Notes on Hamlin's history of public health
I started reading a book on the history of public health - Public Health and Social Justice in the Age of Chadwick, 1800-1854, by Christopher Hamlin - on Abby Cartus’s suggestion. (If you’re not subscribing to Abby’s newsletter, do so! https://buttondown.email/abbycartus/) The book is up my street for a few reasons. There’s the obvious connection to my interest in getting a better understanding of public health related to wanting a better grasp of the covid pandemic. I’m also interested in British history (if it was possible to retrain in another history field I’d absolute do so in the history of the UK), and am also interested in the state and social policy in this particular era since it’s a significant part of the context Marx worked in.
Hamlin situates the development of public health in the context of the development of industry in Britain while also noting the complexity and conceptual slipperiness of what the term ‘public health’ refers to. Three common usages are the actual health of general population AKA ‘the public’, the institutions associated with public health, and some ideal of healthiness for the general population against which various developments are measured. Each of those usages has its place but can also hide as much as they make clear, and specifically hide how public health matters involve significant questions which get worked out through what are fundamentally political processes: “what ‘public’ and ‘health’ are to be, and how they are to be related, are political questions. Someone, somewhere, must say what businesses will held accountable for their effects on health. What rights to what sort of health will I, as one of a certain race, class, gender, nationality, and age, possess?” Once we think this way, and so understand that public health is really a matter of working out which people have what rights to health” and health defined in what way, “it becomes impossible to sustain the illusion of an ideal toward which all progressive public health is ever tending. The history of public health at that point ceases to be a subdivision of state growth or medical science and becomes part of the history of the acquisition of political rights or, if you will, the history of class struggle.” (2.)
Hamlin looks at the UK in the early to mid 19th century, a time and place he says ended up being especially influential on other times and places. He characterizes this as a context as “an age of austere political economy, thriving on conflict and rooted in what are conceived the natural laws of of human society,” with important changes in the organization of the state being a key part of what happened, with the state becoming more centralized and less democratic in the sense of being more expert administrated and less locally deliberatively governed. (3.) Into the tumult and concern of the period stepped - or out of it arose - Edwin Chadwick, a lawyer and would-be social engineer who went from involvement in a commission on the laws governing the poor to writing what he called a report on the “sanitary condition” of the working class - “the labouring population” in his terms - and from there to running what Hamlin calls “the first modern public agency, the General Board of Health,” founded in 1848 and run by Chadwick until 1854. This short term belies Chadwick’s influence: “sanitation became a social movement,” Hamlin writes, one that remade a great deal around it, giving rise to “a great age of sanitary improvement” running until World War One. An important part of that movement and age was the theory that disease came from filth, rather than ill-health being “the appropriate end” or natural condition of the poor. (4.)
Hamlin stresses the unlikely character of the rise of public health. For one thing, the people who expanded state power via the creation of public health institutions did so while at the same time possessed of a view that didn’t immediately lend itself to that expansion, since they were creatures of “a cultural climate that minimized the range of problems considered public.” (4.) Closely related, the idea of preserve population health - and thus life - was in tension with a widespread elite conception that people, and especially poor people, were too numerous. Furthermore, there wasn’t an effective modern state in existence - that state came to exist to a significant degree, Hamlin argues, “through dealing with public health and similar matters” rather than being an enabling condition already in place prior to the effort to deal with public health. (5.) That effort involved some strange bedfellows, as people with disparate parliamentary political outlooks and ideologies collaborated. Medicine as science and as set of institutions and constituencies was poorly developed and internally divided by contention, and lack of state capacity meant the kinds of big picture data we today tend to associate with public health was significantly absent. Taken together, Hamlin presents a picture of soil unlikely to grow the public health that took root, and that picture in turn successfully makes the question of why public health developed as it did in that era a real question worth addressing.
