Zdravlje naroda – bogatstvo države Prosvijećeni apsolutizam i počeci sustava javnoga zdravstva u Hrvatskoj
Ivana HORBEC
ZDRAVLJE NARODA – BOGATSTVO DRŽAVE Prosvijećeni apsolutizam i počeci sustava javnoga zdravstva u Hrvatskoj Nakladnik: HRVATSKI INSTITUT ZA POVIJEST Zagreb Za nakladnika: dr. sc. Jasna Turkalj BIBLIOTEKA HRVATSKA POVJESNICA Monografije i studije III/64 Recenzenti: prof. dr. sc. Željko Dugac dr. sc. Robert Skenderović Lektura: Jasmina Sočo, prof. Prijevod sažetka na engleski: Lidija Šimunić Mesić, prof. Prijelom i tisak: Tiskara Zelina d. d. Sv. Ivan Zelina Naklada: 300 primjeraka ISBN 978-953-7840-41-9 CIP zapis je dostupan u računalnome katalogu Nacionalne i sveučilišne knjižnice u Zagrebu pod brojem 000908584. Tiskano potporom Ministarstva znanosti, obrazovanja i sporta Republike Hrvatske Naslovnica: Gerard van Swieten i Joseph von Sonnenfels. Detalj sa slike: Carl Swoboda, Allegorie zur Fünfhundertjahrfeier 1865 (dvorana Dekanata Katoličko-teološkoga fakulteta Sveučilišta u Beču). Das Josephinum. Crtež R. Alta iz sredine 19. stoljeća.
Ivana HORBEC
ZDRAVLJE NARODA – BOGATSTVO DRŽAVE Prosvijećeni apsolutizam i počeci sustava javnoga zdravstva u Hrvatskoj
Zagreb, 2015.
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SADRŽAJ PREDGOVOR...................................................................................
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UVOD................................................................................................ Tema i metodologija rada.............................................................. O literaturi i izvorima.................................................................... Terminologija................................................................................ PROTAGONISTI JAVNOZDRAVSTVENE POLITIKE: DRŽAVA I TEORETIČARI DRŽAVE............................................ Temelji stvaranja države kao impersonalne moći.......................... Kameralisti kao promotori državnoga angažmana........................ Teorije države i javno zdravstvo.................................................... Utjecaj teoretičara na državnu javnozdravstvenu politiku............
11 18 23 27
INSTITUCIONALNI I ZAKONODAVNI OKVIR SUSTAVA JAVNOGA ZDRAVSTVA................................................................ Upravna struktura Habsburške Monarhije .................................. Institucionalni sustav javnoga zdravstva – formiranje, djelatnost, odgovornost.................................................................. Protuepidemijska zaštita i staleške institucije.............................. Izgradnja stalnih centralnih i lokalnih institucija javnoga zdravstva..................................................................... Stručnjaci u sustavu javnoga zdravstva .................................... Javno zdravstvo kao dio javnopolitičke uprave (publico-politica)........................................................................ Odgovornost upravnih tijela u provođenju javnozdravstvenih propisa............................................................. Značajniji normativni akti na području javnoga zdravstva............
