating to health permeate all aspects of our lives. Hence modes of address developed in the humanities and social sciences become of value in interpreting medical phenomena. This is not new – decades

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

222

Communicating the history of medicine

ago medical sociology and medical ethics were established as significant fields, both of which had the potential to influence policy-making.14 Historians have been slower to make such claims, although in the UK the History and Policy Network has staked out a place where the value of historians to policy-makers, politicians and civil servants can be given tangible expression.15 Once we begin to see the history of medicine as having public benefit, at least potentially, and not just in exhibitions and displays, books, films, art, TV and so on, it is helpful to reflect upon ‘public history’. I have already alluded to examples of public history in one of its senses in mentioning places and types of culture, where the medical past is brought before non-specialist audiences. The Thackray Medical Museum in Leeds, Yorkshire is a good example.16 We can define public history as the means by which the past is presented to the general public. It therefore refers to a huge number and range of phenomena, including heritage sites, historical novels, media representations, websites and publications for non-specialists. It has a second meaning – the academic field that reflects upon and analyses all these means. Indeed, since the Second World War public history has become a discipline in its own right, with a literature, specialists, organizations and university courses, and it necessarily considers audiences. It first took hold in North America, spreading to other English-speaking areas, and is now a considerably wider phenomenon.17 Public historians have made significant contributions to legal cases and to debates about public policy. So far as I am aware, medical history has not been particularly prominent in publications or discussions about public history. In this volume Beatrix Hoffman discusses her work on the Affordable Care Act in the USA, a compelling example of how historians can use their skills and insights in the public domain, whereas Elisabet Björklund and Lene Koch comment on ambivalent experiences from their involvement with the public history of controversial medical issues. There are further opportunities to bring a number of perspectives together. Public history interprets and critiques museum displays, for example. Museums themselves undertake extensive research on their audiences, and those who work in them possess refined frameworks for thinking about visitors and have developed their museological practices with those visitors in mind. Accordingly, collaborations make sense with public historians who reflect upon and deliver the history of

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Audiences and the history of medicine

223

medicine to the general public. Sometimes medical historians are public historians. Once again we need to acknowledge how slippery some of the key terms are: public(s), audience(s), engagement, consumption, public history, impact and so on. Their meanings are changing all the time, and are dependent on the language being used and the contexts in which they are deployed. There is no simple way around these challenges. What helps, I suggest, is precision about how audiences come into being, what participants are actually doing when part of an ‘audience’, the kinds of financial transactions involved and the degree to which they feel themselves to be part of something that goes beyond individual experience. It is implicit in what I have said that historical awareness can take many forms, some of which are considerably more available for conscious inspection than others. Reading a journal article on a medical history topic and seeing portraits – two distinct types of activity – may reinforce each other, or open reflective possibilities for audience members, just as exhibitions, fiction and films do. In academic settings we tend to analyse these genres and media separately, often in separate disciplines, but in lived experience they blend together to form a sense of the medical past, only a small component of which might be called ‘historical knowledge’ by professional historians.18 As a number of contributors observe, it is noticeable that the boundaries between professionals and lay people are considerably more fluid than even a few decades ago. The theme is prominent in Chaney and Walke’s chapter, for example. We can track this shift in the move from ‘knowledge transfer’ to ‘knowledge exchange’, and in the current trend, especially evident in museums, for co-curation, where curatorial authority is shared with participating groups that have special knowledge of the exhibition’s subject matter. Such groups are both producers and audience members: they have a special affinity with the end product; they may well represent and be part of networks that supply a considerable segment of the visitors. These phenomena, to which we are witnesses as interested parties in the ways the history of medicine is disseminated and experienced, invite further attention. In this short essay I have used ‘history’ in a number of ways, and this reflects its flexible, protean nature. Professional historians need to accept that academic history is only one form of ‘history’, and that everyone’s sense of the past, their understanding of earlier eras, is

