Marjaana Niemi, Public health and municipal policy making: Britain and Sweden, 1900–1940, Historical Urban Studies Series, Aldershot, Ashgate, 2007, pp. xiii, 228, £55.00 (hardback 978-0-7546-0334-4).

Abstract

Marjaana Niemi examines the impact of political, social and economic interests on local public health policies in the early twentieth century by analysing and comparing infant welfare and tuberculosis prevention campaigns in the cities of Gothenburg, Sweden, and Birmingham, Britain. According to the author, these campaigns “served to depoliticize and ‘naturalize’ local economic arrangements, social structures and moral norms” (p. 22). Both cities were part of an international public health community and justified their public health policies by scientific knowledge, claiming to be value-free and politically neutral. Yet there were striking differences in their public health policies, partly due to national and local social, economic and cultural differences. In chapter four Niemi presents the infant welfare campaigns in each city and looks at how they served to regulate working-class family life and gender roles, and also how they were used to promote the aspirations of medical professionals. Political ideals and norms were embedded in the campaigns, like the norms of the responsibility of families to be self-supporting, and of the men as breadwinners. Although there were clear links between poverty and infant mortality, in the case of Birmingham, it was claimed that there was no direct connection to poverty. Infant mortality was considered to be primarily the result of ignorance and bad behaviour among the poor. The focus of the campaign was mainly on improving the home environment and the promotion of breastfeeding through education. The campaign upheld existing gender roles by arguing in favour of male breadwinners and criticizing female employment. In Gothenburg infant mortality was clearly lower than in Birmingham, and thus there was less pressure to make improvements. Never-theless, medical practitioners lobbied the government for measures to improve child welfare, partly so as to enhance their own professional status. By contrast to the situation in Birmingham, most practitioners in Gothenburg worked in the public health sector and thus had a vested interest in its expansion. The Swedish campaign was to a large extent directed at reducing the relatively high infant mortality among illegitimate children, blaming single mothers and absent fathers. Nurseries and milk depots were supported, making it possible for single mothers to have employment. In the 1920s the campaign shifted to wider sections of society by starting infant welfare centres for all children. Chapter five discusses how anti-tuberculosis campaigns regulated urban life and legitimized municipal intervention or non-intervention in the housing markets. Gothenburg had relatively high tuberculosis mortality compared with Birmingham. In Gothenburg the efforts were concentrated on isolating tubercular patients in hospitals and on housing inspections. In Birmingham, the poorer areas, characterized by overcrowding and defective housing conditions, experienced higher tuberculosis mortality than the more affluent ones. The dominant policy in combating tuberculosis was not to intervene in the housing market, but mainly to stress the unhealthy attitudes and lack of hygiene among the poor. As was the case in the infant welfare campaign, education was considered to be the most efficient way to combat the disease. The author sometimes implies that the public health actors had a hidden political agenda for promoting the existing social and economic order. The arguments presented often seem plausible, but it is not always clear whether different elements of the public health campaigns were primarily a product of more or less conscious intentions to reinforce or maintain the social and economic order, or whether they reflected the best efforts to promote health within the given political circumstances. Maybe Niemi could have developed this issue more extensively or discussed possibilities of alternative interpretations. I was somewhat surprised that eugenic ideas and theories that had a considerable impact on contemporary public health discourse, should have exercised relatively little influence on local public health policies in the early twentieth century. Niemi mentions that Swedish women who were believed to transmit serious hereditary defects were seen as grave threats to the health of the nation and the Nordic stock. Many were sterilized on these grounds, and pressure was put on mothers diagnosed with tuberculosis to place their children in foster care. This issue could also perhaps have been discussed at greater length. Nevertheless, this book provides valuable insights into the local public health policies in early-twentieth-century Sweden and Britain, and their interplay with political interests, gender structures, science and professional aspirations.