The shifting politics of public health in Germany between the 1890s and 1920s

ABSTRACT

Since the 1970s, social historians have published on the history of public health and the welfare state in Germany. Many scholars have focused on the social security measures installed during the German Empire, while others concentrated on welfare in Germany in the 1920s and the expansion of the welfare state. These studies were often part and parcel of long-running debates discussing the rise of Nazism and the extent to which it was rooted in Wilhelmine and Weimar (mis)developments. Building on these studies of welfare relief, social security and public health, this article focuses on welfare and public health in Imperial Germany. It evaluates the extant German-language literature and proposes that we understand welfare in imperial Germany as a mixture of transfer payments and services developed to improve the living conditions of the working poor, as well as a set of biopolitical public health measures used to influence the behaviour of the poor. After framing the social context of public health in the last decades of the nineteenth century, the article focuses at first on the medical police and public health measures initiated by the Imperial Health Office, the highest medical authority in Germany. Second, it describes the role of Statutory Health Insurance and its effects on public health; and, third, it summarizes local welfare and public health institutions that had to execute public health measures. Finally, it analyses the ways in which the politics of public health changed between 1870 and the early 1920s.

KEYWORDS:

• Imperial Health Office
• Statutory Health Insurance
• health politics
• welfare relief
• social security
• social hygiene
• bacteriology
• Wilhelmine Empire

Acknowledgements

I would like to thank the editors, two unknown reviewers and Eric J. Engstrom for their insightful comments and helpful advice on earlier versions of the article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. See Weindling, Health, Race and German Politics.

2. See Weindling, “Virulent Strain”.

3. Among others, see Tennstedt, “Sozialgeschichte der Sozialversicherung”; Tennstedt, “Errichtung von Krankenkassen”; Sachße and Tennstedt, Geschichte der Armenfürsorge, vol. 2. As an overview Metzler, Der deutsche Sozialstaat.

4. See Frevert, Krankheit als politisches Problem.

5. See Ritter, Sozialversicherung in Deutschland und in England; Ritter, Der Sozialstaat; Hennock, British Social Reform; and Hennock, Origin of the Welfare State.

6. See Mau, Moral Economy of Welfare States.

7. See Hong, Welfare, Modernity and the Weimar State; and Crew, Germans on Welfare. See also the literature in the section about welfare on a local level.

8. See Frohman, “Prevention, Welfare, and Citizenship” (2006). For another example, see Roßberg, Johannes Rabnow.

9. See Dickinson, “Biopolitics, Fascism, Democracy.”

10. A position taken prominently by Peukert, “Genesis of the ‘Final Solution’.” For the discussion see most recently the introductions in Crew, Germans on Welfare; and Hong, Welfare, Modernity and the Weimar State; Hong, “Neither Singular nor Alternative.” The different positions are summarized in Dickinson, “Biopolitics, Fascism, Democracy.”

11. Regarding his concept of governmentality, see especially his lecture of March 17, 1976 in Foucault, In Verteidigung der Gesellschaft, and the first lectures in Foucault, Geschichte der Gouvernementalität I; regarding the term dispositif see Jäger, “Dispositiv.” Furthermore, see the contributions in Sachße and Tennstedt, eds, Soziale Sicherheit und soziale Disziplinierung.

12. See the discussions on the occasion of the 150^th anniversary of the foundation of the German Empire, mainly around the historians Hedwig Richter and Eckart Conze, in the weekly journal Die Zeit, Nos. 2, 4 and 6 (2021), for instance. In recent years Christoph Nonn (among others) has emphasized the modernity of the German Empire: see, for instance, the discussion in Müller and Torp, eds., Imperial Germany Revisited; and recently Nonn, 12 Tage.