31 31 34 36 44 49 50 56 57 61 68 72 76 78
POSTAJA PREMA KRŠĆANSKOJ EUROPI: SANITARNI KORDON.......................................................................................... 85 Izgradnja i stabilizacija Sanitarnoga kordona................................. 87 Kontumac – zdravstvena stanica Sanitarnoga kordona.................. 95
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Protuepidemijske mjere: segregacija i raskuživanje........................ 108 Gospodarski aspekt Sanitarnoga kordona...................................... 112 Prekršaji u protuepidemijskoj zaštiti............................................. 116
MEDICINSKO OBRAZOVANJE: KONTINUITET I REFORMA......................................................................................... 121 Stvaranje modela: Medicinski fakultet u Beču............................... 123 Kirurgija kao akademska disciplina................................................ 129 Ujednačavanje kurikula medicinskih i kirurških studija............... 138 Od centra prema “periferiji”.......................................................... 145 Školovanje primalja........................................................................ 150 Školovanje kao uvjet za obavljanje medicinske prakse.................. 153 Recepcija reforme medicinskoga obrazovanja u hrvatskim zemljama....................................................................... 159 LIJEČNICI, KIRURZI, LJEKARNICI I PRIMALJE U SLUŽBI JAVNOSTI.......................................................................... 165 Od tradicije do profesije................................................................. 166 Liječnici.................................................................................... 171 Kirurzi, ranarnici, baderi, brijači.............................................. 178 Ljekarnici................................................................................. 185 Primalje.................................................................................... 190 Zdravstvena skrb kao javna služba................................................ 196 HOSPITALI I BOLNICE.................................................................. 205 Poticanje razvoja hospitala............................................................. 209 Diferencijacija socijalne i medicinske skrbi .................................. 214 Osnutak klinika: medikalizacija bolničkih ustanova..................... 217 KONCEPT MEDICINSKE POLICIJE................................................ 227 Potraga za redom: medicinska statistika i topografija..................... 231 Zdravstveno prosvjećivanje............................................................ 235 ZAKLJUČAK..................................................................................... 241
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Prilog 1. Opći zdravstveni pravilnik (1770.)....................................... 249 Prilog 2. Dodatak Zdravstvenom pravilniku (1773.).......................... 310 Prilog 3. Uputa za službu županijskih fizika u Ugarskoj i pripadajućim zemljama (1785., 1787.)................................ 315 Prilog 4. Uputa za službu kirurga namještenih u županiji (1787.)...... 321 LITERATURA................................................................................... 325 SUMMARY........................................................................................ 343 KAZALO............................................................................................ 355
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PREDGOVOR Kvaliteta i dostupnost liječenja, prava liječnika i drugoga medicinskog osoblja, uvjeti njihova rada, prava pacijenata, utjecaj struke na formiranje i provedbu javnozdravstvene politike te uloga socijalne države u regulaciji tih pitanja – teme su koje zauzimaju važno mjesto u javnome diskursu od početaka razvoja moderne države pa sve do današnjih dana. Istim je pitanjima protkana i ova knjiga. Odgovore na njih tražila sam u samim počecima formiranja sustava javnoga zdravstva na ovim prostorima te pronalazila trenutke u kojima pojedine teme vezane uz zdravstvo postaju javnima, pa time i dijelom opće politike koja će utjecati na svakodnevni život svih slojeva stanovništva. Ključni poticaj tomu razvoju pronašla sam u prosvijećenom apsolutizmu, odnosno njegovoj habsburškoj varijanti koja je tijekom druge polovice 18. stoljeća, po mojem mišljenju, odlučujuće utjecala na formiranje protomodernih društvenih strukura u hrvatskim zemljama pod habsburškom vlašću. „Moć države ne počiva u njezinom teritoriju nego u bogatstvu i broju njezinih stanovnika“ – riječi su pruskoga vladara Friedricha II., a smisao tih riječi snažno će se zrcaliti i u habsburškoj javnozdravstvenoj politici toga doba. Doba je to kad je po prvi put formirana mreža institucija posvećena upravo brizi o zdravstvu, kad su medicinska znanja postala široko primjenjiva, kad je medicinska skrb postala dostupnija i kvalitetnija, ali i doba kad je pristup pacijentu postajao sve manje individualan, a sve više standardiziran. Središte analize, od kuda je i započelo moje istraživanje, bio je Opći zdravstveni pravilnik iz 1770. koji se u historiografiji medicine na ovim prostorima uvijek javlja kao „početak“ i „prekretnica“. Odluka da taj zakon, izvorno pisan na njemačkom i latinskom jeziku, objavim na hrvatskom jeziku, otvorila je za mene niz novih tema, koje sam pokušala naznačiti u pojedinim poglavljima ove knjige. Iako ova knjiga nije pisana s ambicijom da bude cjelovita studija o sustavu javnoga zdravstva, pa stoga i ostavlja niz neodgovorenih pitanja, mislim da ocrtava odnos države prema javnome zdravstvu u počecima stvaranja toga sustava i nadam se da će potaknuti daljnja istaživanja na tom polju. U ovoj knjizi pokušala sam povijesne procese razvoja državne uloge u zdravstvenim pitanjima na području hrvatskih zemalja postaviti u kontekst širih europskih povijesnih procesa te analizirati čimbenike uspjeha, ali i razloge neuspjeha državnih regulativa, s namjerom da oni, upravo na primjeru javnoga zdravstva kao elementa državne uprave koji se odnosi na najširi krug stanovništva, 9