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

224

Communicating the history of medicine

inevitably shaped by many phenomena, most of which are outside their control. This is an especially sensitive subject for historians of science and medicine, who may be suspicious of scientific and medical practitioners encroaching on their hard-won expertise and seeking a more celebratory mode of address, including more emphasis on great lives. It is important to acknowledge that many such practitioners are fine historians, while specialized institutions often remain stubbornly committed to more heroic discourses. There is an opening here for deft critique. Perhaps this is where the field of public history could be useful – over several decades it has built up ways of thinking, speaking and writing about the manner in which history in all its meanings both touches and works with audiences, including about the ethical and political issues representations of the past raise. We will also want to join debates about the interpretation of the ‘public’, ‘audiences’ and so on, and to open dialogues with those fields that undertake audience research – I warmly support historians of medicine in doing just that. At the same time, it is worth using our historical skills to understand audiences of many kinds, and not just in the past. We have the opportunity to be participant observers, hone our ethnographic skills, critique current trends and develop a distinctively historical commentary on audiences and the history of medicine. Notes 1 On audiences and museums, see: https://www.museumsassociation.org/ museum-practice/audience-research (accessed 16 June 2019) – the website of the UK’s Museums Association, which covers many aspects of audience research. On reception, see L. Hardwick, Reception Studies: Greece and Rome (Oxford: Oxford University Press, 2003). 2 D. Freedberg, The Power of Images: Studies in the History and Theory of Response (Chicago and London: Chicago University Press, 1989) is a classic study. 3 On Donizetti, see F. Izzo, Laughter Between Two Revolutions: Opera Buffa in Italy, 1831–1848 (Rochester, NY and Woodbridge: University of Rochester Press and Boydell and Brewer, 2013), chapter 1, and W. Ashbrook, Donizetti and his Operas (Cambridge: Cambridge University Press, 1982), pp. 72–73, 329–333 and 553. 4 Roy Porter published prolifically. The lists of his publications and other information, see https://www.ucl.ac.uk/histmed/downloads/porter (accessed 16 June 2019).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Audiences and the history of medicine

225

5 Examples of Brett Young’s novels with medical themes are: The Young Physician (1919), My Brother Jonathan (1928) and Doctor Bradley Remembers (1938). See also M. Hall, Francis Brett Young (Bridgend: Border Lines, 1997), especially chapter 3. 6 On the medical humanities, see, for example, A. Whitehead et al. (eds), The Edinburgh Companion to the Critical Medical Humanities (Edinburgh: Edinburgh University Press, 2016). 7 R. Dingwall et al., An Introduction to the Social History of Nursing (London: Routledge, 1988) is an early example. 8 I explore these themes in L. Jordanova, Physicians and their Images (London: Little Brown, 2018). 9 A key figure here is John Freind. See his The History of Physick; from the Time of Galen to the Beginning of the Sixteenth Century (London: J. Walthoe, 1725–1726), deemed the first such history in English. For more information, see https://www.rcplondon.ac.uk/events/harveian-oration-anddinner-2018 (accessed 16 June 2019) and note that many other medical organizations also have such orations in honour of Harvey. Many have been published. 10 In Physicians, I weave these themes through the book. A figure such as Richard Mead is a particularly good example. 11 On Osler, see M. Bliss, William Osler: A Life in Medicine (Oxford: Oxford University Press, 1999) and Jordanova, Physicians, pp. 50–51, 68, 97, 103. 12 See G. Keynes’ autobiography, The Gates of Memory (Oxford: Clarendon Press, 1981); The Portraiture of William Harvey (London: Royal College of Surgeons, 1949); The Life of William Harvey (Oxford: Clarendon Press, 1966). 13 M. Kemp and M. Wallace, Spectacular Bodies: The Art and Science of the Human Body from Leonardo to Now (London: Hayward Gallery, 2000) and A. Patrizio and D. Kemp (eds), Anatomy Acts: How We Come to Know Ourselves (Edinburgh: Berlinn, 2006). 14 See, for example, the journal Sociology of Health and Illness: A Journal of Medical Sociology, founded in 1979, which marked the growth and consolidation of the field. 15 See http://www.historyandpolicy.org (accessed 16 June 2019), which publishes articles by professional historians expressly designed to be suitable for policy-makers, civil servants, politicians and commentators. 16 https://www.thackraymedicalmuseum.co.uk (accessed 16 June 2019). 17 Works on public history include: J. Gardner and P. Hamilton (eds), The Oxford Handbook of Public History (New York: Oxford University Press, 2017) and P. Ashton and H. Kean (eds), People and their Pasts: Public History Today (Basingstoke: Palgrave Macmillan, 2009). We should note that there are distinct strands within public history, for example, those

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

226

Communicating the history of medicine

practitioners who prioritize forms of history from below, those who work within institutions, including government, and those who critique heritage sites, museums, monuments and memorials. I consider historical fiction to be a form of public history. For instance, L. Belfer, A Fierce Radiance (New York: HarperCollins, 2010), which concerns research into penicillin and medical practice during the Second World War, reached wide audiences. 18 L. Jordanova, The Sense of a Past in Eighteenth-Century Medicine (Reading: University of Reading, 1997).