13. Certainly, Germany too also later participated in the hunt for colonies, demanding its own “place in the sun.” German “colonial phantasies” were first directed towards Central and Eastern Europe, aiming to “germanise” the Polish population in the eastern provinces of Prussia and later to conquer Poland and Russia as such. See Blackbourn, Landschaften der deutschen Geschichte; Conrad, Deutsche Kolonialgeschichte; and Turkowska, Der kranke Rand des Reiches.

14. These developments were sketched in Tennstedt, “Sozialgeschichte der Sozialversicherung.”

15. Frevert, Krankheit als politisches Problem.

16. See also Weindling, Health, Race and German Politics.

17. Sachße and Tennstedt, Geschichte der Armenfürsorge, vol. 2, 18–22. Although it had already been put forth by Sachße and Tennstedt, the phrase and concept “scientisation of the social” is usually attributed to Lutz Raphael, who appropriated it without due attribution. (I owe many thanks to Eric J. Engstrom for pointing this out to me). See Raphael: “Die Verwissenschaftlichung des Sozialen.” The idea also figured prominently in Peukert’s reasoning.

18. See Foucault’s last lecture in Verteidigung der Gesellschaft and his lectures in Foucault, Geschichte der Gouvernementalität.

19. On Johann Peter Süßmilch, Johann Peter Frank and early concepts of medical police see Barthel, Medizinische Polizey und medizinische Aufklärung; Möller, Medizinalpolizei; and the contributions in Wahrig and Sohn, eds, Zwischen Aufklärung, Policey und Ver-waltung.

20. See Sachße and Tennstedt, Geschichte der Armenfürsorge in Deutschland.

21. Frevert, Krankheit als politisches Problem.

22. Early health and hospital insurances (for servants and maids) were established in Bamberg and Würzburg, see Brinkschulte, Krankenhaus und Krankenkassen.

23. See Frevert, Krankheit als politisches Problem, and in several contributions in Labisch and Spree, eds, Krankenhaus-Report 19. Jahrhundert; further examples for the Hanseatic city of Bremen are given in Leidinger, Krankenhaus und Kranke.

24. On vaccination in the German Empire see Hüntelmann, “Smallpox Vaccination in the German Empire.”

25. This is emphasized in Nipperdey, Deutsche Geschichte, 84.

26. Regarding the pre-history of its foundation see Hüntelmann, Hygiene im Namen des Staates, chap. 1.

27. Until 1876, beside the IHO, only the Imperial Chancellery (1871), the Imperial Statistical Office (1872) and the Imperial Railway Office/Authority (1873, to coordinate the private and federal railway companies) existed. The Office of National Justice had been separated from the Chancellery in 1877, and the Imperial Office of Interior only in 1879. In 1884 the Imperial Insurance Office (Reichsversicherungsamt) had been founded to supervise local health insurances and later the statutory accident insurance and pension insurance.

28. For the establishment, early development and difficulties of the IHO see Hüntelmann, Hygiene im Namen des Staates, chap. 1 and 2.1.

29. See Frevert, Krankheit als politisches Problem; Dross, “Health Care Provision and Poor Relief”; Hennock, Origin of the Welfare State; and Ritter, Sozialversicherung in Deutschland.

30. Statutory Health insurance had originally been implemented in the context of the introduction of the accident insurance. From Bismarck’s point of view, the risk of poverty in the case of sickness was already covered by the existing health and hospital insurance funds, and the foundation and establishment of the Statutory Health Insurance was more or less an administrative “accident” by itself, initiated by the leading official in the Reichsamt of Interior, Theodor Lohmann; see Tennstedt, “Sozialgeschichte der Sozialversicherung” and Tennstedt, “Errichtung von Krankenkassen.”

31. Regarding the development and motives of the law see Ritter, Sozialversicherung, 28–41; Hennock, Origin of the Welfare State, 155–65; and Tennstedt: “Errichtung von Kranken-kassen”; Tennstedt, Sozialgeschichte der Sozialpolitik in Deutschland, 165–74; and Tennstedt, “Sozialgeschichte der Sozialversicherung.”

