History of Medicine: European Perspectives

In mid-January 2020, a German biotechnology company started working on a potential covid-19 vaccine based on a new technology that uses messenger rna to trigger an immune response – a technology initially developed to fight cancer – rather than inserting a weakened or inactivated virus into the body.1 “Project LightSpeed” was backed by Pfizer, an American multinational pharmaceutical corporation, and Fosun, a Chinese conglomerate and investment company. On 10 March 2020, Austria issued an entry ban for non-Austrians coming from Italy. Over the following days, several European Union Member States independently imposed border closures or border controls, thus suspending the Schengen Agreement, considered as one of the cornerstones of the European integration process. On 21 December of the same year, the European Medicines Agency (ema) approved the Pfizer and BioNTech covid19 vaccine for use in the EU, 18 days after the vaccine was approved by the United Kingdom. This allowed the EU Member States to start vaccination just days later. The EU negotiated vaccine orders from the various laboratories for

This recent chain of events shows some of the challenges facing a European history of medicine: the persistence of the nation state in organising public health and managing medical facilities; the presence of a relatively new political entity -the European Union -that would like to play a supranational role but has only limited health prerogatives;2 the unclear boundaries of what Europe is; and finally the global circulation of the virus, people and drugs. In this short essay, I would first like to outline some general trends in European historiography before exploring potential avenues for European medical histories.

European Historiographies
Over the past 20 years, the European perspective on history has been characterised by three (somewhat contradictory) movements: the global turn, the persistence of national paradigms, and new insights for writing about the history of the Continent. From the 1980s onwards, a European-history approach appeared to be the best way to overcome historiographies that were still dominated by nationalised histories. Strongly supported by a wave of comparative histories (often between two large Western European countries), Europe emerged as the new historiographical horizon. The launch of several history journals that contained 'Europe' in their name was (and continues to be) proof of the extent to which historians considered the European scale as a new meaningful way for telling stories about the past; examples include Central European History (1968-) Europe's Twentieth Century by Mark Mazower provided new master narratives that could without any doubt compete with the national histories written since the nineteenth century by the Frenchman Jules Michelet, the Prussian Leopold von Ranke, or the Pole Joachim Lelewel. In recent years, this optimism has been slightly tempered by the global turn. "Provincialising Europe" is one rallying cry of this movement that challenges the focus on European history compared to other parts of the world.4 As one strand of their argument goes, Europe was only a dominant power for a hundred years: from the 1850s when the European colonial powers established their dominance over Africa and Asia to the end of World War Two. Calling into question the domination of the Global North in general, this historiographical trend not only pleads for greater integration of the Global South but also argues for greater inclusion, on an epistemological level, of "women, the poor, and non-whites as historical agents".5 The "nation state" or "modernity" should no longer be taken as the "natural" paradigm, a sort of gold standard by which other societal developments are measured. Decentring the historiographical gaze not only leads to a less Eurocentric history; it also contextualises these developments in Europe by pointing to their historical boundedness. Furthermore, it challenges periodisations often presented as globally valid. Writing European histories should therefore only be possible as a connected history of Europe with other regions. These intertwined histories have to take into account the structural domination of Europe for several decades in the nineteenth and twentieth centuries. But at the same time, they should not fall into the trap of a top-down narrative (Europe to Africa and Asia) which validates a new imperialism, this time cultural. Instead they need to be attentive to mutual influences: Homi Bhabha's idea of hybridity that "breaks down the symmetry and duality of the self/Other, inside/outside" and establishes another space of power/knowledge is one of several stimulating proposals for the creation of new narratives about the 'The West' and 'the rest' .6 While the legitimacy of a European paradigm has been questioned 'from above' (from a global perspective), it has also continued to be challenged 'from below' (from a national perspective). In preparation for the launch of this new journal, a workshop was held in Bern in November 2019 at which several historians presented reports about medical historiography in their 8 respective countries: it was a convincing if unintended demonstration of how the development of (medical) history remains strongly ingrained in national approaches. The institutional framework in different countries (the existence of the Wellcome Trust in Great Britain, the inclusion of medical history in the curriculum of future physicians in Germany, etc.) determines how the field is structured at national levels. For several practical reasons (mainly national funding, access to archives, language skills, national recruitment schemes, etc.), much that belongs to medical histories remain national histories.
