This volume is the impressive result of the collective efforts of Belgian (medical) historians to do at least two things: first, to put Belgium on the map of medical historiography and, second, to do so using the latest methods and approaches. With a single stroke, the Belgian field presents itself at the forefront of medical history. Not only is Belgium now ready to be included in international comparative research, but the sophisticated chapters in this volume invite us to engage in further research using the concepts and agendas of our Belgian colleagues. The editors invited me to comment on the volume and the potential of its ‘new narratives’. They even suggested a title for my epilogue – ‘Medicine Beyond Belgium’ – implying I take the view from the rest of Europe in evaluating the Belgian case. That does not seem to be feasible, if only because similar volumes about other European countries are lacking. Therefore, I chose to approach the volume as a self-contained unit, asking questions like: what is new to these narratives? How do they relate to earlier ones? What are their strengths? What are their weaknesses? Who is the audience for these narratives? How do they affect our research agenda?

Diversity and dynamism

It has been stated ad nauseam that ‘traditional’ medical history was written by, for and about doctors. This led to narratives mainly appealing to their intended audience, namely stories about progress through science and about the productive collaboration between the profession and the state for the benefit of mankind. This situation profoundly changed when social historians entered the scene in the 1970s and 1980s. They claimed that health, illness and healing are not the exclusive domain of doctors but important to all of us. The way in which we understand our body and its diseases is not primarily scientific. Moreover, the healthcare system is funded by all citizens, while its organisation affects the health and wealth of all of us. Therefore, the ‘new historians’ claimed that it was legitimate for them to write about the medical past as well. They argued that health and illness precede medical consultation, and that cultural notions about them are all-pervasive. Physician-medical historians were held to be unduly selective and monopolistic about the medical past, appropriating a specific version of it. Qualifying their progressivist narrative as finalistic – and thus celebratory rather than analytic – and unpacking categories like science, profession and the state, the ‘new historians’ created new narratives. These were not just populated by medical men, but by patients, alternative healers, clergymen, women and other historical actors as well. The perspective of medical history was turned upside down – taking the patient’s perspective – while its sources expanded enormously – any medium documenting the past was now deemed of potential value – and its methodological toolkit grew and diversified with every ‘turn’. In their Introduction, the editors stress that the innovative character of the volume is in its attention to the multiplicity of actors, places and media. Acknowledging that physicians remain central players, they argue that roles and identities have become more complex, thus fragmenting and blurring the picture.

The agenda of the volume is to move beyond the state, institutions and physicians, because the ‘turns’ in history writing have made us aware that there are many dimensions preceding and accompanying consultation of a physician whose academic training and medical practice is regulated and overseen by the state. While the social turn pointed us to the power dimension involved in medicine and healthcare, the cultural turn made us realise that in referring to our bodies, we are moving in multivocal semantic networks. The ways in which we conceptualise our body and frame our diseases has implications for the ways in which we relate to them and act upon them. With the performative and the praxeological turns, the focus changed from idea to practice and from blueprint to action, while the material turn called to take the built environment (and objects in general) into account. Finally, the somatic turn built on anti-essentialist notions by distinguishing between sex and gender. While not doing justice to these and other turns, the point here is that they all represented a call to move away from a universalist history of ideas, and from taking a top-down (professional, male, bourgeois, Western) perspective. All ‘turns’ pointed to the diversity and dynamic nature of society (and therefore healthcare), calling to do justice to it in our representations of the medical past.