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ukažu na elemente suodnosa državnih institucija i pojedinačnih interesa važnih i za percepciju današnje uloge države. Nadam se da će ova knjiga pružiti barem malen doprinos poznavanju fundamentalnih postavki u razvoju javnoga zdravstva, razumijevanju intelektualnih transfera između sveučilišnih centara i prostora koji su društveno i politički tada smatrani „periferijom“ te doprinos poznavanju interakcije djelatnosti državnih institucija i pojedinačnih utjecaja intelektualne elite, ali i društva u cjelini. Napokon, pisanje ove knjige nužno je potaknulo razmišljanja o temeljnoj socijalnoj ulozi države, shvaćenoj kao vrsti društvene organizacije: ideje prosvjetiteljstva, protkane kroz cjelokupno moje istraživanje, postavile su naglasak na humanitarizam i racionalnost kojima se, vjerujem, u traženju smisla državnih strukura uvijek iznova moramo vraćati. Ove knjige, dakako, ne bi bilo bez potpore mnogih dragih osoba. Prije svega, na podršci zahvaljujem bivšim upravama i sadašnjoj upravi Hrvatskoga instituta za povijest, jer su imali povjerenja u svrhovitost fluktuacija mojih znanstvenih interesa. Zahvaljujem na podršci i brojnim kolegama na Institutu, koje s ponosom mogu nazvati i prijateljima. Ogromna hvala upućena je recenzentima ove knjige koji su predano pročitali rukopis knjige i nesebično pružili neprocijenjive savjete. Neizmjerno sam stoga zahvalna dr. Željku Dugcu na podršci koja me pratila od samih početaka mojega istraživanja ove teme te na zaista vrijednim sugestijama koje su ovu knjigu učinile znanstveno relevantnijom. Također, zahvalna sam i recenzentu dr. Robertu Skenderoviću, prije svega na vrlo inspirativnim razgovorima vezanima uz povijest javnoga zdravstva u 18. stoljeću. Pritom, napominjem da se eventualne pogreške u tekstu knjige mogu pripisati isključivo meni. Lektorica Jasmina Sočo zaslužna je za čitljivost teksta, osobito prijevoda sa njemačkog i latinskog jezika koji se na prvi pogled u današnjem vremenu mogu učiniti anakronima. Moju zahvalnost zaslužuje i doc. dr. Mirela Krešić s Pravnoga fakulteta Sveučilišta u Zagrebu na vrijednim sugestijama vezanim uz pravni kontekst tema obuhvaćenih ovom knjigom. Napokon, svaki znanstvenik će znati da rezultata znanstvenoga rada ne bi bilo bez ogromne podrške obitelji. Zato, velika hvala Branku i Ines, koji su – svaki na svoj način – vrlo strpljivo podnosili moju znanstvenu znatiželju. Posebna hvala i mojim roditeljima, Vesni i Ivanu, na nevjerojatno nesebičnoj podršci mojem izboru karijere i na posveti svojega, zasluženo slobodnoga vremena čuvanju i odgoju unuke.
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The Health of the People – The Wealth of the State Enlightened Absolutism and Beginnings of the Public Health Care System in Croatia - Summary Today, it is quite customary to consider that regulation of the public health care system for the sake of preserving the population’s health falls into the domain of the state – indeed, it is held that the state must have the crucial role in shaping and implementing public health care policy. Nevertheless, awareness of this important role of the state was slow to develop. Political, economic and social processes in the 18th century, especially in its second half coinciding with the period of enlightened absolutism, represent a watershed for the Habsburg Monarchy and in that sense for Croatia. During this period, foundations were laid for a public health care system which, since that time, became exclusively a political issue (politicum) and an object of the state’s field of interest. Croatian lands under Habsburg rule – the Croatian-Slavonian Kingdom and the Croatian-Slavonian Military Frontier – represented a special case in this respect. On the one hand, located on the fringes of the Habsburg Monarchy, they had a peripheral position with respect to current trends in the institutional approach to the public health care system. On the other hand, their very location on the fringes of Christian Europe raised the issue of the public health care system – specifically, the issue of antiepidemic protection - as an important political and social issue. This was an area where, at the time of enlightened absolutism, tradition and reform strongly overlapped, as well as enlightened ideas and efficiency of customs. This clearly reflected on the process of creating a public health care system – irrespective of the fact that, in the 18th century, this system still seemed to be outdated and inadequate – nevertheless, it laid foundations from which its modern versions developed. 343
