Health Care and Poor Relief in Eighteenth- and Nineteenth-Century Northern Europe (review)

Among the great social issues of Europe's common past, that of poverty will always take a central place. Before the twentieth century, before the rise of the welfare states, poverty was real, not relative as is usual today—and that reality haunted both rulers and the ruled, whether as the specter of political and military weakness and disorder, or as actual or prospective individual misery. And in the shadow of poverty stood injury and illness, as recognized causes of poverty. In the 1990s, Ole Grell and Andrew Cunningham conceived the ambitious project of a pan-European survey of provision for poverty and ill health in the early modern period—the latter generously defined as 1500-1900. Four volumes encompass this ambition, organized by period and geography. The first two dealt with the years 1500-1700 in Protestant and Counter-Reformation Europe, respectively; the third is reviewed here; the last will tackle Southern Europe between 1700 and 1900. As the modern states of Europe move relentlessly toward political and economic union, with poverty and migration still critical problems of domestic management, surveys such as this do not just have a scholarly function to perform: they also serve to underscore Europe's historic interconnections, continuities, and interdependencies.

This volume opens, like its predecessors, with three general chapters, including a valuable survey introduction by Grell and Cunningham, and a stimulating essay on risk and welfare by Marco van Leeuwen. Twelve essays on individual states follow. These focus on Germany (three), Russia, Denmark, Norway, Britain (London, the provinces, and Scotland), the Netherlands, and France (Paris and the provinces). These are of consistent quality, clearly written and strong on detail. Taken as a package, the richness of the information provided is somewhat overwhelming, and the serious student should keep pen and notepad (or keyboard) ready as an indispensable aid to mental digestion. The big themes of the book are, however, usefully outlined in the introductory chapter. The fundamental questions center on how European states responded to the challenge of industrialization and population growth, and how ideology influenced that response. These centuries brought the expansion of trade, industry, and agriculture, growing populations, and new problems of poverty. The intellectual revolution of the Enlightenment brought new approaches to poverty—in the German ideology of Kameralismus, which exalted the interests of the state above those of individuals, and in English liberalism, which emphasized the enlightened self-interest of the ruling class. Neither approach brought much comfort to the poor. Christian traditions of charity remained important, and were expressed through voluntary organizations and individual philanthropy.

Notwithstanding changing circumstances and perceptions, the question of poor relief remained inextricably entangled with the health of the poor. Inextricably, but intransigently. States and municipalities wrestled with different solutions: the banning of beggary, the institutionalization of relief, domiciliary care. The treatment of the sick poor came to be seen as a public good in preventing impoverishment, although this realization occurred at different times—in the 1760s in Hamburg, after 1860 in England. Throughout northern Europe, extensive efforts were made to tackle the problem of poverty through ill health, but the remedies were invariably local, patchwork, and complex. Above all, they revolved around medical care. The intention was to prevent chronic disease or debility, to return productive individuals to the workforce, to reduce the burden of long-term care on state or charitable resources.

Within these systems of poor relief, health care meant medical treatment for the individual, not public health for populations. In this sense, the solutions were traditional; the circumstances that created the problems of illness—accidents, disease, old age, insanitary environments, and defective housing—remained beyond contemporary conceptions of poor relief well into the nineteenth century...