Many chapters in this volume are responding to this agenda of diversity and dynamism. In Chapter 1, for example, Jolien Gijbels and Kaat Wils show that even though academia was no place for women until well into the nineteenth century, medicine and healthcare have always been thoroughly gendered. But when women finally knocked on the door – around 1875 – male physicians tried to naturalise medicine as a typically male endeavour, referring women to ‘caring professions’ like nursing and midwifery. While the Royal Academy of Medicine argued that women were too delicate (in body and mind) or indeed too ignorant to become a physician, women dismissed this claim as an attempt to maintain and legitimise the conventional division of labour, with men on top of the medical hierarchy. Feminists were keen on claiming and redefining the female body, in order to liberate themselves and secure their place under the sun. This was by no means an easy task: for the better part of the twentieth century, female physicians had a hard time trying to set up their own practice – some of them even resorting to the colonial route, hoping to be more fortunate in the Belgian Congo. In the end, women succeeded in entering the medical curriculum and making a career as a Doctor of Medicine, but only after a long and protracted struggle in which class and gender differences often reinforced each other. In the late twentieth century, the number of female medical students exceeded that of their male counterparts. The point that Gijbels and Wils are making is that healthcare is a battlefield, and that the combatants are using all rhetorical means at their disposal to support their claims, also including medical historiography. While female voices may be difficult to find in the nineteenth century, this is not to say that they did not exist or that they did not make themselves heard. Therefore, in order to recapture the full and inclusive picture of the medical past, we need to be critical and creative in finding and interpreting our sources, sometimes reasoning ‘against the grain’, sometimes even using silences in the past in a productive way.

The same applies – probably even more so – to the stories that can be told about the colonial past. African indigenous healing practices continued to thrive during the colonial era. They were hardly affected by – or indeed in contact with – Western medicine. Still, the voices of Africans are hardly ever heard, because the colonial narrative has always been told by the European coloniser. The two quotes at the beginning of Chapter 3 by Sokhieng Au and Anne Cornet nicely illustrate the profound difference between both worlds: the rendering of a medical ceremony among the Bakongo in 1941 is followed by a medical report on a trypanosomiasis expedition to the Belgian Congo written almost forty years earlier. The contrast between both texts could not be bigger: while the former describes a healing ritual replete with religious offerings, chants and music firmly embedded in the local community, the latter is a technical report on a diseased woman, filled with clinical details and metrics in an attempt to objectify disease. Thus, Au and Cornet are setting the stage for a story about Western medicine and other colonial institutions. At first sight, theirs may look like a rather traditional story. However, their sophisticated introduction is putting things into perspective by pointing out that indigenous healers and Western medical practitioners were living in two separate worlds. By also reminding us that ‘medicine’ is defined by the disciplinary lens of scholars who are writing about it (both past and present, both physicians and historians), they succeed in avoiding the trap of Eurocentrism. Their story about state-organised medical service, missionary medicine and industrial medicine from the perspective of Belgium loses all of its ‘traditional’ connotations, because the reader is made aware that they are only reading one side of the story. Having said that, the authors make it abundantly clear that the Belgians were not on a humanitarian mission in Congo. Although Belgium was a latecomer on the colonial scene, it quickly and brutally caught up. King Leopold II regarded the Congo as his personal fiefdom, exploiting it ruthlessly. ‘Health’ was not considered to be a public good but rather a commercial or military one, with medicine helping to create a racial and gendered discourse of difference used to avoid the Congolese ever coming to be considered as Belgian citizens. Again, science was instrumental in creating binary distinctions, naturalising difference and inferiority, legitimising colonial hierarchies. Again, we realise that we should not fall into the trap of uncritically adopting ‘actor’s categories’, and that we should never blindly follow the sources that happen to be available to us. Au and Cornet make us keenly aware that colonial archives were produced for specific commercial and military goals, not to satisfy the historical or anthropological curiosity of later generations. The story about indigenous healing practices in Africa is yet to be written.