These multiple challenges made Lynn Hunt, the historian of the French Revolution, ask the provocative question "Is European history passé?"7 But these challenges have not made European history dispensable over the past two decades -as this new journal, among others, attempts to demonstrate. This is not only because of the political project around the European Union, which, like every ideological project, needs history as a "science of legitimation".8 Several new perspectives have also been opened up. First, one of the most stimulating research paradigms has been the question of Europeanisation.9 Initially focused mainly on the processes of European political integration which began in the 1950s,10 it has since gained a broader definition, embracing (visible) common cultural processes and also hidden moments of (technical) integration. Secondly, the fall of the Berlin Wall in 1989 led to a significant shift in the writing of European history. The dichotomous narrative of a Western Europe versus an Eastern Europe, the former being narrated as the "natural" evolution and the latter as some kind of irrational Sonderweg made less and less sense. Just adding Poland, for example, to the traditional triad of European history -Great Britain, France and Germany -proved to be unsatisfactory. Old categories such as Central Europe gained new momentum and reassembled the mental maps of European geography. Finally, by taking into account the multiplicity of geographical entities, moving beyond the proliferation of nation states that Europe experienced after the implosion of the Soviet Union, historians were able to write a fragmented history of Europe.11 Rewriting stories by playing with scales -taking into voices from the editorial board 9 account local, regional and supranational identifications -and by integrating marginal or, to use a less pejorative term, liminal spaces made the narrative more complex but also more stimulating.

European Histories of Medicine
What could then be the European perspective of a journal dedicated to the history of medicine, and how could the history of medicine, often confined to its own niche, participate in these larger challenges? I would like to argue that four topics seem particularly stimulating: medicine as an imagined European community, the centrality of the state in European health policies, (post-)colonial spaces and (hidden) integrations versus fragmentations.
One of the most stimulating areas of research in recent decades has been the fruitful use of Benedict Anderson's concept of "imagined communities".12 When writing a European history of medicine, this opens up three perspectives. First, medical practitioners have regularly defined themselves as European. Scientific communities and controversies have often been international. Hubert Steinke, for example, characterises the dispute about Albrecht von Haller's concept of irritability and sensibility in the eighteenth century as a European one.13 And multiple European medical associations and journals have been set up in the past 40 years. Secondly, the medical field has also developed common commemorative narratives to sustain these communities. Though memory studies was initially strongly rooted in national contexts, more recent research has emphasised the importance of taking transnational memory processes into account.14 As medicine defined itself as an objective, neutral and therefore a-national field of scientific practice, it was prone to adopt transnational commemorative narratives which not only included ancient and medieval history (figures such as Hippocrates, Galen and Andreas Vesalius) but also more recent "(trans)nationalised" individuals such as Pasteur.15 This is not to underestimate the importance of national memories -most national medical histories built their national heroes during the nineteenth and twentieth centuries; nor is it to neglect the global memorial status of some figures, but 10 instead it is to look for processes of Europeanised memories. Thirdly, besides European spaces of practice and memory built from the inside, identities are also constructed from the outside:16 Europe(an medicine) is also framed by Americans, Chinese and Brazilians as imagined communities or communities of practice: the private American Rockefeller Foundation certainly played a leading role in the shaping of European medical and health systems.
In the three configurations, we need to ask which landscapes of European communities have emerged. That these geographies of knowledge are continually shifting will be briefly illustrated through the editorial board of one of the earliest academic journals that defined itself as European, the European Journal of Cancer, created in 1965. The 18 founding fathers -there was not one woman among the founder members -came from seven Western European countries (three respectively from France, Italy, West Germany, Belgium and the Netherlands, two from Switzerland, and one from the United Kingdom). Twenty years later, the editorial board was not only larger -29 men -but also presented a different map: the three leading countries were Great Britain (6), Italy (5) and the United States (4): Eastern (at that time communist) Europe was represented by a Pole, an East German, and a Hungarian. The three Southern, formerly authoritarian states (Spain, Portugal and Greece) as well as the Nordic states were absent. In 2005, the editorial board consisted of 85 members. The researchers from the UK were now by far the largest group (21), followed by their Italian colleagues (11). Three non-European countries were represented on the board: nine from the United States, three from Canada, and one from Australia. Jacek Jassem from Poland had to stand alone for an Eastern Europe that was no longer cut off from the rest of Europe by the Iron Curtain.17 I would certainly not argue that the European Journal of Cancer is representative of European medical journals, nor of European cancer research: the history of each journal is characterised by personal sociabilities and (national) structurings of the field. But I wanted to show the fluctuations and the overand under-representation of certain national groups within a field that defines itself as European. The aforementioned Norman Davies spoke of a "tidal Europe" to define these moving boundaries.
A second stimulating topic for a European history of medicine and health is the centrality of the state. In a historiography where it is often taken for 11 granted that American narratives apply to the Western World, the development of an interventionist governance in the fields of medicine and public health in the context of the creation of the nation state from the mid-nineteenth century onwards appears as a specific European characteristic. The advance of medicine as a profession runs parallel to the rise of the nation state. The latter often regulated the educational and professional curriculum of physicians -and physicians not only cared for individual bodies but were also heavily invested in the national body, often as a means of advancing a hygienic agenda. Access to new social security rights was often conditioned by citizenship. The four pillars of the European welfare state -disease, industrial accidents, disability, and old age -were all closely linked to issues of health.
