Articoli/Articles
Key words: Social medicine - Internationalism in health - Public health
SOCIAL MEDICINE IN THE INTERWAR YEARS. THE CASE OF JACQUES PARISOT (1882-1967)
LION MURARD
Centre de Recherche Médecine Science Santé et Société (CNRS - INSERM - EHESS) Paris, F.
SUMMARY
Hygiene, asserted the “Pasteurians”, is “the very base of politics”. Professor of preventive medicine at Nancy medical school, the phtisiologist Jacques Parisot well epitomized the style of a discipline that had soon shown interest for the avenues of action. Just as many other practical minds in Europe and elsewhere, he lamented the discrepancies between medical innovation and organizational change. However, as a French Professor medicine he had more latitude than his foreign colleagues to try bringing together the laboratory, medical education and the clinics. Chair of the Health Committee of the League of Nations from 1937 to the war, Parisot is an interesting case of these “Statesmen in disguise”: to him social medicine, a science for action, was nothing but a vehicle to improve the Welfare of the community.
:LWK VRPH QRWDEOH H[FHSWLRQV ² *HRUJH 5RVHQ 'RURWK\ DQG 5R\ Porter, Elisabeth Fee1 – medical historians deal with social medicine
only in a “local or national form”2: social medicine in France, in
Belgium, Holland, Italy, Romania, to cite some of the chapter head-ings used by René Sand in his classic The Advance to Social Medicine (1952). One could even say of social medicine what has been said of malariology, torn between the League of Nations’ socio-economic PRGHO TXLQLQH SOXV URDVW EHHI DQG WKH 5RFNHIHOOHU )RXQGDWLRQ·V ecological model (mosquito control), that it was “a house divided”3.
Death, are we told, is a “social disease”4: indeed, the sharing of
this belief does not hide the divisions in a discipline which doubts its guiding science, struggles to distinguish itself from socialist or socialized medicine and is unsure itself if it is a simple “hygiene of the underprivileged”5 DV 1LFRODL 6HPDVFKNR WKH ÀUVW 6RYLHW
Commissar of public health in the 1920s, called it, or a more ambi-tious Menschenökonomie, a medicine of the social.
/LNHWKHVRFLDOKLVWRU\RIPHGLFLQHLWVHOI6VRFLDOPHGLFLQHGHÀHVHDV\
GHÀQLWLRQ ,W KHVLWDWHV RYHU WKH QDPH RI LWV SDWURQ VDLQW ³ 5XGROI Virchow and Albert Grotjahn for the Germanic world, John Ryle for England, Angelo Celli for Italy — and it stumbles over its date of birth. If one can believe the British literature concerning a dis-cipline which was not widespread7 — Charles Webster even said
LWZDV´DOPRVWXQNQRZQµLQEHWZHHQWKHZDUV8, — social medicine
LQ(QJODQGRQO\WRRNRIIEHFDXVHRIWKH6HFRQG:RUOG:DUZKLFK focused attention on bread-and-butter issues. This was a resolutely idiosyncratic development, without any equivalence on the European continent where the concept had been grounded in a political view of health since the revolutions of 1848 in the West and 1917 in the East. “The notion of social medicine is an answer to the notion of social illness” declares the Pasteurian school of the 1930s: “It could even be said that it consists in bringing about equality of the classes in relation to health” 9.
For our part, it is precisely a political reading which we favor, con-VLGHULQJWKHUHFHQWFDOOE\0DUN0D]RZHUDXWKRURIDark Continent.
Europe’s Twentieth
Century WRFRQÀUPWKHVWUHQJWKRILGHRO-ogies. Liberal democracy, communism, fascism… apparently, only the Second World War taught democrats the lesson which had long been contemplated by the ‘Fascist welfare states’, “that granting indi-vidual liberties was not enough to secure people’s loyalties”10. This
DUJXPHQWLVVXJJHVWLYHLQWKDWLWWDNHVVHULRXVO\WKHPDQ\YDULDWLRQV of ‘welfare state’ which were circulating between the two wars: the
eugenically conceived social-welfare state, the German racial wel-fare state, as preface to the British ‘social citizenship state’ which appeared after 194211.
&RPSHWLWLRQEHWZHHQPRGHOVWKHQPRGHOVZKLFKGHÀQHWKHPVHOYHV LQ UHODWLRQ WR HDFK RWKHU VRFLDO PHGLFLQH ÀWV WKLV OLQH RI DQDO\VLV so well that one could practically map the variations according to the main geo-cultural areas, recognizable by their major concerns – social class differentials in fertility, mortality and living condi-tions in the case of England, welfare eugenics for the Germany of Weimar or Scandinavia, etc. Thus, this succession of social, social-ized, socialist medicines that can be readily analyzed in reference WRWKHWUDQVLWLRQVIURP:HVWWR(DVWZKLFK$OH[DQGHU*HUVFKHQNURQ called the European cultural gradient12. From our comparative
per-VSHFWLYHWKHSURSHUDQDO\WLFDOIUDPHZRUNDSSHDUVWREHOHVVQDWLRQDO than transnational, and even translocal.
,WLVVXFKDWUDQVORFDOÀJXUHZHZRXOGOLNHWRLQWURGXFHKHUHQDPHO\ the French phtisiologist Jacques Parisot (1882-1967), professor of EDFWHULRORJ\ WKHQRISUHYHQWLYHPHGLFLQH DQGÀQDOO\ of social medicine (1934) at the medical school in Nancy13, member
(1934) then president (1937) of the Health Committee of the League of Nations14.