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The process of the state’s control over public health care in the 18th century took place at several equally important levels. In the first place, a network of institutions was set up dedicated to the care for health, which, in addition to its clear hierarchical responsibility, was subordinated to the executive power of Habsburg rulers and exempt from the sphere of influence of the then still powerful Estates. Among the most influential ones, one can highlight the Health Court Commission, a central institution in charge of the public health care system, as well as a system of regional health commissions which were at the same time components of the local executive power. A sanitary cordon was established on the eastern borders of the Habsburg Monarchy in the 18th century, whose purpose was permanent anti-epidemic protection – not only of Croatian lands, but also of entire Central Europe. Furthermore, academically educated physicians and other educated medical practitioners were at this time granted the exclusive right to practice medicine. In this process, all other competing providers of health care services (clergy, quacks, midwives trained on the job, herbalists and others) were first marginalised, then criminalised. Physicians, surgeons, midwives and pharmacists turned from private professionals to public servants, in other words servants of the ruler and state, and as such subject to state regulations. Therefore, many instructions pertaining to their work, regulations of their work methods, as well as many provisions related to their obligations, rights and social status can be found in the second half of the 18th century. A third very important level is a significant development of possibilities and quality of education for persons providing some form of medical services. The School of Medicine at the University of Vienna assumed at the time the central role in providing a model of education for physicians and other medical practitioners. Through a number of reforms, the School developed into a referral centre not only for the territory of the Monarchy but for the region as well. All other schools of medicine in the Monarchy were reformed after this model. This academic network was supplemented by other institutions of higher learning, the most significant among them being the Academy of Medico-Surgery Josephinum in Vienna, as well as numerous training centres at the local level. The most significant development in the public health care system was that expansion of the network of medical educational institutions was accompanied by the state’s and the general public’s awareness that treatment required quality. In the second half of the 18th century, education thus became 344
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a conditio sine qua non for medical practice – which may have had the decisive influence on the improvement of medical services and the further professionalization of medical professions. Finally, the greater mobility of medical personnel in the region, the higher level of their education and the strong involvement of the state in the public health care system resulted in a more dynamic flow of new ideas in medicine, social medicine and scientific achievements, and an atmosphere of progress ensured that these ideas and achievements were better accepted both by the general public and by professional personnel. As to the motives for the state’s involvement in the public health care system, they too cannot be reduced to one denominator: a number of motives are behind the state’s involvement and it was only an interaction of different circumstances and initiatives that brought about more decisive reforms. Several motives should be mentioned here that, in my view, significantly prompted Habsburg rulers to place the state apparatus in the service of public health care. As historiography regularly and justifiably emphasised, epidemics of plague and other infectious diseases were a strong incentive for the involvement of state institutions. In the late Middle Ages and the early Modern Era, Europe was often affected by epidemics, which were especially frequent in the area of the Ottoman Empire from where - as a result of trade and circulation of people – they reached the Monarchy’s territory, the Military Frontier and the Croatian-Slavonian Kingdom more easily. These epidemics took a huge toll on human life and left behind an economically and demographically devastated area and a population with significantly diminished survival abilities and a lesser quality of life. The fight against epidemics and their consequences was a reason why the state initially got involved in public health care issues: throughout the early Modern Era, and particularly in the early 18th century, Habsburg rulers systematically developed a sanitary cordon along the entire border with the Ottoman Empire, from the Carpathians to the Adriatic Sea. Therefore, the system of fighting epidemics was at the same time the first one developed in public health care in the area under Habsburg political influence. It was largely implemented in the area of the Military Frontier and the Croatian-Slavonian Kingdom. The second important factor is primarily economic in nature. Under the strong influence of contemporary economic policy ideas – the ideas of theoreticians of cameralism were especially important in the Habsburg Monarchy – awareness developed on the economic significance of each 345
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individual’s productive power. In the territory devastated by incessant wars with the Ottoman Empire and heavily depopulated after the military victory over the Ottomans in the late 17th century and its annexation to the Habsburg Monarchy, Habsburg rule could be consolidated only by means of economic recovery. In addition to continuous projects of organised settlement of insufficiently populated regions and projects of incentives to local economies, the good health of the population played an important role. The Court in Vienna realised then that only with healthy, productive subjects who would not be a burden to the community could it be expected that they would be capable of providing for themselves and their families and, once included in the fiscal system, contribute to the state treasury and thus to the wealth of the state. Furthermore, ideas of the Enlightenment became an important factor in formulating Habsburg home policy since the 1760s – in the very period when significant progress was achieved in the development of the public health care system. Through their