HEALTH IN EUROPE IN THE INTERWAR YEARS. PERSPECTIVES, REALITIES AND EXPERIENCES IN EAST AND WEST

Between May 15 and 18, 2003, an international workshop on Health in Europe in the Interwar Years. Perspectives, Realities and Experiences in East and West took place in Groß-Breesen near Güstrow, northern Germany . It was organised by Professor Wolf D. Gruner and Dr. Iris Borowy ( University of Rostock ) and funded by the Volkswagen Foundation. The publication of a selection of conference papers is in preparation.

Opening the meeting the organisers, Wolf D. Gruner and Iris Borowy, recapitulated how the history of medicine had moved from a marginal position within social history and history of medicine into the mainstream of historical research, revealing significant inter-relations with political and ideological developments. English scholars, in particular, had taken the lead in connecting health data with historical events at large and in recent years research in the field had proliferated in many countries. However, at present there was no coherent overview picture of European health, and particularly with regard to Eastern Europe there were large areas of under- and unresearched. Thus, this meeting had been conceived as an attempt to build bridges, gather existing findings, identify new questions and stimulate further dialogue across states and disciplines. The interwar period had been chosen as it combined a relatively short, clearly defined time frame with a variety of political, economic, ideological and scientific events that interacted with health issues.

The first session addressed different approaches to assess the state of and development of health. Ulrich Koppitz (Düsseldorf) presented a paper on The Concept of Epidemiological Transition in Germany by Jörg Vögele (Düsseldorf), unable to attend in person due to illness. This paper analysed long-term mortality data in Prussia placing them in the context of Abdel R. Omran´s Concept of the Epidemiological Transition. The results showed that the increase of life expectancy resulted predominantly from a decline in infant mortality, which, in the 19 th century, had claimed more lives than cholera. The most drastic mortality decline took place between 1880 and 1920. Sanitary reforms had decreased infant mortality, but breast feeding remained a central determinant of infant chances of survival, more important than the family income. In contrast, Paul Weindling ( Oxford ), in The Politics of Interwar Total Health Surveys , presented various studies in which contemporaries tried to understand ongoing changes in health structures. As early as 1920, Austrian hygienist Rosenfeld highlighted inconsistencies of tuberculosis diagnosis between states. Institutions like the Milbank Foundation and individual medical statisticians like the Americans Edgar Sydenstricker and Frank Boudreau produced studies questioning conventional wisdom regarding tuberculosis, cancer and heart diseases. They called for a reframing of health policies on the basis of health indices to be established. Their Belgian colleague, René Sand, introduced physiological criteria like weight and height into the discussion. The outbreak of the Second World War brought an end to these surveys. Meanwhile, research in Germany followed a different agenda in tune with National Socialist ideas of holism, race, nature and de-industrialization. All studies reflected national mentalities and ideologies of the time and thus represented indicators of perception as much as information on health.

The following lively discussion centered on the interrelationship between national agendas and health information. The problem of a definition of Prussia and Germany for long-term studies was discussed as well as the reliabilitiy of information on breast-feeding, bound to be influenced by social norms of motherhood.

The next sessions shifted the focus towards quantitative analysis. Robert Lee ( Liverpool ) in his disillusioning paper on Cause-of-death classification in inter-war Europe and the quality of mortality data destroyed all hopes regarding the objectivity of vital statistics. Their reliability suffered from the limited use of the standardized lists of causes of death, the lack of expert reporting of infant deaths, of post-mortem examinations and of physician cooperation, as well as conflicting uses of categories like «senility»or «old age».

The ensuing discussion highlighted different conclusions from these disparities. While Paul Weindling felt that they underscored cultural flaws and national conditions and thus enriched research, Robert Lee insisted that, on the contrary, they prevented meaningful research on health realities.

Similar discrepancies characterized the following presentations. Andrea Wagner ( Munich ) in Mortality and Morbidity in Germany between 1920 and 1938 cited various examples to emphasized that mortality and morbidity evolved unevenly in differents parts of Germany at different times and for different diseases. Thus, the overall mortality decline was not very informative about real developments and had to be viewed critically. Iris Borowy (Rostock), on the other hand, in Interwar Health According to the International Health Yearbook of the League of Nations Health Organisation interpreted highly aggregate data and non-standardized texts of the Yearbooks to draw conclusions about general tendencies of health issues and their perception by contemporaries. She focussed on varying discrepancies between the statistic degree of health risk and societal concepts in issues like suicide, alcoholism or heart diseases.

Apart from the issue of data content, the discussion touched on the loss of 8000 Jewish doctors out of a total of 36000 in Germany, which may have had local impact but was probably compensated for by non-Jewish doctors on a national level. It was also discussed, whether the increase in fertility in interwar Germany resulted from Nazi propaganda or the decline in unemployment, and in how it made sense to separate the two.