Some of his publications: Alcoholism in the Lorraine Region,
Tuberculosis among bakery workers, A necessary reform: paid holidays for workers, Tuberculosis infection: the role of slums and overpopulation, Malaria in Europe and the antimalaria campaign in Corsica, Social Welfare Insurance, The economic crisis and pub-lic health, The impact of unemployment on prostitution, The major tasks of public hygiene, The hygiene of milk, History of an unhealthy neighborhood, The return of rural artisans.
These few titles chosen from among his publications are indicative of WKHVSLULWRIFXULRVLW\RIDQDULVWRFUDWLFÀJXUHZKRPWKH¶5RFNHIHOOHU medicine men’ considered equal to the Croatian Andrija Stampar or
the Hungarian Bela Johan, as one of the best European statesmen for state medicine15.
7KLV LV H[DFWO\ ZKDW LQWHUHVWV XV ZLWK 3DULVRW H[SRVLQJ D FXUUHQW RI thought in social medicine advocated by a conservative, but so similar LQLWVFRQWHQWWRWKDWKHOGE\FRQÀUPHGVRFLDOLVWV,QOLQHZLWK$UWKXU 1HZVKROPH·V DQDO\VLV RI +XQJDULDQ VRFLDO LQVXUDQFH DV ´D EXOZDUN against Bolshevism”16, we will thus see him advocating its introduction
LQWR)UDQFHDVIROORZV ´7RRRIWHQDPRQJXVWKHZRUG¶VRFLDO·HYRNHV the idea of a revolution. Quite to the contrary, social medicine and espe-cially social insurance constitute an effective weapon for protecting not just health but also order, by creating an atmosphere unfavorable to communism”17. But in truth, what is the difference between the
social-democrat agenda and his own? Salaries, family allocations, major pub-OLFZRUNVXUEDQLVPKRXVLQJ LW·VWKHHQWLUHSROLWLFDODQGVRFLDOHFRQRP\ which is engulfed by the enlargement of the ‘health-capital’ of the nation. His language is not the same as that of a Charles-Edward Winslow (pro-fessor of public health at Yale University) entrusting to public health WKHWDVN´WREXLOGXSRQHDUWKWKHFLW\RI*RGµ18, nor is it that of Henri
Sellier (the French Socialist minister of Health in 1936) and Robert-Henri Hazemann (former Director of Vitry-sur-Seine’s health bureau) calling for it to “solve the most violent contradictions which oppose the individual to society”19. But all millenarianism aside, the Promethean
tone did not dissipate in the slightest in this physician-sociologist who, throughout his life, continued to call for the abolition of the “general causes” of poverty and disease: “‘%RQLÀFDUH·WRXVHWKH,WDOLDQH[SUHV- VLRQLVWRGHVWUR\WKHVOXPVEXLOGKHDOWK\KRXVLQJFUHDWHZRUNHUV·JDU-GHQVZDWHUZRUNVEXLOGVHZDJHV\VWHPVFOHDQXSFLWLHVYLOODJHVODQG create public baths, swimming pools, slaughterhouses, etc. ”20.
Some aspects of his biography allow for comparison, namely: 1. Creating a technical health consciousness, 2. The local becoming the cosmopoli-tan 3. The agrarian moment in social medicine. These are three dimen-VLRQVZKLFKFXUUHQWKLVWRULRJUDSK\KDVOHIWVRPHZKDWLQWKHGDUN
1. Creating a health consciousness
-RKQ % *UDQW WKH VHOIVW\OHG 5RFNHIHOOHU )RXQGDWLRQ·V ¶PHGL-FDO %ROVKHYLN· DVVXUHV LQ KLV RUDO UHPLQLVFHQFHV WKH FKLHI WKLQJ KHOHDUQHGIURPKLVÀUVWDVVLJQPHQWLQ3XHUWR5LFRZDVWKDW´\RX couldn’t secure implementation unless you had a local agency and not only a local agency but also a technical health consciousness among the consumers”21:KDWLVGLIÀFXOWKHUHHYHU\RQHNQRZVLV
WR QRW \LHOG LQ WKH VOLJKWHVW WR WKH OX[XU\ RI D ¶SRSXODU PRELOL]D-tion from above’. Believing that persuasion and educaPRELOL]D-tion, patient H[SODQDWLRQDQGGHPRQVWUDWLRQZRXOGSHUPDQHQWO\EULQJWKHZDQWV RIWKHSRSXODWLRQLQWROLQHZLWKWKHSODQVRIWKHH[SHUWVLVWRDGRSW the illusion which James C. Scott has rightly called the “populist technocrat’s creed”22.
Does Jacques Parisot totally avoid this? We would not swear to it. His enthusiasm for ‘educational propaganda’ is without limits23. But
this is not the main point. Behind his commitment, there was the specter of a fading population, the brutal plight of the First World War, as he writes in Curing is good, preventing is better (1925), a war which, for France, dramatically posed the problem of ‘to be or not to’, a problem whose solution is “largely a matter of social medicine”24. These are marvelous observations because they
encour-DJH WKH KLVWRULDQ WR DVN TXHVWLRQV QRW RQO\ DERXW WKH UHODWLRQVKLSV between poverty, disease, ignorance, and misgovernment – that is between social medicine and social policy – but also about their no less intense relationships with nation-building, or re-building. Thus ZH KDYH KHDOWK GHPRQVWUDWLRQV DQG RWKHU UXUDO EHWWHUPHQW H[SHUL-ments carried out in emerging Yugoslavia, nationalist China or fascist ,WDO\DQGDVFRQFHUQVRXUH[DPSOHRQWKDWDODUPLQJERUGHUZKLFK /RUUDLQHUHSUHVHQWVIRU)UDQFH7KHÀHOGGHPRQVWUDWLRQWDNLQJSODFH WKHUHKDVQRRWKHUÀQDOLW\WKDQWKDW FUHDWHDQHZ´PHQWDOLW\µLQFLU-FXPVWDQFHVZKHUH´WKHQDWLRQ·VVWUHQJWKµLVDWVWDNH25.