Although medical history has long been fascinated by the ways in which ‘the normal’ and ‘the pathological’ are constructed, the focus tended to be on discursive medical practice. Disability studies challenged the exclusive right of medicine to frame disease – in body and mind – and the monopoly of the state to act upon it. Taking the patient’s perspective, they broadened the scope by pointing to alternative ways of framing health and disease, and by making us aware that other groups (like priests, statisticians or pedagogues) have been involved in understanding and coping with impairment – however defined. In doing so, disability studies challenged the unilinear stories of professionalisation and medicalisation by including other voices than those of the profession and the state. In Chapter 8, Benoît Majerus and Pieter Verstraete show how this may shatter our received image of ongoing civilisation and progress through the doings of the medical profession and the state. In its attempt to create productive citizens and a healthy nation, the newly independent state of Belgium (1830) felt the need to deal with the threat ‘lunatics’ caused to public order and morality. The expert advice of people like Joseph Guislain led the new state to adopt legislation giving rise to the discipline of psychiatry and the building of psychiatric institutions. Next to (or even opposed to) the story about normalisation that has traditionally been told about the rise of psychiatry and its institutions, Verstraete and Majerus present two stories that may be considered as counter-narratives. Keen on showing the agency of laypeople, they tell the story of the Geel colony and that of deinstitutionalisation. Contrary to the treatment offered in asylums by professional psychiatrists, the Geel colony represented an alternative model of community care ‘where the insane lived as a family and in freedom’. To the critics of the disciplinary regimes of psychiatry, the Geel colony was an example to be emulated and followed. In the 1960s and beyond, psychiatry and its institutions were heavily criticised. People inspired by the work of Michel Foucault, Ivan Illich, Thomas Sasz and Erving Goffman argued that the state had grown into a ‘therapeutic state’ – medicalising all ‘abnormal’ behaviour – creating ‘total institutions’ where psychiatrists took total control over someone’s life. They therefore called for deinstitutionalisation: by setting the insane free, their humanity would be restored, while it would also have a healing effect on society at large. Although Verstraete and Majerus fully realise that deinstitutionalisation has its limits, by reminding us of the constructed character of the boundaries between normal and pathological and between lay and professional, they invite us to look beyond (narratives about) the profession and the state.

Another way of toning down the solid character of professionalisation and medicalisation theories is by looking at the ways in which knowledge about the body – in health and illness – circulated in society. Whoever presumes that the profession and the state were dominant and all-pervasive, will opt for a top-down perspective and a diffusion model, using ‘official’ sources only. However, scholars intrigued by the dynamics in the public sphere will allow for agency of laypeople, hybridity and reciprocity, also using ‘grey’ literature. By looking at the mediating role that health exhibitions and medical movies played in the past, in Chapter 9 Tinne Claes and Katrin Pilz intend to show that categories like ‘the state’, ‘the profession’ and ‘the public’ were by no means homogeneous entities. Claiming that the antagonism – and even hierarchy – between ‘official’ and ‘alternative’ medical beliefs was a cultural construct rather than a historical reality, their searchlight is on historical actors outside of academia. Arguing that popularisation was not a monologue but rather a conversation, they focus on the media through which medicine circulated in society, putting the citizen-patient-consumer centre stage. They show that exhibitions and movies moved between the university, the fairground and the cinema. Anatomical exhibitions were taken out of their context, speaking to others than to their intended audience. In these new contexts, they went for the sensational, the grotesque or the erotic rather than for educational value, leaving visitors free to respond in unintended or unexpected ways. Something similar applied for medical movies. At the same, Claes and Pilz observe that ‘it was always an expert authority that prepared and transformed medical knowledge for a public audience … Interactions remained hierarchical’. This makes one wonder how ‘hybrid’ the encounter between science and the public really was. Or to put it differently: are we looking at counter-narratives opposing medical discourse or rather at the elevation of laypeople to medical standards? One is inclined towards the latter: health exhibitions and public health movies – embodying the ideals and agendas of the sanitary movement – reached ever-wider audiences, especially after the Second World War. Ironically, then, the dominance of the profession and the state is confirmed in this chapter.

This is not to say however, that we can simply discard alternative actors’ voices or historiographies, as Joris Vandendriessche and Tine Van Osselaer show in Chapter 2. If there is one thing preceding medical consultation, it is religion. Religion supplies answers to existential questions, giving meaning to birth, suffering and death, offering solace to believers. Therefore, religion may be regarded as a source of health and recovery. In order to understand how people have been dealing with health, illness and healing it is therefore imperative to take religion into account: without it, no medical history can claim to offer a complete story. Over the course of the nineteenth century, the Catholic Church developed into a major institution in Belgium, pervading all domains of society. By the mid nineteenth century almost half of the orders were involved in the provision of medical care, after having been suppressed under French rule. Belgium had the largest Catholic university in the world (Leuven) and even in the Congo Catholics held disproportionate power. It was a force to be reckoned with, and the Vatican always took good notice of what was going on in Belgium. This situation had developed after independence in 1830, with the constitution of the new nation state offering ample opportunity for religious orders to establish themselves. Its liberal freedoms gave free reign to the Catholic Church, making it dominant in the provision of medical care as well. However, contrary to what earlier historiography wanted us to believe, Vandendriessche and Van Osselaer stress that religiously inspired care was hardly ever at odds with medicine. They argue that medicine and religion were not in opposition with each other but coexisted and interacted with each other. This view has implications for their view on ‘secularisation’ as well. Rather than being simply a matter of ‘less religion, more medicine’, the Catholic Church remained an important force when in the late twentieth century issues concerning abortion, euthanasia, in vitro fertilisation and genetic screening came to be discussed. Medical ethics in Belgium tended to be dominated by Leuven academics, who attempted to mediate between medical developments and Catholic doctrine. Today, questions relating to the meaning of life, suffering and death and the goals and limits of medicine are as relevant as ever before.

