Comment: What Historians of Medicine Can Learn from Historians of Capitalism

Christy Chapin makes a very positive and thoughtful argument in her essay for the importance of engaging with the History of Capitalism literature. What I found particularly striking and convincing, though, was her argument that historians of capitalism have at least as much to learn from the history of medicine, and particularly from the long duration and rich variation in the ways in which markets infuse and operate in this area of human activity.

I believe we should make this argument even more strongly. Historians of medicine have explored the organization of medical economies since the earliest studies were published in the field. Attention to capitalism has been a hallmark of the field. However, the more powerful governing concepts of this work have usually not been capitalism, but professionalization and regulation.

This is because medicine offers a case that runs against the narrative of capitalism's emergence in the long nineteenth century that energizes and motivates much recent History of Capitalism literature. Just as "Industrial Capitalism" develops and deepens, medicine retreats from the market. Prices become less free and access to markets becomes more constrained. Medicine in the age of capitalism offers many instances to support Adam Smith's suspicion that businessmen who gather together rarely avoid contriving to raise prices.¹ It is telling that two years after the British General Medical Council created medical registration to limit the practice of medicine in 1858, the Cobden–Chevalier Treaty between England and France created the first free trade agreement. As Chapin's survey of developments in Germany, the United States, and the United Kingdom clearly shows, opposition to, and interference with, markets characterizes the sector in the nineteenth and twentieth centuries, including in the pharmaceutical industry and health insurance.

If tracing the roots of capitalism is our concern, then premodern medicine came far closer to a free market operating under the principles of capitalism than modern medicine. A rich literature on medical practitioners in early modern Europe has detailed the ways in which physicians, surgeons, and irregulars promoted their practices, developed innovative contracts for services, seduced potential patients, and built quasi-firms to distribute work to their peers.² Medical entrepreneurism thrived even where regulation was active, as Italian licensed quackery epitomizes.³ There are two linked implications of this characterization of the evolution of medical economies: first, that students of the history of capitalism need to attend to countervailing trends that weaken markets; second, that students of the history of medicine need to be cautious about assuming parallels between shifts in economic structures in the wider economy and in health care.

Indeed, most definitions of capitalism—at least those that focus on capitalism as a form of market organization characterized by private contracts, responsive prices, and third-party enforcement—can be shown to hold for an array of services, not just medicine, in many parts of early modern Europe. As Chapin shows, we can go further, and identify forms of capitalism in healing in ancient Egypt and medieval spiritual medicine too. This very long continuity speaks to the fundamental and long-running debate about whether economic organization did shift at some basic level from precapitalist to capitalist economies.⁴ But I would suggest the most intriguing questions for the history of medicine are subtler than this. Rather than arguing about "markets or not," we have the challenging of explaining the changing scale of markets in medicine. And scale here should be thought of in more than one dimension. We surely need to understand the changing balance between open and regulated markets in health care provision that is highlighted in Chapin's essay. We should extend this to the ways in which capital accumulation and concentration—hospitals, diagnostic technologies, pharmaceutical factories—reshape health care, and also to the attendant questions of productivity that are rarely asked. Yet we would also want to attend to the differing contribution of family, neighborhood, and commercial medical support in the strategies adopted by the sick. The ways in which care might be offered between friends and kin in the context of "economies of regard...