$QGWRGRWKLVEHJLQE\PDNLQJPHGLFLQHVRFLDO:LWK-DFTXHV3DULVRW as with his mentor Léon Bernard (1872-1934, the grand Parisian phtisiologist, born in a Jewish family from Lorraine), the profes-VRURIK\JLHQH´KDVWRWDNHWRWKHVWUHHWVµ26. As Arthur Newsholme
insisted, it is ‘medicine from the social standpoint’, medicine as the QXFOHXVRIFRPPXQLW\VHUYLFH+HUHZHÀQGDFRPPRQGHQRPLQD-tor on which the René Sands and the Winslows, Grants, Stampars or Sigerists can agree – all descendants of Virchow. Social medicine cannot be separated from a critique of clinical medicine and a reas-sessment of clinical training. A step beyond preventive medicine, it is presented here as a polemical concept directed against those practitioners suspected of only wanting to “grope the patient in his KRPHµDQGWR´H[WUDFWKLVODVWSHQQ\µ(WLHQQH0DOYR] GLUHFWRURI WKH/LqJH,QVWLWXWEDFWpULRORJLTXH ZURWHWKLVLQEODFNDQGZKLWHDW the dawn of the last century to his friend Albert Calmette27. It is easy
to understand this tone: clinging to absolute secrecy, averse to the declaration of contagious diseases, devoured by contempt for dis-pensaries, paralyzed by fear when faced with social insurance (to the point of raising millions against the law of 1928-1930 on health and disability insurance), the private physician is all too often the worst enemy of public medicine in France. The brilliance of Jacques Parisot can especially be appreciated in that 80% to 90% of persons consulting in anti-tuberculosis dispensaries in Nancy and the sur-rounding area were reportedly sent there by their family doctor28, as
opposed to 24% for France as a whole in 1929, 50% in 193729. These
ÀJXUHV FOHDUO\ LOOXVWUDWH WKH WUDQVIRUPLQJ SRZHU RI D ´8QLYHUVLW\ Faculty of Social Medicine”30.
By Faculty of Social Medicine, we mean in this case the close vol-untary association achieved in Lorraine between the teaching and practice of preventive medicine. In Nancy, the central anti-venereal GLVSHQVDU\ RI WKH UHJLRQDO 2IÀFH RI 6RFLDO +\JLHQH ORFDWHG QH[W door to the School of Medicine’s anti-syphilis chair, is presided over
by the professor who holding this chair. The same is true for the central anti-TB dispensary, where medical students are required to SDUWLFLSDWHLQWKHZRUN7KHPDLQSRLQWEHLQJWKDWHDFKRIWKHFKDLUV devoted to tuberculosis, childhood diseases, or other illnesses directs the corresponding section (child care, cancer, propaganda and TB VWDPSVHWF RIWKH2IÀFHRI6RFLDO+\JLHQHZKLFKXQGHUWKHSUHVL-GHQF\RI-DFTXHV3DULVRWGRHVQRWKLGHWKHIDFWLWLVZRUNLQJIRUWKH interpenetration of preventive and curative medicine. He never tires of repeating that “The patient is a unit, but a unit in a group, which LV WKH IDPLO\ WKH ZRUNVKRS WKH WRZQµ31 /LNH +HQU\ 6LJHULVW LQ
%DOWLPRUHZKRVHVWXGHQWVDW-RKQV+RSNLQVZHUHLQVWUXFWHGWRPDNH a thorough survey of the state of health in each county of Maryland32,
Jacques Parisot required candidates for a degree in hygiene to con-duct case studies of rural Lorraine villages, thus using the social sur-vey as a tool to shape a profession.
A positive outcome of this ‘saturation’ of medical teaching by the spirit of preventive medicine was the three-party agreement, the ÀUVW RI LWV NLQG DQG WKH RQO\ RQH LQ )UDQFH33. This agreement was
VLJQHGLQ'HFHPEHU E\3DULVRW·V2IÀFHRI6RFLDO+\JLHQHWKH local Medical Association, and the Union of Insurance Funds, which ZRXOGSURYLGHWKHSULQFLSDOSDUWRIWKH2IÀFH·VEXGJHW7KLVZDVD gold mine which enabled increases in visiting nurses and dispen-saries, the latter under the name of health centers. With additional effort, Parisot would obtain from these same partners, joined by pri-YDWHFKDULWLHVSXEOLFKRXVLQJRIÀFHVPXQLFLSDOLWLHVDQGSURYLQFLDO authorities, the creation of a joint ‘committee for the development of the means for protecting public health’, conceived as a planning WRRO LQ WKH VWUXJJOH DJDLQVW VRFLDO DIÁLFWLRQV RQ D UHJLRQDO VFDOH 7KLV LV ZKDW JLYHV WKLV H[SHULHQFH LWV GHPRQVWUDWLYH DQG WUDQVOR-cal importance: the compromises made among differing interests, rational understanding organized to reach a certain goal. It is this problem-solution approach, local and tailored to the situation, which
the Popular Front would support when it called for generalizing the Lorraine precedent to the whole country. By preparing a ‘health bal-ance sheet’ for each département, civically minded ‘coordination committees’ would guide politicians, and would encourage public opinion to be built on technical foundations.