Hamlin notes that early British public health efforts heavily emphasized clean water and waste removal and made a lot of use of the notion of sanitation. He doesn’t quite put this in so many words (I don’t want to put words in his mouth) but he points out that this emphasis came to take on a deep-seated obviousness - of COURSE public health will emphasize sanitary drinking water and waste removal! And I agree, I’m just as much a product of that outlook as anyone else (the complexes of ideas we live within are in important respects just as real as the built environment we live in), though obviousness tends to indicate a presence of ideology, and in this case and in many others the obviousness is the product of a victory that can’t be explained in terms produced by that victory. (Analogous: it’s common for people in the US to think of the American Revolution as Americans battling the English but really what happened was a process of English people battling English people and over time some of those English people began to wonder if they should politically break from England; projecting the non-Englishness of those former English backward makes a great deal of sense insofar as it’s sort of just what happens - winners write a certain kind of history that mythologizes the past - but it’s simply not accurate to, and so is not explanatory of, the actual historical process.) This “is at best perilously close to making an event the cause of its own happening.” (P9.) As Hamlin points out, it didn’t actually have to be water, waste, and sanitation - it could have been food, say, or wages, Hamlin notes, presumably a mix of wry and radical. It only feels like it had to be water etc afterward because Chadwick and co won out so decisively. He also points out how unlikely that victory would appear if it were predicted to people just a few years prior, given the ideologies and political forces that the sanitarians improbably won out against.
So what explains these events? Not a simple rational logic of state formation unfolding as actors became better informed! Hamlin suggests that some historians have understood the matter that way, which retroactively writes out of history the improbable nature of what happened. Hamlin notes (p9) that if this were accurate there wouldn’t really be any need to bother writing the history of public health, and if he’s right that this is a widespread view among the historians writing on the topic then maybe that’s a factor in why (in my admittedly relatively uninformed view as someone outside the field of the history of public health) there isn’t a larger field of history of public health. Alternatively, maybe this is a kind of just-so mythology that facilitates the activities of public health as a field so that story promotes demand for history written from that point of view, I dunno, I’m just speculating. Hamlin again: “the simple appeal to truth” doesn’t suffice as an explanation (p10). After all, the forces of truth lose sometimes and the forces of deception win sometimes, and also very important, which truth, with what ramifications, is an ongoing subject of dispute, so the victories need to be explained if they’re to be understood. (And sometimes, as I’ve tried to imply, reproducing the victory or just going about business after the victory is facilitated by mythologizing to which accurate explanation is at best irrelevant and at worst an obstacle.)
Closely related, Hamlin rejects appeal to “conditions” as explaining events - “the idea that public health activity is driven by public health need.” (P10.) That practically leapt off the page when I read it as I sure as shit had that idea in mind before the pandemic started and spent a long while after it broke out trying to make sense of why the pressing public health need wasn’t eventuating in better public health activity. (Goran Therborn again: it’s ideology! I’m interpellated!) “Of course conditions were deplorable, but their deplorability tells us nothing about who responded to them and how.” Or why, as Hamlin stresses: “responsibility had to be recognized to be acted upon” (p10), and these are all political processes ultimately.
“Conditions do not bring us to the realm of motives, strategies, interests, ideologies, and power.” (P11) Another bit that leapt off the page, again not least because reading it I realized how long I spent in the pandemic making the mistake he’s criticizing - and to be totally honest, how frequently and intensely I’m still tempted by that mistake. (Again, ideology, interpellation, or, again the shaping of social consciousness by actually lived social life: I’m a creature of my environment, as a relatively formally included member of a liberal democracy, and that encourages a mistaken set of political and analytical impulses.) Conditions are the context in which politics happen, they don’t themselves practice politics.
Hamlin notes in passing that part of the issue, and only part to be clear, is the sources themselves: the sanitarians (I’m told by Hamlin, all I know about them is the about ten pages of his I’ve read so far) postured rhetorically for political purposes, framing their issues as obvious such that no reasonable person would oppose them. If we’re convinced by that rhetoric then we’re in effect living out effects of and illustrating the power of the sanitarians’ political-rhetorical practice, and the flip side of that is that we can’t understand their actions in context. In doing so we “float right by the great puzzle of how people come to take particular steps to improve health and well-being.” (P11.)
Hamlin adds - in a long footnote, the presence of which demonstrates he is a writer of good conscience and great charm, naturally - that “it was not conditions that were at issue, but perceptions of them.” I’d quibble there and say that when something is ‘at issue’ we’re always in the realm of the representation of that something, but the point is important anyway. He continues, “The battle was over public sensibilities.” (P11, note 20.) And presumably the battle was also over who counts as ‘the public’ and which sensibilities translate into what actions.
Part of the gist seems to be that public health is variable, or at least could have been. Maybe it can’t be remade anymore because too locked down by various forms of weight and inertia, no more than it seems possible to re-England the United States, but ‘no longer possible’ doesn’t mean no such possibility ever existed.
Another jump off the page line: “we cannot count on reaching a level of intolerability that will once-and-for-all impel us to fix things.” (P14.) The ‘us’ could be interrogated here, being itself a product - much of the time there’s a them and an us, and we’re encouraged to think there’s only an us. Anyway. The point is, as someone said - Alef Heffron maybe? - we make a huge mistake if we outsource the politics of how to respond to the pandemic to the pandemic itself.