32. Comprehensive, Wickenhagen, Geschichte der gewerblichen Unfallversicherung; recently and for the German Empire Knoll-Jung, “Zwischen Verfahrenslogik und ärztlichem Eigensinn”; and embedded in a broader theoretical frame for Switzerland, Lengwiler, Risikopolitik im Sozialstaat. The Imperial Insurance Office (Reichsversicherungsamt) dealt mainly with matters of the Statutory Accident Insurance and Pension Insurance. It acted as an appellate instance in questions of conflict between workers, applying for pensions, and accident and pension insurance.

33. See, for instance, the weekly periodical Veröffentlichungen aus dem Kaiserlichen Ge-sund-heits-amte (since 1877); Mittheilungen and after two volumes renamed into Ar-bei-ten aus dem Kaiserlichen Gesundheitsamte (normally one volume per year, since 1881); for statistical publications Medizinal-statistische Mittheilungen aus dem Kai-ser-li-chen Gesundheitsamte (since 1893); and the Tuberkulose-Arbeiten aus dem Kaiserlichen Gesundheitsamte (since 1904).

34. See the Festschrift Das Kaiserliche Gesundheitsamt.

35. See Hüntelmann, Hygiene im Namen des Staates, chap. 2.

36. The Institute of Experimental Therapy, directed by Paul Ehrlich, had been founded as the Royal Prussian Institute for Serum Research and Serum Testing. It was renamed in 1899 and moved from Berlin to Frankfurt; see Hüntelmann, “‘Eigenartige Sonderstellung’ in der Welt”; regarding Robert Koch and the foundation of the Institute for Infectious Diseases see Gradmann, Krankheit im Labor; and regarding the interrelations between these institutions Hüntelmann, “Biopolitische Netzwerke.”

37. For the history of the IHO, see its Festschrift on the occasion of its fiftieth anniversary: Das Reichsgesundheitsamt; and Hüntelmann, Hygiene im Namen des Staates, chap. 2 and 3.

38. On the efforts to ensure healthy food see Hierholzer, Nahrung nach Norm. Regarding the importance of (a healthy) food supply in industrialized societies see the contributions in Atkins, Lummel and Oddy, eds, Food and the City.

39. See Reichsgesundheitsamt, 179.

40. See, for example, the handbooks of hygiene and occupational health of Max von Pettenkofer, Carl Flügge or Theodor Weyl, all contained in a large number of volumes and published in various editions between the 1880s and 1910s.

41. See Hüntelmann, Hygiene im Namen des Staates; for Rudolf Virchow, who was among many other things also active in the Liberal Progress party and in the social movement, see Goschler, Rudolf Virchow.

42. Regarding Julius Moses see Reuland, “Humanexperimente in der Weimarer Republik”; for Adolf Gottstein see his autobiographical notes, Erlebnisse und Erkenntnisse; and for Grotjahn see the short biography by Tutzke, Alfred Grotjahn.

43. In reaction to Virchow and Salomon Neumann, and later Alfred Grotjahn, who had characterized medicine as social measures.

44. Emil von Behring in Weindling, “From Infectious to Chronic Diseases,” 308; and Schlich, “Einführung,” 17.

45. See Simon, “Emil Behring’s Medical Culture.”

46. For details see Hüntelmann, Hygiene im Namen des Staates. Hamburg’s resistance against bacteriological methods is described in Evans, Tod in Hamburg. The late adoption of bacteriological methods had the consequence that in 1892 Hamburg experienced the last cholera epidemic in Germany with more than 8600 victims, followed by an economic breakdown.

47. Some of these associations had emerged from older associations of factory workers or occupational associations.

48. In contrast to Bismarck’s intention to tone down the Social Democrats and unions by pacifying the workers with the social security systems, employees usually took over control in the health insurance boards, becoming more powerful. Regarding the autonomous self-administration see Tennstedt, Soziale Selbstverwaltung.