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Index

ACA, see Affordable Care Act Affordable Care Act (ACA) 66–68, 70–73, 75–76, 78, 222 Anthropological Committee (Copenhagen) 96, 98–99 Armitage, David 22 art/artists 25, 140, 144–145, 150–153, 156–157, 197–198, 200, 212, 215–216, 219–222 fiction 187, 218, 222–223 graphic novel 73 opera 4, 217 painting 152, 187, 220, 223 performance 4, 151, 216–217 poetry 218 Asilomar conference 9–95, 99 audience 2–9, 12–13, 186, 220 active audiences 114–115, 216 administrators as 185 anatomists’ audiences 198–199 art lovers as 220 audience participation 142 audiences for controversial topics 5, 89–94, 103–104, 162–163, 179, 222 citizens as 19, 109–110, 114–115, 122

consumers 109, 215 definition of 215–216, 223–224 depictions of 139 engaging audiences 114, 129 exhibitions and museums’ audiences 2, 141–143, 154–155, 195, 198, 200, 202, 205, 216, 221 historians as 185, 219 implicit/implied audience 5, 109, 165, 170–172, 178 medical students as 24, 198, 218 physicians and health professionals as 8–9, 43–44, 52, 54, 61–62, 109–110, 114, 120, 129–130, 198, 219–220 policy-makers and politicians as 3, 11–13, 36, 66–82, 129, 222 ‘produsers’/knowledge producers as 4, 223 public and 4–5, 7, 13, 67, 72, 109, 113–114, 129–130 audience research market research 215 media and cultural studies 3–7, 13, 19, 215

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

228 Index

museum visitor studies 141–142, 215, 222 reception studies 4, 165, 169, 186, 215–216 audiencing 2–3, 5, 9, 13, 44, 89–90, 92–94, 104 definition of 2, 5, 90 Badgley, Robin 118–120, 123, 129 Barootes, Efstathios William (Staff) 115–116, 129 Baur, Nicole 139 Bengtsson, Bengt 169 Benjamin, Walter 184–186, 192, 202–203, 205 Beresford, Peter 141 Bergström-Walan, Maj-Briht 174–175 Berridge, Virginia 79 Bethlem Museum of the Mind see museum bibliometrics 57–60, 74–75, 188 Bidloo, Govard 198–200, 203 Billings, John Shaw 188–190, 202 bioethics, see ethics biomedicine 2, 10, 22–25, 29–30, 33–35, 53–54, 58, 60, 95, 101, 185, 191 biotechnology 5, 89–91 Blease, Charlotte 10, 12 Bologna Declaration 20–21 Bondio, Mariacarla Gadebusch 45 Boris, Eileen 76 British Medical Journal 31, 116 Broberg, Gunnar 12 Bulletin for the History of Medicine 58 Bush, Vannevar 94 Butsch, Richard 114, 139 Canadian Medical Association Journal 117, 120 Cate, Olle ten 23–24 citations (indexes), see bibliometrics

citizen-physician 20, 22, 25, 28 citizenship 19–20, 31, 37, 110 Clinton, Bill 74, 78 cloning 89, 95, 99 compulsory sterilization, see sterilization Cook, Harold 24 Cooter, Roger 193 co-production 99–101, 140–143, 149 as service user participation in mental health history research 138–157 Cullhed, Sture 174–176 Degler, Carl 80 de Lairesse, Gerard 198–199 democracy 7, 18, 22, 30–32, 101, 112, 140–141, 163, 205 Dinshaw, Carolyn 208 Donizetti, Gaetano 217 Donnelly, Kevin 78 Donoghue, Frank 57–58 Douglas, Tommy 107–108, 111–112, 115, 117–119, 121, 125–128 Duffin, Jacalyn 35 Eberwein, Robert 172 Edelman, Lee 210–211 Ehrlich, Paul 172 Elliot, Beth 148 Ellis, Rob 146 Entrustable professional activities (EPAs) 24–25 EPAs, see Entrustable professional activities eugenics 5, 89–93, 96–104 ethics 2, 21, 23–26, 31, 34, 43–46, 48–54, 56, 62, 80, 89, 91–92, 95, 102–104, 116, 222 European Research Council 51 exhibition 3, 9, 11, 138, 141–143, 145, 151, 185–186, 188, 191–192,