Hamlin calls for being aware of “all the ways social arrangements affect health,” (14) the implications being, I think, 1) that really creating health involves intervening into social relations, or at least that there are serious differences between forms of health-promotion that do so intervene and that don’t, and 2) any particular health effort conducted by health officials is going to intervene in only some of the underlying social relations (absent massive social upheaval like a revolution anyway). The second point makes it particularly important that we not take our map of the world - our social ontology, so to speak - from any historically situated health effort, as those efforts are likely to have a limited percecption of “all the ways social arrangements affect health.” Getting this wrong “reifies a peculiar and restricted public health.”
Having read the intro and written these notes a thought strikes me: as I’ve said on here a lot, borrowing from Tony Smith, in capitalism there’s a tendency to restrict the scope of politics in the sense that a lot of social life to be treated as outside the scope of collective decision-making and just to be taken as given. This means that while the capitalist state is in one sense a specialized domain for where politics is to happen, it’s also significantly a set of institutions for preventing or defusing politics, as part of maintaining the fundamentally private character of a great deal of social production. And yet capitalism is a violently dynamic social system, prone to intense crises and conflicts of various forms, so that any specific set of institutions that express and organize capitalist social relations are likely to be temporary or at least forced to change over time due to system-generated pressures. Those changes and some of the conflicts that they’re bound up with are, among other things, potential openings for politics, and that’s often a problem for lots of people. It occurs to me that public health as a profession and body of professional knowledge is, like law, in part a set of concepts for simultaneously unfreezing a small section of social relations for the sake of re-organizing them - that is, for a bounded, localized politicking - and also helping keep frozen the larger set of social relations such that they’re not subject to re-organization. That is, these are simultaneously politicizing and depoliticizing sets of concepts and practices. They produce small and only small political openings and work against big political openings.
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I wrote the above after reading the book intro. I’ve now finished the first chapter and started the second. My notes from chapter 1 are below. I’m currently leaning toward putting all my notes in this post though that may get unwieldy. Cross that bridge when I come to it I suppose!
Hamlin’s first chapter lays out a history of medicine as a set of ideas and practices in the UK in the late 18th through mid 19th century. He notes not quite in so many words that health was a moral concept insofar as it centered on what people deserved, an individual-focused concept insofar as the ‘people’ who just deserts it concerned itself with were individual persons who needed care, and a political concept insofar as it had important bearing on social arrangements as health-shaping, often negatively so. Part of the point of all this is to show how unlikely was the development of what became public health in Britain and that alternatives were not only possible but arguably more likely than what actually happened. Part of the point is also to show the thicket of competitor positions that early public health had to cut through in order to become what it became. Hamlin situates these early medical ideas in relation to developments in governanc and policy, especially over the poor, like workhouses to house (confine!) and mold the moral character of poor people, the growth of factories, and efforts to regulate factories. In that context, medicine was often to a limited extent a critical force, denouncing the ill effects of factory life on working class people, especially child laborers. This is very in keeping with Marx and Engels’s writing, and Hamlin quotes Marx, digging into his source materials on working class health in intriguing ways, and showing how Marx drew from a wide body of social criticism by medical practitioners. Hamlin also notes that medicine and political economy were transforming in their meaning internally as bodies of thought and practice and also transforming in their relationship to the larger social context. Social criticism by physicians indicates a concern with the social as part of medicine. That concern seems to decline somewhat as medicine’s appropriate object, I think, becoming more centered on the physical body not as site of socially-induced health effects, but as a kind of biological atom that goes awry for internal reasons or due to contagion from biological agents like germs. (I’m speculating a little here, I’m not as up on the history of medicine as I’d like to be and I want to note that any error here is mine, not Hamlin’s.) Hamlin puts this in terms of health being a public matter in a different sense than later public health: health was a concept for making a given state of affairs become a matter of public concern,with the sco pe of that state of affairs being fairly open ended and the criteria for being of concern being largely self-reports. whereas later public health narrowed the scope of what health was, the range of interventions was, whose concerned reports could make something a matter of attention, and the gist was less democratizing than the purview of specialists employed by the state or making policy.