2. The local becoming cosmopolitan
Collaboration, consistent methods and actions, the model here is a German one, namely that of the ‘Committees for medico-social cooperation’ – Gesundheits-Arbeitsgemeinschaft – which the mem-bers of the Health Organisation of the League of Nations (LNHO)-,QWHUQDWLRQDO /DERU 2IÀFH ,/2 MRLQW VXEFRPPLWWHH EHJLQQLQJ with Parisot, were able to admire across the Rhine in the spring of )URP WKLV VWXG\ WULS ZKLFK KH WRRN LQ FRPSDQ\ RI &($ Winslow through Germany, England, Austria, Hungary, Poland and <XJRVODYLD3DULVRWEURXJKWEDFNÀUVWKDQGNQRZOHGJHRIWKHVH´WHFK-niques” for pooling disparate resources such as hygiene, insurance, assistance, private charities, and even medical practitioners, which seemed to be the Weimar Republic’s secret34.
But Weimar is only one of a thousand reinterpreted models circulat-LQJDERXWDVWKRXJKQHZO\UHFUHDWHG7KH'DQLVKIRONKLJKVFKRROV the Croatian ‘Peasant University’, the Italian ERQLÀFKH studied in the VXPPHURI «WKHOLVWLVHQGOHVVRIWKHVHH[FKDQJHVDQGUHFLSUR-cal borrowings between closely connected ‘transloVXPPHURI «WKHOLVWLVHQGOHVVRIWKHVHH[FKDQJHVDQGUHFLSUR-cal’ professionals. (YHU\WKLQJ EHFRPHV D JDPH RI PLUURUV ZLWK LGHDV UHÁHFWHG EDFN DQGIRUWK)RUH[DPSOHWKHFDVHRIWKHVH¶VRFLDOFRQVXOWDWLRQV·EHJXQ during 1935 in the Lorraine health centers for the neediest patients:
Doctors and hygienists, argued Parisot, might think it completely abnor- PDOZKHQYLVLWLQJRQHRIRXUFHQWUHVWRÀQGFRXUVHVLQKRPHPDNLQJFRR-NLQJ«35.
7KH H[DPSOH FDPH IURP WKH IDPRXV ¶3HFNKDP KHDOWK FHQWHU· LQ London where mothers bring their babies to the nursery, spend the DIWHUQRRQ WRJHWKHU VHZLQJ FRRNLQJ DQG RIWHQ FRPH EDFN LQ WKH evening with their husbands to see a show, attend a concert or dance LQ D URRP QH[W WR WKH SUHYHQWLYH PHGLFLQH GHSDUWPHQW36. Mention
should also be made of the “bibliobus” or “circulating libraries” inaugurated in the Lorraine countryside as a sort of substitute Italian Dopolavoro37. Social medicine in the 1930s is nothing less than this
LOOLFLWPL[LQJEHWZHHQHQWLWLHVDSSDUHQWO\DOOHUJLFWRHDFKRWKHUVXFK as housing, nutrition, physical education, leisure activities and even civil service. There is a sort of generalized interconnectedness. John Grant said when he was in China, “The lower economic levels are, the PRUHWKHXVHRIPHGLFDONQRZOHGJHGHSHQGVXSRQRUJDQL]DWLRQµ38.
:H VSRNH RI WUDQVORFDO UHFLSURFDO VFKHPHV RI LQQRYDWLRQ :KDW LV IDVFLQDWLQJ DERXW WKH /RUUDLQH H[DPSOH LV WKH OLQNV HVWDEOLVKHG EHWZHHQWKHVWXGLHVFDUULHGRXWE\WKH2IÀFHRI6RFLDO+\JLHQHDQG the new projects on the impact of the Depression that the LNHO was launching at a feverish pace. Synchronization was perfect: in the winter of 1932-33, his visiting nurses were carrying out studies on income, housing, health and especially nutrition among 8000 fami-OLHV6LPLODUWRSLFVVLPLODUFRQFHSWV«$QRWKHUHDUOLHUH[DPSOHZDV the inventories made in villages in Lorraine on typhoid fever or a VDIHPLONVXSSO\ 39, in line with the proposals of the European
Conference on Rural Health (Geneva, 29 June-7 July 1931)… as though Lorraine were the LNHO’s testing grounds, as though the local were becoming global.
3DULVRWH[SDQGVWKHIURQWLHUVDQGPDNLQJKLV2IÀFHLQWRDVWDJLQJ DUHDIRUWKH/1+2JLYHVLWSULPDU\LQÁXHQFHLQ*HQHYD7KHVDPH is true for Winslow in New Haven, Sand in Brussels, Stampar in Zagreb, Johan in Budapest, who are carrying out the same evaluations RQW\SKRLGIHYHURUPLONVXSSOLHVVKDUHWKHVDPHLQWHUHVWLQWKHFRVW of medical care and draft the same tools for measuring public health.
$WWLPHVRQHRUDQRWKHURIWKHVHH[SHULPHQWVZDVRIDSLRQHHULQJ QDWXUHDQGDWWLPHVLWZDVVHHNLQJWRWUDQVSRVHDQGDGDSWLQLWLDWLYHV ZRUNHGRXWHOVHZKHUH PLQLJOREDOLVDWLRQDQGLQWHUFRQQHFWLYLW\« 3. The agrarian moment
It is commonly agreed, to cite Gertrud Kroeger, that social medicine was merely “the outcome of the industrial revolution”40. Inspired
by Engel’s Anti-Duhring, Robert-Henri Hazemann thus proposed LQWKH VWKDWWKHSURGXFWLRQH[FKDQJHDQGFRQVXPSWLRQRILOOV DPRQJWKHLQKDELWDQWVRIDZRUNLQJFODVVFLW\ZHUHFRQGLWLRQHGE\ WKH ZD\ WKH\ SURGXFHG H[FKDQJHG DQG FRQVXPHG JRRGV41. Armed
ZLWKPDWKHPDWLFDOIRUPXODV¶LQGH[HVRISRYHUW\·WKHIDWKHURIWKH ÀUVW)UHQFKKHDOWKFHQWHUGHFLGHGLQWKHVDPHYHLQWRHOXFLGDWHWKH economic underpinnings of health. The picture changes completely in the 1930s. Until now dedicated to the working classes, the
danger-ous classes, social medicine in the 1930s would become obsessed
with helping the Central and Eastern European peasantry, which the *UHDW'HSUHVVLRQZDVSXVKLQJLQWRWKHPDJQHWLFIRUFHÀHOGRIIDV-cism. In this sphere of lofty politics, it would be but another name for rural reconstruction.