The threefold system to fight tuberculosis in Europe from the late nineteenth century onwards -a widespread public health campaign, a state-funded dispensary system to trace cases, and sanatoria to isolate patients -was a good example of how preventative health care was considered as a compulsory, collective and national effort. This system proved to be a blueprint for many other state-funded health services.18 While chronologies and practices differed from one country to another, World War One proved to be a breaking point: even if the war was global, nowhere else did the state gain and maintain as much fiscal and legislative power as in Europe. The centrality of public institutions in the Beveridgean welfare state built after World War Two was stronger and longer lasting in Europe than anywhere else. While in European countries some sort of national health insurance was implemented, occupational or corporate welfare provisions remained dominant in the United States. State social spending during the second half of the twentieth century was higher everywhere in Europe than in any other continent (Table 1). The amount invested by the state in health expenditure, which accounted for about a quarter of social expenditures, kept climbing from the beginning of the twentieth century until the 1990s.20 Philanthropy, private companies and families were, of course, also important players in spreading knowledge about illness and health, shaping medical practices and framing institutional settings, but unlike in other world regions, in Europe the state (whether local, national or European institutions) structured what medicine and public health would mean, defining a specific European approach.21 It remains to be seen if the individualisation of health care responsibility will change the future role and investment of the state in Europe.
Some historians, such as Frederick Cooper, have recently argued that in the last two hundred years, empires have played a more central role in European history than the nation state.22 From the beginning of the nineteenth century to the present day, Europe has established itself as an imperial and/or (post-) colonial power. The invention of the notion of 'European' was closely linked to moments of colonisation and decolonisation. In the discovery of the 'other' , medicine played an important role at various levels. First, it was without doubt one of the most powerful arguments for legitimising imperialism through its apparent civilising mission. Even today, (European) health standards are considered as one of the "irrefutable" benefits of colonialism.23 Secondly, medicine and health initiatives were significant tools for ordering, prioritising and sometimes dominating colonial spaces and bodies. The historiography of imperial health is currently driven by a debate about the extent to which imperial medical governance was actually a means of profound social transformation rather than just a rhetorical framework. But colonial medicine undoubtedly revealed European identities. Empires not only produced difference; they were also moments of hybridisation that went beyond a mere binary opposition between coloniser and colonised. Finally, the history of medicine and health is sometimes a very simple monitor of degrees of colonisation. voices from the editorial board 13 the Spanish flu was thus an explicit marker of colonial networks of circulation at the end of the First World War. As Edward Said has prominently argued, colonisation did not only happen in exotic places; it was seen to operate at the very centre of European society. The "pasteurisation of Europe" which is still hailed as a turning point in European health policies was intertwined with colonial preoccupations, as Bruno Latour already argued thirty years ago. 24 The extent to which the slogan "global health", postulated by the World Health Organisation and also increasingly by global financial stakeholders such as the World Bank, is a continuation of imperial practices, in particular through the imposition of a Western medicine-based conception of health, remains controversial. 25 That the history of (post-)colonial medicine is the field that is best integrated into more overarching narratives is undisputable, and it therefore continues to be a stimulating field that connects general and medical history. The question of Europeanisation has long been monopolised by researchers working on the European integration process that began in the 1950s. Medicine and health were not a priority within this political process. The idea of a European community of health, to be built in parallel with the European Coal and Steel Community (ecsc), came to nothing.26 As for other social and societal matters, the European Court of Justice proved to be an important player -if not initially intended as such -for the Europeanisation of health care rights. It was only in the field of pharmaceutics that institutional integration was pursued, first through informal collaboration to organise medical trials (for example, the European Organisation for Research and Treatment of Cancer, established in the early 1960s), and later with the creation of the European Medicines Agency in 1995.27 Fifteen years ago, Thomas Misa and Johan Schot proposed the notion of "hidden integration" to go beyond the political process and the narrative of international relations between nation states.28 Exploring how technologies have united spaces but also sometimes divided them has proved a stimulating way to write stories of hidden integrations and fragmentations in Europe. This historiographical agenda, inspired by science and technology studies (sts), has given rise to an impressive rewriting of European history in which medicine and health is, unfortunately, barely touched upon.29 As argued at the beginning of this essay, the covid-19 pandemic acted as a moment of both fragmentation -with the reimposition of borders between nations; and integration -through the common purchase of vaccines. Addressing these questions through the lens of the history of medicine and public health will help enrich the historical narrative of European integration, confirming it as a complex process that also tells us about class, gender and race, and cannot be limited to an institutional storyline.
Developing an interconnected European medical history can therefore prove to be a stimulating practice, calling into question the notions of space and time that structure traditional European narratives and decompartmentalising medical historiographies by making them interact with other historiographies.