According to the conviction that accounting isn’t necessarily subordinate to economics, the chapter does not deal with accounting practices in a classical sense but aims to highlight the use and value of calculative practices in treatment and research. By examining Elliott Joslin’s principles and practices of diabetes therapy, it shall be shown how he used calculative and administrative techniques as a tool to combine both therapeutic measures and scientific investigation. Drawing on archival materials of the Joslin Diabetes Center, as well as on Joslin’s published manuals, textbooks, and early seminal articles, it shall, first, be shown how Joslin systematised his patient files for comparing cases and evaluating new therapies. Second, it will be shown how Joslin begun to conceptualised diabetes in rather epidemiological and socio-medical terms at the same time, which subsequently led to new collaborations between physicians, government authorities, life insurance companies, and patients bound together by accounting practices. Finally, it is focused on Joslin’s relationship with his patients and how the qualitative and quantitative information he gathered could be used in therapy and research.
The Mennonite church, the US National Institutes of Health, and the trade in healthy bodies, 1950–70
Accounting shapes the epistemic possibilities of medical knowledge – and shows how practices seemingly ancillary to bioscience can alter both organisational and human bodies, as well as the available ways for living in each. From the 1950s through 1990s, members of Anabaptist churches, who joined ‘voluntary service’ programmes, were able to ‘volunteer’ as Normal Control human subjects at the US National Institutes of Health. Each group had a ‘unit leader,’ who worked informally as the churches’ local account. As documented in traditional archives and in a publicly available ‘vernacular archive’, Anabaptists were both accounting and being accounted for. First, Mennonites appeared literally in the legers of NIH. They were essential research materials whose time the government purchased for a given price. Accounting practices helped NIH and the Anabaptist churches temporarily to align their missions, which had the structural effect of allowing a moral market in healthy civilian bodies to emerge. Second, Anabaptists were enrolled at NIH in experiments, including studies of metabolism, for which bodies were seen as in vivo accounts through which scientists could record input and output. As a mode of attention in metabolic medicine, accounting clarifies when and how categories such as age, gender, and race, were made real and they reinforced shared social biases. Third, Anabaptists were doing the physical labour of bookkeeping at NIH. Their labour of accounting, and the practices of peer surveillance and discipline it required, enforced the embodied discipline that clinical researchers capitalised upon without needing to assert directly.
Accounting is about ‘how much’ and is usually assumed to be about money. It is viewed as a financial technology related to the administration of finances, costing, and the calculation of efficiency. But this book suggests a broader understanding of accounting, linking related perspectives and lines of research that have so far remained surprisingly unconnected: as a set of calculative practices and paper technologies that turn countable objects into manageable units, figures, and numbers that enable subsequent practices of reckoning, calculating, valuing, controlling, justifying, communicating, or researching and that generate and appear in account- or casebooks, ledgers, lists, or tables. And Accounting for Health involves both money and medicine and raises moral issues, given that making a living from medical treatment has ethical ramifications. Profiting from the ‘pain and suffering of other people’ was as problematic in 1500 as it is in today’s debates about the economisation of medicine and the admissibility of for-profit hospitals. In current debates about economisation of medicine, it is hardly noticed that some versions of these patterns and problems has been with health and medicine for centuries – not only in the modern sense of economic efficiency, but also in a traditional sense of good medical practice and medical accountability. Spanning a period of five centuries (1500–2011) and various institutional settings of countries in the Western world, Accounting for Health investigates how calculative practices have affected everyday medical knowing, how these practices changed over time, and what effects these changes have had on medicine and medical knowledge.
Sixteenth-century physicians were a major group among the rising class of urban professionals whose economic fortunes rested almost entirely on their academic training and their skills. But little is known so far about their financial situation and economic aspects of sixteenth-century medical practice. Michael Stolberg’s chapter will follow these issues by using the example of the German practitioner Hiob Finzel (c. 1526–89). Finzel, a town physician in Weimar and later in Zwickau, left three heavy folio volumes of his practice journal where he recorded for a period of almost twenty-five years more than 10,000 consultations and the fees his patients paid in return for his services. The practice journal, called Rationarium praxeos medicae, functioned foremost as an account-book, recording the fees paid by thousands of patients, but it also offers a wealth of information on Finzel’s diagnostic and therapeutic practices. At the end of each year, Finzel balanced the accounts to sum up his income and, at the same time, to justify his own work before God. Stolberg’s chapter provides a brief sketch of Finzel’s biography, describes the practice journal and the recorded payments in detail, and highlights the striking religious elements and connotations of Finzel’s Rationarium. Finally, Stolberg analyses the economics of Finzel’s practice and of the relative importance of the payments he received from patients of different social and economic status.
The workings of an all-female sickness fund, 1898–1931
This chapter investigates the characteristics of a successful voluntary sickness fund in early twentieth-century Sweden. The practices of the Seamstresses Sickness and Burial Fund reveal how a working-class organisation functioned in improving the living conditions of its members. When it was first founded in 1898, it was a small all-female and marginal sickness fund, but by the 1930s it had developed into one of the largest in the city of Gothenburg, with good financial reserves. While successfully attracting new members and retaining its old, the fund also proved to be effective in reducing the costs of long-term sickness cases, one of its greatest concerns. Moreover, the social nature of the fund, its emphasis on mutual aid, and its economic decision-making practices, which went beyond mere capital accumulation, holds much of the explanation for the fund’s success. The fund also took part in initiating discussions on maternity benefits and participated actively in the general women’s rights movement, while also playing a part in the male-dominated sickness fund movement at large. Members’ engagement and willingness to remain members was likely reinforced by how the fund in this way gave a voice for working-class women.