49. For instance, the number of sick days or hospital days were enlarged, the daily amount of sick benefits increased, additional family members insured, and so on.

50. See Tennstedt, “Errichtung von Krankenkassen”; Hennock, Origin of the Welfare State, 155–65. On the creation of health insurance funds and associations in Swabia see Förtsch, Gesundheit, Krankheit, Selbstverwaltung, 39–48, 78–107.

51. On the foundation of the Hartmannbund see Wolff, “Mehr als nur materielle Interessen”; and on the conflicts Moser, Ärzte, Gesundheitswesen + Wohlfahrtsstaat.

52. See Frank, “Die geschichtliche Entwicklung,” 38–48. Ritter, Sozialversicherung, 54 notes that at least 50% of the population had been included by 1913.

53. See Tennstedt, “Sozialgeschichte der Sozialversicherung” ,Tab. 1, p. 403.

54. Ibid., 395–6. On health insurance funds in Swabia Förtsch, Gesundheit, Krankheit, Selbst-ver-wal-tung, 159–67.

55. The different health and hospital insurance schemes in the second half of the nineteenth century are discussed for Bremen in Leidinger, Krankenhaus und Kranke; for Swabia see Förtsch, Gesundheit, Krankheit, Selbstverwaltung.

56. See Freiberg, “Der Charité-Boykott”.

57. See Tennstedt, “Sozialgeschichte der Sozialversicherung,” 403.

58. See Guttstadt, ed. Krankenhaus-Lexikon, p. IV. Spree, “Quantitative Aspekte,” Tab. 4, p. 61 counted only 1985 hospitals and ca.76,000 beds in 1876; for 1900 he calculated 3146 hospitals with ca. 165,000 beds; up to 4020 hospitals with 260,000 beds in 1910. Spree might have limited the number of hospitals to general hospitals, while Guttstadt might also have included smaller and special clinics. However, the trend in both publications is clear: a rapid increase in the number of hospitals.

59. Since the 1910s and especially the 1920s hospitals published extensive brochures with costly extra services and therapeutics, see for instance the brochure with price lists for the Municipal Hospital Düsseldorf in City Archive (Stadtarchiv) Düsseldorf, Dept. IV, No. 37792 and No. 37815, items 20–1.

60. Especially after the 1920s, chronic diseases (like silicosis) were recognized as occupational diseases. Questions of occupational health had been discussed in the IHO. For instance, research had been done and reports written on lead poisoning and their prevention in printing houses, mining and lead- and metalworking industry, intoxications due to alkaline chromates and in the chemical industry: see Reichsgesundheitsamt; for occupational health, see the contributions in Weindling, ed., The Social History of Occupational Health.

61. See the Festschrift 25 Jahre Preußische Medizinalverwaltung; Stürzbecher: “Die Berliner Krankenhäuser”; Füssel-Schaffrath, “Beitrag zur Geschichte der Berliner Krankenhäuser”; and recently Verlohren, Krankenhäuser in Groß-Berlin.

62. The involvement of architects, engineers and urbanists in Hardy, Ärzte, Ingenieure und städtische Gesundheit; welfare and hygiene in Munich, Münch, Stadthygiene im 19. und 20. Jahrhundert; and all aspects of municipal welfare Rudloff, Die Wohlfahrtsstadt; and for the Ruhr area Weyer-Von Schoultz, Stadt und Gesundheit.

63. They both considered ‘medicine as a social science,’ arguing for a common ‘Right to Health’ (Recht auf Gesundheit). For Virchow see Goschler, Rudolf Virchow; for Neumann see Neumann and Karbe, Salomon Neumann; Regneri, Salomon Neumann; and recently Gostomzyk and Mittelstaedt, “Salomon Neumann.”