Moving beyond the profession and the state

This volume opens up new vistas in other ways as well. Its chapters look not just beyond the profession and the state, but they do so by presenting a rather under-researched case: Belgium. For a long time now, the centre of gravity of European medical history has been the United Kingdom. Thanks to the generous funding by the Wellcome Trust, the field has been thriving there, as it no doubt will continue to do. Many wonderful monographs have been written about Britain’s medical past, inspiring colleagues across the world. But for history to thrive, it is in need of many more national perspectives. While medicine may be an international intellectual endeavour transcending national borders, healthcare systems tend to be a product of their national context. Different political cultures produce different constellations of healthcare, while the logic of path dependency limits the extent to which national systems may derive from each other. Given the fact that there are many different national styles of healthcare, it makes sense to compare them – if only in an attempt to put any given healthcare system into perspective. Medical history is therefore in need of national narratives, as many as possible. This volume is a courageous attempt to supply just that for Belgium. And although there is some irony in the fact that these new narratives – keen on moving beyond the state – are framed in a national context, they succeed in showing how productive this new approach may be. It has not been the ambition of the editors to supply a new unifying narrative, but rather to present a handful of perspectives on the medical past of a particular country. Belgium took shape as a modern nation state from 1830 onwards, when it liberated itself from the Netherlands, its northern neighbour. The bond between them had been an uneasy marriage, arranged at the Congress of Vienna in 1815. The new state was intended to be a middle-sized power, meant to contribute to the post-Napoleonic balance of power in Europe. The marriage had lasted fifteen years, when it ended in a ten-day military campaign. The differences between the north (the former Dutch Republic) and the south (the former Austrian Netherlands, belonging to the Habsburg Empire) had been too big to make for a viable nation state.

In the nineteenth century, the state came to be seen as responsible for the health of the nation. However, before preventive measures for the public benefit could be put in place, health determinants needed to be established first: what factors caused disease, and how could their detrimental effects be prevented or countered? In their quest for answers, the profession and the state relied on each other. While medicine was looking for a way out of its etiological fatalism (e.g. to understand cholera), the state tried to realise its self-imposed goal of catering to the needs of its citizens. Until then, the medical profession had been rather weak and poorly organised, so it needed the support of the state. Building on Hippocratic notions, environmental medicine seemed to provide the answer, and it was considered imperative for the state to act upon advice supplied by the profession. In Chapter 4, Thomas D’haeninck, Jan Vandersmissen, Gita Deneckere and Christophe Verbruggen show how this process slowly materialised over the course of the nineteenth century. At international conferences, physicians and statisticians informed each other about the correlation between health determinants and morbidity patterns in their country. By exchanging and superimposing their observations, they hoped to be able to trace regularities. Ultimately, their deeper understanding of epidemic disease was expected to inform (local) policies at home. In this sense, the profession and the state legitimised each other, one presupposing and reinforcing the other. Their relationship was famously expressed by Rudolf Virchow, when he stated that politics is nothing but medicine on a large scale. This is when the narratives about the beneficial alliance between the profession and the state found their origin, serving an emancipatory goal for the medical profession. Much later, these narratives came to be criticised as being self-serving and celebratory, unduly legitimising a professional monopoly protected by the state. Critics argued that the alliance between the profession and the state had sometimes even done more harm than good. During the interwar years, for example, some states had used medicine to naturalise and support eugenic racial policies, while in the post-war years medicine proved unable of formulating a viable response to chronic disease or to growing inequities in healthcare. In a globalising world there was a growing need to move beyond the profession and the state.

