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.
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.
What does the Charité’s cabbage garden have to do with medical knowledge and economy? And how are accounting, economy, and health interconnected beyond current discussions about economisation? Bringing together health, medicine, and accounting, the chapter on hospital economies investigates the Charité hospital’s various economies between 1780s and 1910: its Ökonomie of functional entities, like the kitchen, laundry, brewery; the bodily economy of its sick inmates; and the hospital’s administrative economy that, after 1900, professionalised as ‘hospital economics’. Hüntelmann argues that all of these economies were linked together and that health and accounting have long been deeply entangled with one another. The chapter demonstrates this by focusing on inmates’ food and diet: in the hospital’s Ökonomie, the production and supply of food was registered and balanced against consumption; daily consumption rates and diets were calculated for each person, monetised, and used to derive daily cost-rates and patient fees; annually budgeted and retrospectively balanced. Surveying more than a century, we find that calculative practices and accounting at the Charité hospital were remarkably stable. But there are also major changes over time as the collection of data became more formalised – as the entire process of organising food production, calculating diets, and accounting for food-stocks became more standardised, not least because it involved more people gathering and transforming the necessary dates – and professionalised as ‘hospital economics’. And as the 1780s hospital Ökonomie diminished over time, from the early decades of the twentieth century it mainly existed on paper, interlinked by and represented in the hospital’s accounts.
International health accounting in historical perspective, 1925–2011
In the twenty-first century, the need for countries to reliably measure and compare how much they spend on health is somewhat obvious. By accounting for health expenditure, governments can identify how money flows through their health systems: who funds health care and who provides it, how much money is being spent, and on what. In this way, governments can adjust their priorities, evaluate the impact of interventions, improve health services, and address various structural problems. The complexity of health systems and methodological problems surrounding national health accounting, however, have undermined attempts to compare health expenditures globally over the last century. This chapter traces the history of international health accounting: organised attempts to measure and compare health spending across national boundaries, including the rules and conventions that ensure the coherence of this information. Although a comprehensive system of health accounts (SHA) has been established only recently, it has had various precursors over the twentieth century. This chapter traces its antecedents through the work of various international organisations, including the League of Nations Health Organisation (LNHO), the United Nations, the International Labour Organisation (ILO), the Organisation for Economic Co-operation and Development (OECD), and the World Bank. In presenting a genealogy of international health accounting, this chapter describes the evolving role the issue of health care financing has played in international health. It also highlights the development of accounting technologies, such as standardised tables and accounting manuals, which have facilitated international measurement and comparison.