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Index 229

195–200, 205–206, 213, 216, 221–223 Dream Anatomy, exhibition at National Library of Medicine 194–205, 216 expertise 1, 7–8, 11–12, 19, 32–33, 45, 52, 58, 99, 139, 142, 147, 153, 156, 224 see also sex education films, history of medicine and Fangerau, Heiner 45 Fee, Elizabeth 184, 195, 205–207 film 2–3, 201, 215, 218, 222–223 see also sex education films FLSA, see United States Fair Labor Standards Act Foucault, Michel 94, 175 Fraser, Nancy 114 genetics 5, 89–100, 102, 104 German Medical Licensure Act 43, 45–46, 53 Ginsburg, Ruth Bader 70 Golden, Janet 76 grand challenges 93, 95–97, 100–103 Gruber, Jonathan 73 GTE, see History, Theory, Ethics of Medicine Guldi, Jo 22 Habermas, Jürgen 4 Habilitation 50–53, 59 Hall, Stuart 6 Hammarfelt, Björn 57, 60 Harvey, William 189, 219–220 Haskell, Thomas 80 health (care) policy 2, 9, 67–68, 72–73, 81, 92, 215 health law and 21, 25, 89, 97, 102 history and 107–130, 222 health humanities, see medical humanities

Hegeler, Inge 174–175 Hegeler, Sten 174 Henne, Carolyn 198–199 history academic 153, 222 activism and 32, 77, 79, 184, 204 advocacy and 79 as collecting 184–186, 202–205, 213 commodification of 60–61 heroic 59, 62–63, 170–172, 177, 193, 204, 224 historicity/historicism 77, 193, 208, 212 historiography 113, 117–122, 129–130 as idling/pleasure 193, 201–202, 204–205, 207, 213 personal 209–210 uses of 7–9, 26, 186–188, 192 History and Policy Network 222 History News Network 76 History, Theory, Ethics of Medicine (Geschichte, Theorie, Ethik der Medizin, GTE) 45–46, 49–55, 57–58, 60 Holocaust 89 Horizon 2020 93 Horton, Richard 22 Houston, C. J. 125–127 Houston, C. Stuart 124–128 HPV, see human papilloma virus human papilloma virus (HPV) 29–33, 35 humanities 2, 6–11, 22, 44, 49, 51, 54–61, 67, 74, 81, 191, 205, 215, 221 impact 7–12, 33–35, 43, 58–61, 67, 75–76, 141, 154, 200 assessment/evaluation and 2, 7–12, 74, 81–82, 186–188 audiences and 3

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

230 Index

stakeholders and 7–8, 11 see also bibliometrics; media, impact and policy; publication/ publishing; research evaluation; Research Excellence Framework in vitro fertilization (IVF) 89, 95, 99, 102 innovation 7–8, 21, 27, 98–99 Institute of human genetics and eugenics (Copenhagen) 92, 98–99 interdisciplinarity 2, 25, 44, 53–54, 56, 61 Isis 58 IVF, see in vitro fertilization Jasanoff, Sheila 99, 140 Johannsen, Wilhelm 96–97 Jost, Timothy 69–70 Journal of Policy History 78 Kelly, Arthur D. 116–118, 120–121, 127, 129 Keynes, Geoffrey 220 King v. Burwell 70–71 Kinsey, Alfred C. 175 Klein, Jennifer 76 Koselleck, Reinhart 93 Kristof, Nicholas 68 Kühl, Stefan 55–56 Kuhn, Annette 170–171 Lerner, Barron 76 Lévi-Strauss, Claude 213 Livingstone, Sonia 4–5, 109, 113 Lloyd, Woodrow 112, 115, 127 LOM-system (Leistungsorientierte Mittelvergabe) 55, 57–60 Long, Vicky 147 Lorenz, Chris 54–55 Lunt, Peter 5, 113 Lynch, Bernadette 142

MacTaggart, Ken 120–123, 127 Markel, Howard 76 Masters, William H. 175–176, 178 McLuhan, Marshall 6 media 113–114, 149, 162 artefacts/objects 146, 153, 184–185, 189, 192, 195–197, 199–203, 208–209, 215, 219 audiences and 3–7, 89–90 fiction 218 film 2–3, 189, 191–192, 201, 215, 218, 222–223 illustrations 191, 198–200 impact and 11, 67, 75–76 Internet 216 photographs 138, 189 print 44–45, 55, 58–59, 78, 111, 114, 116–120, 123–128, 164, 185–186, 188–189, 191, 198–200, 206–207, 209, 213, 218–219, 221–222 social media 9, 29–33, 66, 68, 75–77, 146, 150–151, 185–186, 188, 191, 201, 205, 207, 213, 217, 221–222 television 1–2, 32, 73–74, 107–108, 114–115, 117, 127, 222 see also exhibitions; museum; sex education films Medicaid 66, 69–70, 75 Medicare (Canada) 4, 107–117, 122, 124–130 Medicare (US) 69–70, 75, 79 medical education/schools 2–3, 9, 11, 20–24, 43–46, 49, 51–52, 61, 74, 215, 218–219 mental health education 139, 150 see also sex education films medical humanities 2, 7–8, 10, 20, 24–26, 33–35, 37, 218, 221 medical liberalism 108, 111, 128