C-E.A. Winslow had stated it following the First World War, “The rural problem was the great unsolved problem of public health”42.
7KHYLOODJHDQGQRORQJHUWKHZRUNSODFH LWLVWKLVUHYHUVDORISULRUL-WLHVWRZKLFKWKHHSRFKPDNLQJ (XURSHDQ&RQIHUHQFHRQUXUDO health is devoted43
&DUULHGIRUZDUGE\DQHZZDYHRIKROLVWLFWKLQN-ing on health care, Geneva had come to see the Depression as a cri-sis of under consumption rather than of overproduction. Home eco-QRPLFV HOHFWULÀFDWLRQ ODQG EDQNV DQG IDUPFRRSHUDWLYHV« UXUDO hygiene from now on would be seen with an eye towards raising the standard of living rather than simply improving medical issues. 7KHUH ZDV WKXV QRWKLQJ UHPDUNDEOH DERXW WKH FDVH VWXGLHV RI UXUDO communes in Lorraine that Parisot demanded of his students at the
regional Institute of Hygiene. Each snapshot of peasant life recorded in the thesis for the diploma in Hygiene was to be a complete epide-miological study of a given region or village — a locality’s patho-logical history during the past thousand years, for instance, with miscellaneous items such as: peasant housing, lighting, ventilation, GXQJKLOOVÁLHVPRVTXLWRHVDQGURGHQWVIRRGVDIHW\FRQWURORIIUHVK SURGXFHGLVHDVHVDIIHFWLQJERWKSHRSOHDQGDQLPDOVZRUNKRXUVWKH organization of leisure, sports, the population in the armed services, divorces, etc. In other words, a sort of return to the spirit of medical topographies44$QGZK\EHVXUSULVHGRIWKHDIÀQLWLHVGUDZLQJVRFLDO
medicine toward ‘open-air geography’, at a time when half of Europe was rural? Field surveys, and more generally, familiarization with a community’s mores, customs and economic status, were ways of OHDUQLQJ´DVLQGLVSHQVDEOHWRWKHKHDOWKRIÀFHUDVFOLQLFDOREVHUYDWLRQ is to future doctors”457KLQNVLPSO\RIWKH¶KHDOWKLQYHQWRULHV·RIUXUDO
communes bordering Paris drawn up around 1930 by Robert-Henri +D]HPDQQ7KLVIRUPHU5RFNHIHOOHUIHOORZDQGIRUPHUFRPPXQLVW QRZH[SHUWLQ*HQHYD·V+HDOWK6HFWLRQÀOOHGPRUHWKDQÀIW\WDEOHV ZLWKQXPEHUVUDQJLQJIURPWKH¶TXDQWLW\RIPHDWFRQVXPHGSHUZHHN and per person’ to the ‘distance of wells from unsanitary outhouses’, while not forgetting the ‘legal status of property’ or ‘ventilation at night’46. Doctor-sociologist, doctor-geographer, all are one.
$WWKHVDPHWLPHLQ*HQHYDWKHUHZDVWDONLQWKHPLG VPHUHO\ of a ‘marriage’ of health and agriculture47. Imbued with the potency
of a ‘Keynesian medicine’ as the soothing balm of international strife, the League was now interested only in the family’s purchas-ing power, and consumer economics. Vitamins turned into political facts. From Moscow in June 1936, Jacques Parisot, in the name of the LN Health Committee, thus called for a far-reaching European Conference on Rural Life – instead of on Rural Hygiene, as in 1931 – which would embrace nothing less than: I. The rural ambiance: SHDVDQWDUWDQGIRONORUHIDUPORDQVDJUDULDQUHIRUPWKHFRRSHUDWLYH
movement, repeopling the countryside, community planning, trans-SRUWDWLRQHOHFWULÀFDWLRQORFDODGPLQLVWUDWLRQ II. Food and produce;
III. The rural house and its outbuildings; IV. Peasant education:
JHQHUDOWHFKQLFDOKRPHPDNLQJ V3HDVDQWVDWZRUN QHZIDUPLQJ methods, rural industries; VI. Peasants at rest: organization of leisure activities, physical education, libraries, radio, cinema; VII. Medico-social policy: maternal and child care, birth control, nurseries and NLQGHUJDUWHQV LQ UXUDO DUHDV PDODULD DOFRKROLVP YLOODJH KHDOWK ZRUNHUV PLGZLYHV feldscher, etc.48 6XFK DQ DJHQGD FOHDUO\ WDNHV
RQ DQ$XVWUR+XQJDULDQ KXH 7R ¶VWDUW XS EDFN XS DQG VSHHG XS· the raising up of Central and Eastern Europe signaled a last-minute attempt to reinforce LN’s declining legitimacy by shifting its center of gravity from the city to the hungry countryside.
