Chronic Disease in the Twentieth Century: A History

8. Health, Wealth, and the State

For much of the twentieth century, the American preoccupation with chronic disease was exceptional. Most of the issues associated with such illness were not specific to the United States but they were perceived, understood, and classified in different ways in other countries. I illustrate this point in the following two chapters by examining developments in the United Kingdom and France. My goal is to (1) underscore the uniqueness of the American focus on “chronic disease”; (2) attempt to understand how distinctive national realities produced different conceptual frameworks and axes of disagreement that structured debates about healthcare policy; and (3) explore the international circulation of the notion “chronic disease” during the second half of the twentieth century and beyond. Before examining each nation in detail, a number of general observations are in order. Britain and especially France were during the first half of the twentieth century older societies than the United States. In 1921 around 7.5% of the population was aged 60 and older in the United States, whereas the comparable figures were 13.7% in France and 9.4% in England and Wales. In 1950 those 65 or older made up 8.3% of the American population and roughly 11% in the two European nations. Such discrepancies continued well into the 1970s.1 In France population aging was a longstanding phenomenon due to traditionally low birth rates. In both European countries, the deaths of large numbers of young men during the two World Wars raised the overall population age. Finally, neither European country experienced prolonged high rates of immigration characteristic of the United States, that land of such extravagant promise. This reality had paradoxical results. Since chronic illness was associated with age, both Britain and France should have experienced a significantly more intense chronic disease problem than did the United States. This did not occur, however, because the sad reality was that chapter eight Health, Wealth, and the State 172 Chronic Disease in the United Kingdom and France no one was particularly concerned with older persons. American preoccupation with chronic illness was predicated on the assumption that it affected large numbers of young or middle-aged men and women. This made their cure and rehabilitation a significant national priority with major implications for the future of the nation. The illnesses of older people, in contrast, appeared to be part of the natural order and had little if any consequences for the productivity or might of the nation. Precisely because chronic disease was identified with the elderly population , it was largely ignored in the United Kingdom and France during the first half of the twentieth century. The poorest members of this group were placed in national networks of institutions: Poor Law or successor institutions in Britain and hospices in France. When their condition did emerge as a major humanitarian issue during the second half of the century, the chronic diseases that afflicted many were perceived as an aspect of service provision rather than one of health status. A second major difference had to do with national wealth. The United States emerged in the twentieth century as the richest nation in the world and as a superpower . This position was enhanced after World War II when it became the undisputed leader of the noncommunist world. It had more money than any other country to spend on healthcare at a time when health was becoming a major consumer demand. Without a national health insurance system to fund, postwar American authorities had greater financial margin and, I have argued, political incentive to confront challenges like chronic illness that threatened few entrenched interests. France and Britain emerged from the war relatively impoverished and with major reconstruction tasks to undertake. They had to renovate and modernize aging and technologically outdated hospital systems that now served larger patient populations and that utilized more expensive equipment and techniques. Like most nations, they were dealing with specific illnesses like tuberculosis , venereal disease, and increasingly cancer—some of which might be considered chronic; but no one was seeking to confront a huge and amorphous new category like “chronic disease” whose costs were impossible to calculate. The political choice to invest large amounts of money in a national healthcare service or health insurance scheme precluded investment in other areas but also defined the issues to be faced during the following decades. These included pressure to extend coverage, increase equality of access, manage relations with powerful medical professions, and, not least, control costs. The growing wealth and power of the American...