Book review: Rural health – a difficult concept

Michael 2006;3:116–21.

Barona JL, Cherry S. (eds.) Health and medicine in rural Europe (1850–1945). València: Seminari d’estudis sobre la ciència, 2005. 372 pp. ISBN: 84–370–6334–5.

The dichotomy between rural and urban districts when it comes to health and medicine is met with considerable interest for the time being. Urban health has been a hot topic in medical and historical circles for long, and now conferences and publications on its rural counterpart are gaining in interest.

This book is an offspring from collaboration between the University of East Anglia, Norwich, UK, and the University of Valencia, Estudi General, Spain, later joined by historians from the Stein Rokkan Centre for Social Studies in Bergen, Norway.

The volume, published through the Spanish research project Movimientos Sociales y Organismos Internacionales, has a general, introductory part dealing with rural health and public policies. Here one of the editors, Steven Cherry, opens with a chapter on medicine and rural health care in 19th century Europe, followed by a paper where the other editor Josep L. Barona is first author of a review of the same topic for rural Spain 1854–1936. In a later chapter in this part of the book he also presents the European conference on rural health in Geneva 1931 and the relationship to the Spanish administration.

Francis King addresses rural health care in Russia 1864–1914. Astri Andresen from the Rokkan Centre in Bergen has written two of the papers of the introductory part; the first one together with Teemu Ryymin on rural health and health acts in Norway 1860–1912, which is the heyday period for establishing and consolidating of a public health service in rural Norway. Her second paper concludes the first part of the book, giving a thorough discussion of the interaction of medicine and rural cultures, based on the development in Spain, Norway, and European Russia from the 1860’s and in the following fifty years.

The second half of the book presents point studies: Steven Cherry takes up the East Anglia region in England 1800–1948, Carmen Barona Vilar tells from rural Valencia, and so does also Maria-José Báguena Cervellera, who highlights the role of medical topographies in the study and combat of infectious diseases. The importance of the geographical approach is underlined in the next chapter, where Ian Farr draws attention to the medical, topographical reports from Bavaria in the 19th century.

Chapters 11 through 16 in the book deal with the disappearance of malaria from the East Anglia «fens», which are the low wetlands of the area (Tom Williamson), the story about the 20th century anti-malaria campaign in Alicante (Enrique Perdiguero-Gil), hygienic work in Catalonia in the early 20th century (Josep Bernabeu-Mestre), health care networks in rural Majorca (Isabel Moll), child care in an infirmary in Norwich 1854–1929 (Bruce Lindsay) and child care in rural and urban Alicante (Enrique Perdiguero and Josep Bernabeu).

There is a 12 page selected bibliography to the topics at the end of the book.

The general conclusion drawn by this reviewer after having read this book is very simple: I like it! Going into more detail: The two parts of it serve different purposes. The first part takes up the problem of studying health, medicine and health care in a rural setting, as opposed to the urban society. The examples given in the second part are interesting in themselves, but they will probably also serve as basic information for later surveys and analyses on a broader scale.

The emphasis which has been laid on medical topographies is important, as new quantifying methods make systematic historical studies of material of this type easier. Such sources are available for several countries.

However, if the book is to be used as an introduction to the field of urban/ rural studies of health, there are some minor weaknesses. Studies of rural health imply a series of methodological problems. Some of them are duly dealt with in this book, especially in the chapters by Cherry and Andresen. Their papers should be read by everyone who takes up health issues in the urban/rural perspective. But there could have been even more discussions of methodology.

The theoretical considerations should start already with the concept of health, which is the point of origin for needs, setup and action-taking in health care. There exists a morbidity and mortality in every society, but the key to the contemporary and historical understanding of these parameters has often to be sought more in the local perceptions of the conditions and in the prevailing attitudes towards health, than in the situation itself, such as it comes to sight through figures and hard facts.

One also has to discuss the concept of «rural» even more deeply, as this links to the concept of «place» held by the geographers, where one of the main messages is that the definition and function of a «place» depends on what functions and impacts you look at, and to which context it belongs. What is «rural» in the health perspective? Is that different from «rural» as seen in a pure demographic sense? The topic is touched upon in the present book, but in studies of rural health it should as an example be more strongly stressed that «urban» health problems also may occur in «rural» areas. An appalling example is the heavy load of infectious diseases found in the fishing seasons in coastal Norway in the 18th century due to the work migration by fishermen, gathering in miserable fishing dwellings for short, but medically disastrous periods.

The importance of migration should also be underlined. In the period covered by the book, rural Europe was in no way a stable society. On the contrary, migration was substantial within the countries themselves, in addition to the emigration waves. The importance of commuting in districts close to cities should have been dealt with, and important issue for e.g. Norway, where the rapid urbanisation had a health impact on the rural societies situated close to the growing city.