Hamlin situates medicine in relation to the older social order depicted by EP Thompson under the heading ‘moral economy’, meaning a set of norms that could be used to regulate - in effect, render moral, in the sense of acceptable - how social production was conducted. Medicine shared some of that sensibility of an orderly, healthy-ish social world and interventions to prevent illness-creating new developments. As Hamlin notes, medicine didn’t change so much as conditions changed around it giving the medical moral economy a newly seemingly (that’s my term, not sure Hamlin would accept it) subversive orientation. That had to be dealt with - neutralized - by early forerunners of what become public health insofar as public health was to become a provision of ostensibly apolitical social management. A key part of the changing conditions in the background was the growth of dependent waged-workers, as distinct from self-employed artisans, and changes in the organization of production, specifically industrialization. The former brought out a new organization of poverty and financial constraint (artisans too must work but might have a portfolio of people they work for rather than one employer - again this is my speculation to be clear) the latter a new organization of labor processes involving both more physical dangers and taxing kinds of work due to both duration and intensity, and also lower pay. This new order, and here Hamlin greatly echoes Thompson in a way he had to realize though he didn’t say so, in that the new order simply saw the earlier relative social commitment to keeping everyone fed enough-ish to an order defined by market forces understood as asocial, apolitical, and implacable. That condition introduced a new norm of there being far less of a socail floor or safety net - as Beatrice Adler-Bolton has written ‘in capitalism you get as much survival as you can afford’(that’s from memory, I know I got the gist right; it recalls the great Dillinger Four: “this isn’t what we want, this isn’t what we need, it’s what we can afford”). There was capitalism before that but it got even worse as the older moral economy social support norm went away. Furthermore, the new norm was ideologically defended by appearing as no norm at all, just the way of the world, humanity’s economic human nature. (I’m riffing here on p21 of the Hamlin.)
Part of what this chapter shows is a medical concern with the effects of work, income, and access to food of sufficient quality and quantity on workers, pre-dating what became public health and, as Hamlin foreshadows in the introduction, falling out of that later public health. Here again Hamlin’s emphasis is on how we could have had a different public health within capitalism. Two other quick notes: there’s a lot of fascinating-sounding works in the footnotes, on the history of medicine, social policy, and public health in England. That’s exciting to me as someone who fantasizes about being a historian of those subject areas in the 19th century and about becoming a Britis historian.I’m tempted to buy the bookjust for the footnotes, though I despair at the thought of how long it would take me to read Hamlin’s sources. Two, Hamlin notes that for all its critical force in this particular context, medicine still had a significant streak of positing people as objects of care rather than subjects in a democratic process. These were people fighting over different versions of capitalist health practices, they weren’t forerunners of health communism (if you’ve not read Health Communism, do! Thats the gist of the review I wrot of the book). Hamlin doesn’t indicate this - his focus is solidly on a turn within capitalism, like Thompson’s focus in his moral economy essay. That’s appropriate and facilitates some insights but it’s limiting analytically as well, as the best position considered is a kinder capitalism and neglects how these are all in effect in-house debates distinct from revolutionary perspectives. Anyway, the focus of medicine on (or habit of taking) people as objects, Hamlin suggests, was in context a source of the reason why this kind of medicine didn’t develop into a full blown competitor public health (in the sense of a program of political action leading to a set of institutionalized practices governing a wider swathe of society). The working class movement was organized hevily around notions of dignity,rights, and independence, that independence being significantly gendered. As Hamlin points out, for the movement of the day it was one thing to depict women and children as vulnerable and in need of saving, it was very different to do so about working men, and the workingmen’s movement (gendered term here deliberate to emphasize the dominant gender make up and politics of the movement) shied away from the latter. I lied, third thought: I suspect all of these developments could be usefully thought about in relation to Goran Therborn’s three fundamental questions underyling ideological depictions - what exists, what is possible, what is good - as those kinds of claims from various contending positions are all over this chapter. And likewise it could be interesting mapping these developments via Raymond Williams’s framework of a dominant culture (internally contesting itself and so internally dynamic), safely alternative cultures and dangerously oppositional cultures, and each of the latter being sometimes old and longstanding (residual, in Williams’s terms) or new (emergent, in his terms). I think it’d be fair to say that on Hamlin’s depiction, medicine was an element of the dominant culture that got sidelined, became temporarily oppositional as the dominant changed as part of the over all transformations of capitalist society in Britain, was in conflict with the new emergent and also but diffeently oppositional public health, got sidelined by that new public health, while the new public helth became part of the re-organized dominant culture and the medical politica Hamlin discusses, further sidelined, became first merely alternative then got remade itself internally (this is going beyond the scope of the chapter somewhat and again me speculating), and after that remaking became more incorporated into the dominant.