Jacques Parisot was not outdone in Lorraine itself. What he now called a medico-social organization – a miniature ministry of welfare – set out to “penetrate the intimacy of the peasant life, improving WKHIDWHRIFRXQWU\GZHOOHUVÀJKWLQJDJDLQVWWKHLUH[RGXVDQGSUH-SDULQJ>WKLV@PRYHPHQWEDFNWRWKHHDUWKµ49 for which Fascist Italy
RIIHUHGWKHH[DPSOHDQG5RRVHYHOWLDQ$PHULFDDVZHOOYLVLWHGLQ WKHDXWXPQRI 9RFDWLRQDOVFKRROVIRUNHHSLQJ\RXQJVWHUVLQWHU-ested in mechanics in villages, ‘social centers for entertainment on Sunday’50HWF HYHU\WKLQJZDVMXVWLÀDEOHIRUHQJDJLQJWKDW´SHRSOH·V
war for health” which would transform rural dwellers from passive RUUHOXFWDQWRQORRNHUVWRWKHEHVWFUDIWVPHQIRUWKHLURZQLPSURYH-ment. The creation, through education, of a general will towards KHDOWK WKDWZDVWKH\DUGVWLFNXVHGIRUFRPSDULQJSUHYDLOLQJPRGHOV of regional rural development (Tennessee Valley Authority, Croatia, Northern China, etc.).
At that point, the nature of social medicine changed. While retaining its original equity-derived, multisectoral and participative orienta-WLRQLWVDJHQGDZRXOGLQFOXGHIXOO\ÁHGJHGUXUDOUHKDELOLWDWLRQ1R longer simply a by-product of a Depression-era program, it would be
but another name for comprehensive, durable development. Because the trend was tricontinental. As shown by the August 1937 Bandung FRQIHUHQFH DQG WKH DERUWLYH 0H[LFR &LW\ FRQIHUHQFH SODQQHG IRU 1RYHPEHU WKHVWDJJHULQJDJHQGDGHÀQHGLQ0RVFRZZDVWREH EURDGHQHGWRFRYHUWKH)DU(DVWDQG/DWLQ$PHULFD%DQGXQJ0H[LFR we are on the road to the WHO 1978 Conference at Alma-Ata.
Conclusion
2XUFRQFOXVLRQLVFRQÀQHGWRDVLQJOHTXHVWLRQ DUHVRFLDOKLVWRULDQV WKRVHEHVWHTXLSSHGWRWDONDERXWVRFLDOPHGLFLQH":KHQLWFRQFHUQV (XURSH EHWZHHQ WKH ZDUV WKH\ DUH XVXDOO\ VDWLVÀHG LQ SRUWUD\LQJ food, housing and income as currencies of health, and to state that this social model of health ran right across the political spectrum. But social medicine cannot really be reduced to medical sociology. And shouldn’t there be concern that, if he does so, the historian will sweep under the carpet those things with which he does not wish to GLUW\KLVKDQGVVXFKDVWKHSDUWWDNHQE\VRFLDOPHGLFLQHLQWKHELUWK RIQDWLRQDOLVPVIRUH[DPSOH7RDSSURDFKWKHSUREOHPRQO\IURPWKH angle of social policy – the State as pater familias – is to paint only that corner of the picture that is not subject to controversy.
$QG\HWWKHUHLVQRODFNRIGLYHUVLW\7RUHDG&KDUOHV:HEVWHU$QQ 2DNOH\-RKQ6WHZDUWRU'RURWK\3RUWHUVRFLDOPHGLFLQHLVQRWKLQJ more than a short-lived discipline consistent with the ethos of postwar reconstruction and the move towards state-funded health services; a discipline, as Jane Lewis notes, which must narrow its concept in order ´WRVWDNHDFODLPWRDFDGHPLFUHVSHFWDELOLW\µ51, and furthermore, it was
supplanted in the 1960s by ‘community medicine’52. There is nothing
KHUHLQFRPPRQZLWKWKDWHQF\FORSHGLFDQGJRYHUQLQJVFLHQFHGHÀQHG by Albert Calmette urging French public authorities at the centenary of Pasteur in 1922, to see social hygiene as “the very basis of poli-tics”53. This is precisely the position of a Rudolf Virchow in the
on a grand scale’. A world separates these antithetical visions. British medical historians dispute the frontiers between biology and the social sciences, continental activist-reformers debate an all-inclusive ‘medi-cine applied to the nations’, in other words, politics.
It is this cultural divide which we should study, using concepts such as that of ‘path dependence’, as Peter Baldwin proposes in his recent
Disease and Democracy54
%DVLFGHFLVLRQVWDNHQLQWKHHDUO\QLQH-WHHQWKFHQWXU\WRFRQWUROFKROHUDDQGV\SKLOLVFRQWLQXHWRLQÁXHQFH the response to AIDS. Tactics adopted 150 years earlier created a template, so that each nation tailored its AIDS strategy largely to its ORQJGRPHVWLFWUDGLWLRQVRISXEOLFKHDOWK1H[WWRSDWKGHSHQGHQFH broad geo-epidemiological factors that pushed nineteenth-century SROLF\PDNHUV WR DGRSW RQH VHW RI WDFWLFV RYHU DQRWKHU FRQWLQXH WR LQÁXHQFHXV7KLVLVWRVD\WKDWWUDGLWLRQDOSROLWLFDODQDO\VLVRIWKH response to the epidemic is inadequate. Left and right, conservative DQGOLEHUDO WKHVHDUHQRWODEHOVWKDWKHOSH[SODLQZK\QDWLRQVGLI-IHU LQ WKHLU DSSURDFKHV WR WKH HSLGHPLF 6XFK GHFLVLRQV DUH WDNHQ in accord with deeper, pre-political policy structures already set in SODFHGXULQJWKHSUHYLRXVFHQWXU\LQDGGLWLRQWREHLQJLQÁXHQFHGE\ current national political cultures.