After Belgium had gained independence from the Netherlands in 1830, it faced the challenge to organise the new nation state – and this included setting up a system of medical education. The new state was in need of physicians who could do research on epidemic diseases threatening the nation and who could serve the state by giving advice on health matters. As Renaud Bardez and Pieter Dhondt show in Chapter 5, the new Belgian state was quick in reinventing itself, at least in a formal sense. After drafting its own Constitution, it proceeded by completely reorganising the university system. This also affected the medical faculty and its curriculum. Belgium was the first European state to introduce a single medical degree (it was to take another sixteen years before the Netherlands realised this). In 1849, the patchwork of competences – a legacy of the Ancien Régime – was a thing of the past. From then on, physicians were allowed to practise medicine, surgery and obstetrics in all of Belgium. Having said that, we should realise that this was only a legal settlement, accelerated by Belgian independence and the need for the new Belgian state to set up a system of public health and the educational system belonging to it. Bardez and Dhondt show that, more often than not, the educational system and the profession failed to deliver what the state required. First, curriculum reform was paralysed by intense parliamentary discussions between Catholics and liberals on the composition of university boards. Second, medical faculties had to resort to foreign professors – most of them German – due to a lack of Belgian candidates. Third, there was conservative resistance to reform; for example by Liège professors, for whom the transition was moving too fast. Fourth, there was a lack of state funding for the so-called free universities, and the price they had to pay for their freedom of education. And finally, there was the issue of language; it proved to be very difficult to build a nation in a country that is trilingual (French, Dutch and German), especially when the demarcation line is heavily socially charged. Again, by moving beyond the profession and the state, it becomes clear that there is a huge difference between dream and reality and between blueprint and practice. Thus, Bardez and Dhondt’s chapter causes us to reconsider the value of professionalisation and medicalisation theories.

Another way to move beyond the older narratives is to resort to other sources, such as material objects. In doing so, more historical actors may be involved in the stories that we tell, like nurses, servants and – last but not least – patients. Although artefacts do not talk, they may contain useful information about the way daily life on the ward was organised, adding layers and nuance to the story. In Chapter 7, Valérie Leclercq and Veronique Deblon argue that the architectural plan of a hospital, for example, may tell us more about the way space was organised. Going to hospital involved a range of segregations, first of all from the outside world. In addition to that, patients were classified and segregated by class, gender, illness and/or behaviour. They were categorised and disciplined by and through medicine, but by religion and morality as well. Thus, the materiality of a hospital reiterated social and moral distinctions in society. The hospital may be considered as a microcosm reflecting cultural values on the outside. In their chapter Leclercq and Deblon are looking at domesticity, religious symbols and social norms as they are expressed through material objects in hospitals. It becomes clear that around 1900, hospitals were still very much involved in charitable care. This started to change at the turn of the century, when the status of medicine improved and the hospital became increasingly accepted as a place for medical treatment. From then on, the artefacts tell a story of physical segregation, the imperative of ventilation and cleanliness and the emergence of the block hospital and new management styles: all of them medical imperatives advocated by medical men. In the process, sanitary goals, medical surveillance and cost effectiveness came to prevail over domesticity, aesthetics and religious symbolism, even though religion continued to be very present until well after the Second World War. Leclercq and Deblon successfully challenge two older teleological narratives – one of medical progress and the other of social control – adding new dimensions of hospital life to their story. Still, its overall trend is one of medicalisation. Over the course of the twentieth century, Belgian hospitals transformed from being charitable institutions for the poor to high-tech, business-oriented centres where patients were redefined as consumers.

