International Public Health Research Papers (original) (raw)

The main goal of the book is to contribute to the history of the social policies and public health practices with respect to the so called “social diseases” and in particular to tuberculosis in Bulgaria from the turn of the 19th century up to the 1950s – between social initiatives and state institutional engagements. The research is based on original archival materials – arhives in Bulgarian Central State Archive of the Main Department of Public Health, the Civil Sanitary Direction, the Bulgarian doctors’ Union, the Society for the Fight against Tuberculosis in Bulgaria, the Rockefeller Foundation in Bulgaria, the Near-East Foundation in Bulgaria etc. In the analysis additional sources were attracted: books, press materials and historiography. The book provides a reconstruction of the general institutional frames, the interaction between the state and private institutions under the influence of the international medical organizations.
From the second half of the 19th century, tuberculosis increasingly engaged public attention, being identified as one of the most frequent reasons for sickness and death – thousands of people annually died and hundreds of thousands became invalid. Public discussions concerning the topic permanently reminded that the disease affected particularly the young and “prospective” generation. In Bulgaria tuberculosis considerably began to be viewed as a social problem at the end of the 19th century and all experts shared the same opinion: the fight against tuberculosis had to be preventive, that meant: improvement of hygiene and labor conditions, overall information about the disease aimed at reaching widest circles of the population and last not least, medical treatment.
In the early 20th century in Bulgaria 20 000 persons annually died from tuberculosis, which was one of the highest percentages in Europe at that time. The conquest of the tuberculosis seemed possible with the tools at hand. These tools included, first, isolation of infectious cases — concerns about heredity and constitution were replaced by concerns about infection- and, second, provision of rest, good nutrition, fresh air and education. But the elimination of tuberculosis required much more: it required above all official and voluntary action; patients should comply with all elements of control; betterment of those marginalized in society should be reached. Discipline and control became an increasingly dominant part of the treatment, being considered rather as end than means. Later, as tuberculosis control became a public responsibility, the state sanatoriums preempted the private institutions in terms of the numbers of beds, services offered, and public recognition.
The First World War marks a turning point in the overall orientation of Bulgarian antituberculosis efforts. Tuberculosis was considered as “social disease”. In the interwar period this term meant those diseases which are usually related to a given set of living or working conditions and were most common among specific socioeconomic groups. In the Bulgarian case tuberculosis, malaria, venereal diseases, alcoholism and, from the second half of the 1920s, also cancer, were treated as social diseases. Tuberculosis, in particular, plagued the lower classes, due to their living and working conditions and poor nutrition; because of its epidemic character tuberculosis was considered a danger to the general state of health, economic productivity, military strength, and to the reproductive capacity of the society and the nation; many experts feared that tuberculosis was a symptom of the degeneration of the biological substance of the nation or race and that it was the mechanism through which hereditary weakness was perpetuated.
There is a reliable statistic for the death-rate and partly for the tuberculosis morbidity for the towns from 1925, when a statistic was established that registers death reasons in the towns. With the acceptance of the new Public Health Law in 1929 it is made obligatory to report the tuberculosis death-rate (but still there no data for morbidity).
The nation’s arsenal of dispensaries, sanatoriums, and related institutions which declared “war on tuberculosis”, in the reformers’ military terminology, was subject to increasingly anxious inventory and scrutiny. While Bulgaria have been slower than other countries in building antituberculosis facilities, it was hardly alone in allowing social anxieties and stereotypes to determine its response to the disease. Other preoccupations came to the fore when tuberculosis was perceived as a social problem or as a threat to the nation. In Bulgaria, efforts to curb the ravages of tuberculosis took place within a general framework that Paul Weindling has called “the hygienization of private life.” In the crusade to bring more “air, light, and space” into the everyday lives, the blame for tuberculosis was related to poor diet, unsanitary living and working conditions, and alcoholism.
Bulgarian reformers (doctors and hygienists) placed also special emphasis on personal responsibility in the fight against tuberculosis. They promoted moderation, cleanliness, and a temperate lifestyle. The ethos of the individual responsibility in Bulgaria left a little space for genetic reasons, which were downplayed as a cause of tuberculosis. Spitting became central in the social etiology of tuberculosis.
From the early 20th century a group of physicians attempted to define the health problems within social and economic discourse, while protesting about the absence of public health statistics and the lack of public health system. The Anti-Tuberculosis Society set up in 1909 served as a typical example of facing such criticisms carried out by various charitable societies, established by medical authority. These active hygienists, educated abroad usually worked as medical officers and tried to fund TB dispensaries, sanatoria or other institutions for the relief of tuberculosis patients. Moreover they attempted to educate people by explaining sanitation in simple terms to the public and convincing politicians to provide against contagious diseases and to take action in order to strengthen those susceptible to diseases, particularly children.
Vigorous campaigns against spitting have been a nearly universal feature of the battles against the disease in this period. Throughout the 1920s and 1930s the state started to introduce standards and common bureaucratic rules of social work and centralized the public health care, including the fight against tuberculosis. International models and standards influenced the tuberculosis control policies in Bulgaria – especially the activities of the League of Nations Health Organisation, the International Health Division of the Rockefeller Foundation and the American Near East Foundation.
Throughout the 1930s the balance between state and public initiatives, state institutions, media and societies was reached and new forms of collaboration were discovered. These new forms made possible free expression of different ideas, inspired by humane, religious, modern or nationalistic, socio-controlling and eugenic views. Keeping pluralism intact meant rivalry, but it also called for coordination between the separate institutions. The legislation tried to balance between the State and the associations, and to assist for the formation of partnership between them. However, the centralization effect gave rise to fears of excessive “nationalization” of the social activities in public health sphere. After 1934, the state introduced standards and common bureaucratic rules of social work and centralized the public health care. International models now influenced the social care organization in a rather tangible way – these international models and standards covered also social care for children, mothers-workers, destitute peasants, consumptive patients.
After 1945 the tendency to "nationalization" all practices of social assistances affected the Society for Fight against Tuberculosis as well. Until 1945 the Society formally existed in unchanged format with the main difference that from the winter of 1944 the former key figures in the Central Committee and in the Sofia branch of the Society were changed. In 1945 the Society was turned into the state National Union for Fight with Tuberculosis. The National Union continued to exist till July 1948, when with reference to the consolidation of the organisations and obeying to the decision of the Ministry Council, the Union dissolved in the Central Union of the “Red Cross”. Some of the statements printed in the reports of this First Congress in 1947 figured out the notions of the new rulers for former activities of the Society for Fight against Tuberculosis. The main motives in these statements focuses on the changes “before and after the 9th September 1944”. The speakers of the Congress qualified the anti-tuberculosis fight before the establishing of the “new power” as “an organization of cheap clemency and private charity” and insist in transforming the Union for Fight against Tuberculosis into a “mass” organization, which became a fact in 1948 – the Society was transformed in a state organization and became a part of the Soviet system for health services.