Social medicine constitutes a means to broaden the question of how political cultures and states differ across Europe. How do they treat the patient who is both citizen and disease carrier? How are individ-ual rights and the public good pursued simultaneously? Public health allows a deeper plumbing of political instincts and attitudes than the VXUIDFHRIRIÀFLDOLGHRORJ\:KDWDUHPRUHLPSRUWDQWWKHULJKWVRI patients or of the uninfected? To understand why the models adopted here and there were so surprisingly and counter intuitively different, we should certainly not commit that error formerly denounced by Raymond Aron, of reducing the political to the sociological, that is to say to the infra-political55.
BIBLIOGRAPHY AND NOTES
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His journal, La Revue d’Hygiène et de Prophylaxie Sociales (Nancy, 1922) WRRNWKHVDPHWXUQDQGEHFDPHLa Revue d’Hygiène et de Médecine Sociales (1931).
MURARD L., Health Policies Between the International and the Local: Jacques
Parisot in Geneva and Nancy. In: BOROWY I. and GRUNER W.D. (eds.), Health in Europe in the Interwar Years: Perspectives, Realities and Experiences in East and West. Berne, Peter Lang, 2005, pp. 207-45. And MURARD L., Les 0pGHFLQVGHODVDQWpSXEOLTXHHQ)UDQFH . In: BRECHAT P.-H.,
SALINES E., and SEGOUIN C., Médecins de santé publique. Rennes, Editions de l’Ecole Nationale de la Santé Publique, 2006, pp. 25-139.
Alan Gregg was enthusiastic: “P. is the best man I have seen in hygiene
out-side Paris”, “Quick intelligence, engaging personally, and with a very unu-sual record and local reputation” (A.Gregg’s Diary, 13 June, and 19 April,
1927). This set the tone. Parisot was “the most oustanding public health man
in France”, according to C.-E. A. Winslow, quoted in Dr Strode’s Diary, 10
0D\ 5RFNHIHOOHU$UFKLYH&HQWHU5*,+'6HULHV NEWSHOLME A., International Studies on the Relation between the Private
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SELLIER H. and HAZEMANN R.-H., La Santé publique et la Collectivité:
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Pactat, 1937. On Hazemann, author of the Service Social Municipal (1928), 5RFNHIHOOHU IHOORZ DQG H[PHPEHU RI WKH &RPPXQLVW 3DUW\ KLV ELR LQ MAITRON J. and PENNETIER C., (eds), Dictionnaire biographique du
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PARISOT J., 'LUHFWLYHV SULQFLSDOHV DSWHV j RULHQWHU ORJLTXHPHQW XQ SODQ
d’équipement national pour une action sanitaire et sociale, A Report to the
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Minister of Labor on 2 May 1934. Reprinted in: Le Projet d’Equipement na-tional et les Assurances sociales. Nancy-Paris-Strasbourg, Berger-Levrault,
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7KDQNVWR6FRWWIRUSHUPLVVLRQWRXVHWKLVPDWHULDO
$VRI -3DULVRWDGGVD3URSDJDQGD6HFWLRQWRWKH2IÀFHRI6RFLDO+\JLHQH (OHS) at the helm of which he stands in the Meurthe-et-Moselle département: ´3LVWKHÀUVW´JRJHWWHUµWKDW,KDYHPHWDPRQJXQLYHUVLW\SHRSOHLQ)UDQFH His enthusiasm over propaganda would satisfy even Haven Emerson” (Robert $/DPEHUW'LDU\-XQH 5RFNHIHOOHU$UFKLYH&HQWHU
PARISOT J. and SPILLMANN L., Guérir est bien, prévenir est mieux.
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PARISOT J., La Médecine sociale. Ses buts. Principes et méthodes dont elle
doit s’inspirer. Revue Médicale de Nancy 1939; 6: 16. See too: PARISOT J., De l’enseignement théorique et pratique en matière de médecine préventive HW VRFLDOH DX[ pWXGLDQWV HQ PpGHFLQH 5DSSRUW j OD UpXQLRQ GHV GLUHFWHXUV des écoles d’hygiène organisée par la Section d’Hygiène de la SDN. Dresde,
MXLOOHW 5HYXHG·+\JLqQHHWGH3URSK\OD[LH6RFLDOHV Eighteen months earlier, in the summer of 1928, he provided statistics even PRUH WULXPSKDQW LQ IRU WKH ÀUVW VL[ PRQWKV RI ,Q PARISOT J. and SPILLMANN L., L’Organisation de la lutte antivénérienne
dans le cadre départemental. Sa réalisation en Meurthe-et-Moselle. Nancy,
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France. In: VIBOREL L. (ed.), Savoir prévenir. Guide pratique de la santé et de la lutte contre les maladies sociales. Paris, L.V., F. Bouchy, 1939, p. 167.
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(eds.), Making Medical History: The Life and Times of Henry E. Sigerist. %DOWLPRUHDQG/RQGRQ7KH-RKQV+RSNLQV8QLYHUVLW\3UHVV S AUBRY P., described the agreement reached in the département as a “fortu-QDWHH[FHSWLRQµ,Q Le fonctionnement des assurances sociales en
Meurthe-et-Moselle. Revue d’Hygiène et de Médecine Sociales 1931; 10: 266. Whereas,
in many départements, the heads of insurance funds and representatives of PHGLFDO DVVRFLDWLRQV ´VSHQW WKHLU WLPH WDONLQJ GLVDJUHHDEO\ WR HDFK RWKHUµ tough negotiations between these very parties had ended in an agreement in 0HXUWKHHW0RVHOOHRQWKUHHSRLQWV)LUVWRIDOOGLVSHQVDULHVWKRVHH[LVWLQJ and any to be set up, were to be open for free to all persons covered by the in-surance funds. Secondly, the OHS would follow up on the insured persons sent to curative or preventive establishments, and the Medical Association would H[HUFLVHFRQWURORYHUPHGLFDOWUHDWPHQWV7KLUGO\WKHLQVXUDQFHIXQGVZRXOG pay two francs per semester per person insured to the OHS for its services. PARISOT J., La Collaboration, base de l’action sociale. Revue d’Hygiène et de Médecine Sociales 1932; 4: 168.