The 19th century, and the first decades of the 20th century also were unstable because of the ravaging pandemics, from the cholera to the Spanish flu. Geographically, these diseases affected both the rural and the urban regions, but both the immediate and the long time effects of such diseases on society has to be studied on the local level.

The concept of «rural» also changes its contents during this time when the percentage of rural dwellers as compared to the number of inhabitants in the cities decrease substantially, at the same time as communications are becoming better and better. When almost all people lived in the countryside, the notion of urban health has less meaning as a special category or has at least quite another meaning as when large cities have developed, exposing greater number of inhabitants for the living conditions in a town.

In the migration perspective, together with people, not only diseases but also conditions for impairing and maintaining health were wandering, making even the most remote place a herd for spread of disease if luck was bad, or for prevention and cure if luck was good.

In the book rural North-West Russia is taken as one of the examples. It may be that this mainly forest-covered wilderness was a comparably stable region in the Russian society at the time. But if we look at the district covered by the chapter by King, and select one of its apparently most isolated places, the Kishi islands in Lake Onega, a closer acquaintance will make you doubtful: To reach the villages at Kishi today, you have to travel some 400 kilometres by train from St. Petersburg to the Karelian capital of Petrosavodsk, then change to a high speed hydrofoil vessel which in one hour and fifteen minutes cruises the open and windy lake before landing in the small settlement. Here is an interesting open-air historical museum which justifies the visit. One of the things the guide will point out to you is that this society in former times was not perceived as isolated at all, as traffic passed over the ice in winter and by boat in summer. And even more important for our topic: Men from the villages were regularly migrating to the distant metropolis of St. Petersburg for work in longer periods, then coming back for taking up farming on the fields in the summer season. In a perspective of medical topography, such tiny villages may be far more important for the function of the rural society and also for effects on rural health than their size and geographical position might indicate. In the book, Andresen gives an important discussion touching on these methodological problems.

The impact of rural health exerted by travel activities and migration has been beautifully shown on maps by the Giessen-, later Berlin-based Swiss historian and demographer Arthur E. Imhof; e.g. for the 18th century using demographic crises (years when mortality exceeds birth rates) as a crude indicator for failing health. An internet search will open up to an interesting literature in this field.

Quantitative studies performed by Imhof and his group even indicate class-related differences in health due to differences in demographic stability between the rural population layers. Possibly are differences found because the immunity towards infections could be higher among the survivors in high-mortality migrating groups, as compared to the more well-off but stable upper layers where less immunity made them more vulnerable when infections came back!

It was shown that quite typical patterns of countryside epidemiology followed the trade and the exchange of local products with imported necessities. However, most appalling were the effects seen in the wake of bad harvests or as a consequence of high grain prices. Wartime might inflict health even in districts only indirectly afflicted because men and horses had been taken away from farming work through mobilizing, and often even more seriously when soldiers returned and brought dangerous infections with them.

Admittedly, many of the early quantitative studies of rural health refer to a period which lies before the time covered by the book by Cherry and Barona. On the other hand, this research has revealed mechanisms which seem to be universal. Therefore, the reader of this book will miss a more explicit reference to the vivid interest for the historical dynamics of rural health which existed in the 1970’s in Germany, and also in Sweden, where the access to digitalized rural data from Tabellvärket opened quite new perspectives for studying the geography of health over time, not at least because causes of death have been registered in the statistics.

Among the quantitative studies from the 19th century the studies of regional differences in infant mortality should be paid due attention when rural health is discussed. Here, the effects of medicine, medical skills and the health care for mother and child probably also comes statistically to sight, perhaps most clearly for those periods when mortality figures are more favourable in urbanized areas than in the countryside.

Medical reports submitted by local district physicians have been used for detailed quantitative studies of urban/rural differences, and also for studies of the function of health care, attitudes towards health and so forth. More references to newer works, e.g. from the Nordic countries could have been given.

Because the cultural impact of health is so important for the setup of health services and also for the considerations about prioritizing health when other values of life are at stake, there are clear links between the studies of rural/urban health and health care and the history of ideas and mentality. In other words: There is a relationship to the topics taken up by the Annales-school in France and the way of historical thinking which developed in this tradition in the 20th century. Some more attention to such issues had been an asset to the book.

The selected bibliography is comprehensive and useful. However, this reviewer looks in vain for some works which could have defended their inclusion, and feels that the list as a whole is a bit skewed towards writings in English, so that some important studies in French and German are missing.

However, these comments should not throw shadow on the gratulations to the editors, and on the encouragement to the collaboration group behind this book, so that they continue their efforts to shed light on the history of rural health in Europe.

Øivind Larsen

University of Oslo

Institute of general practice and community medicine

Group for medical history 1130 Blindern

N-0318 Oslo