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Index 231

mental health (care) 11–12, 90, 92, 96–97, 103, 138–57 Milliken, Christie 173 museum 2–3, 11, 48, 139, 141–144, 150–151, 154, 189, 203, 212, 215, 220, 222–223 art and 140, 144–146, 150–153, 156 Bethlem Museum of the Mind 11, 138, 144–146, 149–150, 153, 155–157 National Federation of Independent Businesses v. Sebelius (NFIB v. Sebelius) 66, 69, 70–71 National Institutes of Health 185, 189, 191–192, 205 National Library of Medicine 185, 188–192, 195, 205–207 see also exhibition Naylor, C. David 122–126, 128–129 nazism 62, 92, 95 New Public Management 7, 54–55, 62 New York Times 68, 72, 74–76, 200 New Yorker 75 NFIB v. Sebelius, see National Federation of Independent Businesses v. Sebelius Nietzsche, Friedrich 193–194, 202, 205, 207 Northwood, Victoria 150 Nursing Clio (blog) 77 Nursing, history of 77, 149, 155, 217–218 Obama, Barack 66, 68, 72, 76–79 oral history 138–140, 145, 149, 154, 156 Osler, William 220 Ottesen-Jensen, Elise 164 Palin, Sarah 68 peer review 27, 58–59

Perspectives 66 Plos Biology 27 Plos Medicine 27 PNAS 27 Politifact 68 Polke, Sigmar 212 Portelli, Alessandro 139 Porter, Roy 36–37, 218, 221 Posner, Miriam 166 public engagement in the history of mental health 138–142, 144–145, 149–152, 154–157 with science and technology 7 public history 154, 222–224 public sphere 4, 109, 113–114, 128, 130 public understanding of science 11 publications/publishing 55, 57–59, 61, 69, 73–74, 81, 114, 188, 195, 206–207, 220, 222 Quadagno, Jill 71 queer theory 210–212 racial hygiene/biology, see eugenics Reeves, Max 143, 151–152 REF, see Research Excellence Framework research assessment, see research evaluation research evaluation 7–8, 10, 12, 28, 33–35, 57, 67, 81–82, 101, 154–155 Research Excellence Framework (REF) 9–12, 81, 217 research funding 9–10, 16, 44, 54–59, 61–62, 93–94, 154 research policy 3, 6–7, 12–13, 93 Reverby, Susan 12, 72, 80, 204 Rochefort, David A. 78 Rockefeller Foundation 30, 98, 100 Rose, Nikolas 94

232 Index

Downloaded from manchesterhive © Copyright protected It is illegal to copy or distribute this document

Rosenberg, Charles E. 69 Rosner, David 204 Russell, David 139–140 Russo, Jasna 141 Schaefer, Eric 166, 171, 173 Science and Technology Studies (STS) 7, 13, 29, 99 Science in Transition 24, 27–28 science policy, see research policy scientific literacy 25, 27–29, 32, 34 Sennett, Richard 4 sex education films 5–6, 162–183, 215 censorship and 6, 162–165, 167–169, 173–174, 176–179 commercial cinema and 162–163, 165–166, 169–171, 173, 177–178 educational aspects of 165, 167, 170–174, 177, 179 history of medicine and 164–165, 167, 169–170, 174–178 Kärlekslivets offer (‘Victims of Love’) 171–173 Language of Love (Kärlekens språk) 174, 176–177 medicalization and 5, 164–165, 178 representation of physicians and scientists in 170–172, 177–178 Shapin, Steven 1 Small, Helen 22 Social History of Medicine 58 Sprengel, Kurt 19, 36–37 Starr, Paul 71, 74, 78 Steincke, Karl Kristian 97–98

sterilization 12, 90–92, 96–97, 99–103 stigma, reduction of 139, 141, 145–146, 150, 154, 157 Strohschneider, Peter 56 STS, see Science and Technology Studies The Economist 28 The Lancet 22, 28, 116 The Triple Helix 27 Trump, Donald 68 Tydén, Mattias 12 UMC, see University Medical Center at Utrecht United States Fair Labor Standards Act (FLSA) 76 United States Supreme Court 66–67, 69–71 University Medical Center at Utrecht (UMC) 11, 20, 23 vaccination see human papilloma virus (HPV) Washington Post 75, 200 welfare state 90, 98, 108–109, 127, 178 Widerström, Karolina 1, 164 Williams, Linda 173 Wolfe, Sam 118–120, 123, 129 Zelizer, Julian 75 Zinn, Howard 80