PARISOT J., Le Comité français de Service social. A Lecture for the Journées
du Service Social. 23-24 October 1937. Revue d’Hygiène et de Médecine
Sociales 1938; 3: 84.
SAND R., L’Evolution des centres de santé. Le Mouvement Sanitaire 1933; 12: 565.
On this point, AMIDIEU DU CLOS L., L’amélioration des conditions
sani-taires et sociales de la vie rurale. L’effort réalisé en Meurthe-et-Moselle. Nancy,
1935; 368, a thesis for the hygiene diploma under J. Parisot’s direction. GRANT J.B., Principles for Medicine and Public Health in the China
Experiment [1934]. In: SEIPP C. (ed.), Health Care for the Community. Selected papers of Dr John B. Grant. %DOWLPRUH 7KH -RKQV +RSNLQV
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SOXV DSWHV j HPSrFKHU O·pFORVLRQ GHV PRXFKHV. Bulletin de l’Organisation
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KROEGER G., The Concept of Social Medicine as Presented by Physicians
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HAZEMANN R.-H., Le Service Social Municipal et ses relations avec les
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WINSLOW C.-E. A. to VINCENT G.E. 5RFNHIHOOHU)RXQGDWLRQ3UHVLGHQW
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S., MURARD L., and ZYLBERMAN P., (eds.), Shifting Boundaries of
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As Carl Prausnitz noted in 1930, each “snapshot” of peasant life recorded in the thesis for the Nancy diploma in Hygiene was to “be a complete sanitary and epidemiological study of a given region or village. […] The candidate must study the region’s pathological history”. PRAUSNITZ C., Rapport sur
OHV7UDYDX[GHV&RQIpUHQFHVGH'LUHFWHXUVG·(FROHVG·K\JLqQHWHQXHVj3DULV PDL HWj'UHVGH MXLOOHW ). Geneva, November 1930,
&+$SSHQGL[,, ´(QVHLJQHPHQWGHO·K\JLqQHHQ)UDQFHµS HAZEMANN R.-H., Application de la méthode des indices en vue de
O·pWDEOLVVHPHQW GH O·H[pFXWLRQ HW GX ÀQDQFHPHQW GHV SURJUDPPHV VDQL-taires. Bulletin de la Statistique Générale de la France 1939; 4: 668. On
this: MURARD L., Atlantic Crossings in the Measurement of Health:
From American Appraisal Forms to the League of Nations’ Health Indices.
In: BERRIDGE V. and LOUGHLIN K. (eds.), Medicine, the Market and the
Mass Media: Producing Health in the 20th Century. Londres, Routledge,
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HAZEMANN R.-H. and TAYLOR R.M., Les Inventaires sanitaires. Revue d’Hygiène 1933; 2: 82.
)ROORZLQJ XS D SURSRVDO E\ WKH $XVWUDOLDQ GHOHJDWH 6WDQOH\ %58&( RQ
6HSWHPEHU LQVSLUHG E\ KLV HFRQRPLF DGYLVHU ) 0F'RXJDOO WKH LN Assembly called for the League to ‘marry health and agriculture’. SDN, -RXUQDO2IÀFLHO, Actes de la Seizième Session Ordinaire, p. 53.
40. 41. 42. 43. 44. 45. 46. 47.
PARISOT J., /·°XYUHSRXUVXLYLHHWjSRXUVXLYUHGDQVOHGRPDLQHGHO·K\JLqQH
rurale par l’Organisation d’Hygiène de la Société des Nations. A report to the Health Committee’s Bureau during the June 1936 session in Moscow.
Geneva, League of Nations Archives, CH 1218, pp. 14-15. PARISOT J. and RAJCHMAN L., Note on further rural studies, Fifth Meeting of the
Health Committee’s Bureau, Paris, 29 October 1936. CH/Bureau/6, Geneva,
8 October 1936, typescript, 4 p. On 30 October, Parisot declared to the Bureau meeting, attended by the French minister of Health, H. SELLIER: “It LVDOPRVWXVHOHVVWRWU\WRGRSXEOLFKHDOWKZRUNLIZHDUHQRWDOVRFRQFHUQHG with improving the general conditions of rural life.”
PARISOT J., /·°XYUH SRXUVXLYLH HW j SRXUVXLYUH GDQV OH GRPDLQH GH
l’hygiène rurale.... A report to the Health Committee’s Bureau during the June 1936 session in Moscow. CH 1218, pp. 14-15.
PARISOT J. and RICHARD G.,&RQWUHOHFK{PDJH/HUHWRXUjO·DUWLVDQDW
rural par l’organisation de ‘cours de dépannage’. Revue d’Hygiène et de
Médecine Sociales 1935; 1: 1-5.
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PORTER D., Health, Civilisation and the State: A History of Public Health from
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CALMETTE A., L’Œuvre de Pasteur et les progrès de l’hygiène. Bulletin de l’Académie nationale de médecine 1922; 88: 692.
BALDWIN P., Disease and Democracy. The Industrialized World Faces
AIDS.%HUNHOH\DQG1HZ<RUN7KH8QLYHUVLW\RI&DOLIRUQLD3UHVV0LOEDQN
Memorial Fund, 2005.
ARON R., Les Sociologues et les institutions représentatives [1960]. Reprinted in: Etudes politiques. Paris, Gallimard, 1972, pp. 275-90.
Correspondance should be addressed to: murard@vjf.cnrs.fr 48. 49. 50. 51. 52. 53. 54. 55.