64. Regarding complaints about military and recruit statistics see Hartmann, “Die Produktion der Wehrbevölkerung”; Hartmann, Der Volkskörper bei der Musterung; on tuberculosis treatment and prevention in Germany Hähner-Rombach, Sozialgeschichte der Tuberkulose; and on venereal diseases in the German Empire and Weimar Republic Sauerteig, Krankheit, Sexualität, Gesellschaft.

65. Discourses on population in Germany at the end of the nineteenth and the early twentieth century appear in Ferdinand, Das Malthusische Erbe; Fuhrmann, Volksvermehrung als Staatsaufgabe; Weipert, “Mehrung der Volkskraft”; and Etzemüller, Ein ewigwährender Untergang. Tuberculosis and infant mortality are identified as a major problem in Frohman, “Prevention, Welfare, and Citizenship” (2006).

66. See Weindling, Health, Race, and German Politics; Etzemüller, Ein ewigwährender Unter-gang.

67. See for instance Turkowska, Der kranke Rand des Reiches.

68. The two most influential reformers of social hygiene who had published important handbooks before the war were Grotjahn, Soziale Pathologie and Fischer, Grundriß der sozialen Hygiene; see also the Handwörterbuch der sozialen Hygiene, edited in two volumes by Alfred Grotjahn (among others) in 1912.

69. See Möllers, ed. Gesundheitswesen und Wohlfahrtspflege; Fischer, Grundriß der sozialen Hygiene (2nd ed. 1925); and Grotjahn: Soziale Pathologie (3rd ed. 1923) in their revised editions.

70. The number of tuberculosis welfare centres rose to more than 3000 in the 1920s. For details, see Frohman, “Prevention, Welfare, and Citizenship” (2006), 438; and in short idem: “Prevention, Welfare, and Citizenship” (2016). As a local example for Berlin-Schöneberg see Roßberg, “Johannes Rabnow und das ‘Modell Schöneberg’”; and Roßberg, Johannes Rabnow.

71. See the contributions of Stephani (chap. III.C and D) in Möllers, ed., Gesundheitswesen und Wohlfahrtspflege.

72. See Reichsgesundheitsamt, 145–8.

73. On welfare programmes for the prevention of tuberculosis and infant mortality, see Frohman, “Prevention, Welfare, and Citizenship” (2006); on welfare in the Prussian provinces Posen Turkowska, Der kranke Rand des Reiches.

74. See Condrau, Lungenheilanstalt und Patientenschicksal.

75. Summarized in the chapter “From Hygiene to Family Health Care” in Weindling, Health, Race, and German Politics.

76. Hüntelmann, Hygiene im Namen des Staates.

77. See Weindling, Health, Race, and German Politics.

78. Dickinson, “Biopolitics, Facism, Democracy,” 10, 30, quote p. 15.

79. See for instance the 2nd editions of Fischer, Grundriss der sozialen Hygiene; and Möllers, Gesundheitswesen und Wohlfahrtspflege.

80. See for instance Hong, Welfare, Modernity and the Weimar State.

81. See Gostomzyk and Mittelstaedt, “Salomon Neumann.”

82. Already requested by the social and racial hygienist von Gruber, Die Pflicht gesund zu sein.

Additional information

Notes on contributors

Axel C. Hüntelmann

Axel C. Hüntelmann is Postdoctoral Research Fellow at the Institute for the History of Medicine at the Charité Medical School in Berlin, where he is currently part of a project on brain research at Institutes of the Kaiser Wilhelm Society between 1939 and 1945. He has also worked and published on the German Imperial Health Office (PhD 2007) and other European public health institutions between 1850 and 1950; scientific infrastructures; the history of laboratory animals; the production, clinical testing, marketing and regulation of pharmaceuticals in Germany and France; and has written a biography on the immunologist Paul Ehrlich (2011). He trained in accounting as well as history and is currently finishing a book on accounting and bookkeeping in medicine (1730–1930). He has also recently edited (together with Oliver Falk) a volume on Accounting for Health: Calculation, Paperwork and Medicine, 1500–2000 (Manchester University Press, 2021).