The state-supported mental hospitals that sprung up in abundance in Europe and North America from about 1820 became founts of data and statistics. Doctors always insisted that the asylums were medical institutions, and on this basis, they distinguished administrative accounts, denominated in money, from medical tallies of patients. These institutions, however, were seriously expensive, and as they grew, ever more so. Medical administrators could never ignore the relationship of asylum costs to patient outcomes. A few doctors even presented numerical ratios of costs to cures as the ultimate justification for asylum care – though they often added that inadequate or delayed care was disadvantageous even from the standpoint of financial costs alone. Any such calculation depended data routines and conventions of calculations, none of them straightforward. The numbers, in fact, were not always passed by without criticism, especially since the dubious statistics of one institution tended, by comparison, to show others in an unfavourable light. Hence, although these accounts were often presented in reports as routine and unproblematic, and even on occasion as recipes for effortless administration, they were condemned at other moments as groundless or absurd. Such criticism did not owe to any knee-jerk rejection of numbers by doctors. The necessity of statistics in this and other fields of public health was widely acknowledged. The problem was that doctors as well as administrators were almost compelled to look to the accounts for something they could never provide, a numerical basis for fixing the benefits of treatment.
The Royal Jennerian Society and vaccine production
This chapter examines the mutually reinforcing nature of financial and medical accounts in medical charities through a detailed analysis of the Royal Jennerian Society for the Extermination of the Small Pox, established in London in 1803. The Royal Jennerian Society created three types of accounts: financial (revenues and expenses), medical (numbers of individuals vaccinated and of vaccine packets sent to correspondents), and epistemological (a chronological register of names and residences of vaccinated individuals and sources of vaccine). The last type – the vaccination register – introduced an innovative method for reconstructing the lineal descent of a vaccine, and enabled the Royal Jennerian Society to investigate alleged claims of failed vaccinations. The vaccination register marked an important shift in the presentation and use of case histories from narrative prose to enumerated table, the modern constitutive form of medical knowledge.
This chapter places Churchill’s description of the Munich Agreement as ‘a total and unmitigated defeat’ within the context of his evolving attitudes to diplomacy over the course of the 1930s. In particular, it investigates his understanding of what he referred to as ‘the European system’. As a young man, he had adhered to a brutally realist view of Great Power politics, but in the interwar years this was somewhat tempered by his promotion of ideas of collective security. Such rhetoric had an opportunistic aspect, as he sought to court progressive opinion in Britain; and it was well said of him that he only became enthusiastic about the League of Nations when he thought it might lead to a war. Nevertheless, his views did undergo a genuine evolution. Notably, his approach to the USSR changed, as can be demonstrated by reference to newspaper articles that he published that have up to now escaped notice by scholars. He was never less than strongly anti-communist, but he was perhaps above all anti-Trotskyist; thus, whereas at the start of the decade he highlighted the threat of Soviet rearmament, by the mid-1930s he had become convinced that Stalin’s policy of ‘socialism in one country’ meant that Russia could potentially be trusted to act as a Great Power within the system on traditional tsarist lines. Churchill’s belief that the Soviet Union would behave selfishly but rationally and predictably therefore constituted a key element of his approach to the Munich Crisis.
In the latter part of the nineteenth century, and especially in the first third of the twentieth century, the urban hospital saw its purpose move from the protection and care of patients to their diagnosis and cure. As a result of this process, the numbers and types of patients entering hospitals in England and France, and the funding structures supporting those admitted, underwent a substantial change. These changes were underpinned by new ways of accounting for treatment which saw starkly different approaches adopted by institutions in the two countries. Drawing on evidence from the hospital services of Leeds and Sheffield in England and Lille, Rouen and Le Havre in France, this chapter explores those differences. It utilises a range of sources, including hospital annual reports, financial returns, and internal enquiries, to examine the development of the daily rate – prix de journée – calculated for patient treatment by hospitals in France and the growth of block grants provided by working-class mutual societies in England. It shows that the daily rate, which initially emerged as a way to charge external organisations for using community funded hospitals, became a highly contested site in which accounting practices were deployed to police the boundaries of permissible costs. In contrast, the block grant was adopted, in part, to minimise accounting complexity and administrative costs, but more importantly to shore up the residual charitable elements of the ‘voluntary hospital’ system and impose strict financial discipline. Each of these approaches fed into postwar socialised hospital services, shaping accounting and financial practices for decades to come.
Hungary and Poland in the vortex of the Munich Crisis of 1938
Hungary, like Germany, was a vanquished power after the Great War, and propaganda denouncing the peace settlement was ubiquitous. Slogans condemning the peace permeated public life, politics, education, academia, literature, the press and broadcasting. The mentality engendered by this atmosphere infused the private discourses of families and individuals. The victimhood mentality helped to mould and sustain Admiral Horthy’s interwar regency. The ‘Szeged idea’ – drawn up in the southern town of Szeged in 1919 – remained the binding element of public and private discourse, predicated on anti-liberal and anti-Western principles that would rebuild and govern Hungary along Christian-national lines. In this atmosphere, Hungary’s small liberal elite, who had no sympathy with Hitler’s regime, struggled to denounce the injustice of Munich. An annex of Munich referred the territorial dispute between Hungary and Czechoslovakia to direct negotiations that eventually awarded Hungary southern Slovakia in November 1938 and Subcarpathian Ruthenia in March 1939. Thus Hungary, a country with a largely silent opposition, became a beneficiary of Munich. The politicians’ views are easily decoded, deriving from geopolitical circumstances. However, the absence of dissent by public intellectuals, the press and public opinion points to a deeper crisis in interwar Hungarian political culture. Using a range of non-political publications, journals, literary magazines, private diaries and other sources, this chapter elucidates the social and psychological dynamic behind Hungary’s quiescent and often complicit attitude during the Munich Crisis.