The next session addressed social conceptualizations of health and their political uses. First Sylvelyn Hähner ( Stuttgart ) referred to The construction of the anti-social consumptive' in the Interwar Years. The combined effect of economic difficulties, the need of sanatoria beds for war victims and lack of therapeutic potential served to marginalize tuberculosis patients in interwar Germany. Uncooperative patients were considered «worthless» or «vicious» and risked forced hospitalization, harsh treatment or life-threatening neglect. Foreshadowing Nazi ideology, treatment of Tb patients clearly reflected a shift from health of the people to health of the nation. Similarly, Nadav Davidovitch (Beer Sheva) in European Jewish immigrants, Zionist Ideology and the Medical Selection Dilemma analyzed the function of medical examinations before and at immigration. Here, the Zionist goal of welcoming all Jews to a new home competed with the equally Zionist concept of creating a new Jewish race. While the «human material» was categorized in different grades and some, mostly Eastern European, immigrants were returned to their places of origin, it only concerned relatively few people, so that the procedure served more as an initiation ritual for the community than a meaningful health measure.

The following session addressed health insurance schemes. Martin Gorsky ( Wolverhampton ) and Bernard Harris ( Southampton ) examined the quantity and stated reasons of sickness reports in The measurement of morbidity in interwar Britain : evidence from the Hampshire Friendly Society . They found that while the First World War, the economic crisis and the financial policy of the society all played a role, the single most important factor determining incidence and length of sickness reports was age. This seemed to confirm James Riley´s thesis that increased life expectancy brought about increased morbidity. Brigitte Widdershoven (Tilburg/Amsterdam), on the other hand, focussed on the institutional aspects of Mutual health insurance in the Netherlands in the period 1920-1941. Health insurance was voluntary and private in the Netherlands before 1945. Yet, despite internal and external difficulties, insurance companies could increase their status during the interwar years thanks to their flexible arrangements in the face of individual (unemployment, death of breadwinner) and general problems (economic crisis).

The May 17 sessions assembled papers addressing regional health experiences using a variety of approaches. Humphrey Southall ( Portsmouth ) for The changing geography of death in England , Edward VII to George VI drew on the Great Britain Historical Database for vital statistics covering 1800 English districts. These allow statistically sophisticated correlations with local data regarding infant mortality, general mortality, housing, unemployment, professions of parents etc. In contrast, Pamely Michael ( Bangor ) emphasized in Health Variations in Inter-War Wales the importance of statistically undetectable aspects like family ties, teacher status or community involvement. Using a variety of sources, including photographs, travel and doctors´ reports, she painted a vivid picture of the experience of health and disease for Welsh communities and its formative effect on the collective identity. The following lively debate compared the strengths and limitations of quantitative and qualitative analysis: while statistical work could produce more «hard» evidence, its results in isolation could be misleading. Thus the absence of tangible results on health after the change of one factor (i.e. unemployment) might suggest its having had no effect, while in reality it might have provoked a variety of interacting contradictory effects.

A similar discussion resulted from the papers by Petr Svobodny and Hana Masova ( Prague ) on Health and Health Care in Czechoslovakia 1918-1938. Their data, including extensive contemporary map material, pointed to a continued profound dichotomy between Eastern and Western Czechoslovakia , in terms of vital statistics, age, mortality and morbidity structure and healthcare systems. The ensuing discussion questioned in how far this East-West division could be accepted at face-value or might be placed into different proportions taking into account different statistical traditions in the areas or possible motives of contemporary authors to portray a divided country with a «modern» West and a «backward» East. There was some controversy about the need for statistical standardizations (e.g. regarding age structure) and whether this would remove distorting elements from the analysis or distract from the practical non-standardized experience of the people at the time.

The remaining papers involved case studies of social, political and scientific perspectives on health issues. Esteban Rodiguez-Ocaña ( Granada ) presented with The Fight against Malaria, a show-window for the Spanish Public Health Department in inter-war Europe an account of the public attitude in Spain towards malaria. While a long-time scourge in Spain , the increased incidence of malaria after the Spanish-American war and improved understanding of its etiology provoked increased public attention in the interwar period. It was a major problem for a largely rural population, causing a loss of five millions working days per year. Following several fact-finding missions, a Central Committee against Malaria was founded and took energetic steps to combat the disease. Among others, some social benefits for malaria patients depended on their completion of quinine treatment.

Wolfgang Eckart ( Heidelberg ) delineated Foreign Cultural Policy and Medicine between the Wars: Heinrich Zeiss and the Soviet Union, 1921-1930. Heinrich Zeiss, a German nationalist bacteriologist, stayed in the Soviet Union on a medical-cultural mission. While subjectively philo-Russion, he used his good standing in Soviet circles to propagate Germany pharmaceuticals and send reports about his observations to the German embassy. In the process, he followed a strange amalgamation of «geomedicine», holistic thinking, epidemiology and «blood-and-earth» ideology, elements of which came to be included in the infamous General Plan East. Captured in East Berlin after the war, Zeiss was executed in the Soviet Union in 1948.

Boleslav Lichterman ( Moscow ) explained in The birth of the neurosurgery clinic in the interwar period (in the USSR , UK and France ) how an experimental medical practice moved across Europe from the West to the East.

In the end there was a consensus that the interdisciplinary composition of participants had ensured lively and fruitful discussions. The differences in approach and methodology, particularly between quantitative and qualitative work had forced everyone to reconsider seemingly safe assumptions. At the same time, it was felt that more questions had been found than answers and that there was ample room for more research in the field. Therefore, it was decided to continue contact via a mailing list in an informal network of scholars of interwar health.