This seems to point to an important shift in focus of the alliance between the profession and the state: from preventive measures for the benefit of the nation to curative interventions in the lives of individuals. To fully understand the ‘system’ of healthcare however, we need to include a third stakeholder complicating the story: the Catholic Church. With poverty and illness being two sides of the same coin, individual care in the nineteenth century was mainly a matter of charity provided by the church. While the young Belgian state did its best to put sanitary measures in place – as much as its liberal ideology would allow – Catholic charity was crucial in supplying the bare minimum of care to individual citizens, either in hospitals or in their homes. In Chapter 6, on the organisation and funding of the healthcare system, Dirk Luyten and David Guilardian introduce funding mechanisms of care and cure as an important dimension. By taking money into account, we are invited to think about the motives for funding and about the entitlements and responsibilities involved. Over the course of the twentieth century the state took over from the church as being the most important funding body of healthcare. In 1853, 75 per cent of all expenditure on care was supplied by the church, with only 18 per cent being supplied by the state. In 2015, this had profoundly changed: 60 per cent of all the expenditure on healthcare was derived from the national compulsory health insurance scheme, 18 per cent from the state, another 18 per cent from out-of-pocket payments by patients and 4 per cent from voluntary insurances. By that time, the church had vanished from the scene. This situation is the result of a complex interaction between many factors. On the one hand, the twentieth century witnessed many scientific and technological breakthroughs, leading to impressive therapeutic results and an increase in the average life expectancy, but to exponentially rising costs as well. On the other hand, secularisation gave rise to new coping strategies with regard to illness, especially after the Second World War. While disease had often been considered as divine fate or as a trial bestowed by God to test a sufferer’s belief, it came to be seen as simply bad luck that could and should be remedied at all costs. With the secularisation of society, healthcare increasingly came to be seen as a right to be guaranteed by the state and delivered by the profession; citizens considered themselves to be entitled to all available interventions. In modern neo-liberal society, citizens no longer fatalistically accept their fate. Rather, they expect the state to take care of them from the cradle to the grave and account for its funding priorities in rational and transparent ways.

This brings us to the paradox of our time: although the alliance between the profession and the state has brought a lot to mankind, we are now living in an era of rising costs, diminishing returns and increasing anxiety about the system. In The Greatest Benefit to Mankind, Roy Porter took the long view on health, illness and healing in an attempt to contribute to much needed reflection on the system. In his introduction, he observed: ‘Medicine is an enormous achievement, but what it will achieve practically for humanity, and what those who hold the power will allow it to do, remain open questions’.¹ Porter concluded his book by formulating a mission for (Western) mankind: ‘For centuries medicine was impotent and thus unproblematic … Today, with “mission accomplished”, its triumphs are dissolving in disorientation … Medicine will have to redefine its limits even as it extends its capacities’.² Reflecting and redefining the goals and limits of medicine entails looking beyond the profession and the state. At the same time, we need to rethink the rights and duties of all of us, and the present volume may help us accomplish this. In the past, medical history was written by male, Western physicians. This led to rather unilinear stories of progress through the doings of the profession and the state, referred to as professionalisation and medicalisation. As this volume shows, today’s medical history is (also) written by historians, women and non-Westerners, producing multiperspective and multivocal stories. While some may regret this development because of the fragmentation this entails, I would argue that much is to be gained by including all historical actors. We should be prepared to take new perspectives, looking at more domains and using more diverse source material. Moving beyond the great doctors, decentring the big picture and provincialising Europe may lead to a diversity of narratives. Yet this is no reason to shy away from it, since it represents the diversity of today’s world.

The famous Dutch historian Johan Huizinga once observed that history is the mental form in which a culture takes account of its past. He wrote this in a time when historians were still living under the illusion that the culture of a nation was one and that historians were uniquely equipped to represent its history. We have come to realise that there are many (sub)cultures, both within and between nations, and that each of them is entitled to take account of its past. Of course, there have always been more subcultures than one, but after the emancipation of workers, women, black people, patients and others, they have become vocal – shaping their identities by taking account of their past. Their narratives may be complementary and in line with each other, but more likely they will be in competition with each other, taking their own positions and agendas as their point of departure, showing the sheer richness and diversity of society, both past and present. Like medicine, medical history is not owned by physicians, but by all of us. We should therefore be grateful to our Belgian colleagues, not just for making us realise this, but also for building on that notion by supplying us with wonderful case studies of Belgium, showing the diversity and dynamism of its medical past and inviting all of us to join in the debate.