eudaemonistic approach, Enlightenment thinkers in the Monarchy turned the attention of rulers and political centres of power in Vienna to the social role of the state promoting order and rationality in the state administration. Participation of the ruler and his institutions in regulating major social systems, such as education or public health care, was, under the influence of Enlightenment ideas defined not only as a right but also a duty of the ruler and state. The ruler was thus placed in the position of rational protector of the Monarchy’s population and, deeming himself responsible before God for the state of his population, was, in the eyes of the intellectual public of the time, obliged to implement reforms aimed at preserving and raising that state. For this reason, in her decrees on public health Maria Theresa emphasised that they were adopted “out of her motherly care”. Finally, it goes without saying that without the development of medical sciences there would be no state incentives in the field of public health and no possibility for society to accept reforms. In the history of science – including history of medicine – the 17th century was an important turning point. Principles that were generally accepted hitherto began to be re-visited, particularly under the influence of English, French and Dutch scientists, and methods of induction gained prominence among science and research methods. With this tendency continuing into the 18th century, people of the time witnessed many innovations in medicine, the beginnings of the clinical medicine as well as a growing awareness of the 346
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importance of case history. Writing, printing and distributing specialist literature was on a steady rise at the time, and many distinguished physicians played a prominent role in shaping the ruler’s and public servants’ views having a direct impact on public health legislation. Gerard van Swieten, a professor from Leiden and personal physician of Maria Theresa, was an individual who exerted greatest influence in this field of science reform in the Habsburg Monarchy. There were several distinguished physicians and scientists who were publicly active in Croatian lands leaving a profound imprint on the enlightenment of the population in health care issues – John the Baptist Lalangue, a disciple of van Swieten and county physician of the Varaždin County among others. Croatian aristocrat Count Adam Oršić (1748-1820) wrote in his memoirs: “During my lifetime, medicine has undergone drastic changes”. Thereby, he recognised that development of medicine and activities of physiciansscientists in the public truly managed to leave an impression of medical sciences’ progress even on the non-professional public. There would have been no involvement of the state in public health care system, had it not been for the ruler’s capability to implement initiated reforms. In this context, the development of the state played a key role – this process unfolded in Europe throughout the early Modern Age and reached its peak in the Habsburg Monarchy in the 18th century. During the process, prerequisites for the implementation of reforms were created. This primarily referred to the formation of a proto-modern administration and an institutional network as a framework for public action: during the early Modern Age, and in particular during the 18th century, an entire network of executive and economic institutions was created enabling the implementation of reforms initiated by the Court in Vienna, as well as those initiated by local communities. Thus, in addition to the system of the ruler’s executive power that almost exclusively dealt with fiscal issues in the 18th century, a number of institutions emerged exerting influence on economic and social developments. The area of the Croatian-Slavonian Kingdom was not exempt and this differentiation of public administration occurred especially after the establishment of the Royal Council in the Kingdoms of Dalmatia, Croatia and Slavonia (or the Croatian Royal Council) in 1767. A Health Commission was its separate part, linked with central institutions in Vienna. Moreover, a major prerequisite for the implementation of reforms was ensuring funds for the public engagement of the state and for a 347
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system of institutions in charge of implementation of reforms. This was achieved primarily by introducing a permanent tax (Kontribution) which, unlike former subsidies (Subsidien) collected during war, enabled a planned inflow of revenues into the ruler’s treasury. The treasury became the main state exchequer that, in the second half of the century, provided regular funding for a system which could not be sustained by revenues of local organisations (districts or counties). Such a development encouraged the involvement of traditional administrative bodies of the Estates in a system controlled by the state or, if this was impossible, their marginalisation. It is important to note that the Estates, the traditional corps intermédiaires, were, in the course of this process, not eliminated from performing administrative tasks, since traditional social structures provided a necessary framework for the state’s incentives at the local level. Therefore, central authorities encouraged the participation of the local administration, but simultaneously introduced strict control of its operations. For the public health care system in the Croatian-Slavonian Kingdom, this specifically meant that resolution of public health care issues was now a task of a collegial body of the executive power rather than the Croatian-Slavonian Diet. Until 1779, this executive body was the Croatian Royal Council and afterwards the Hungarian Vice-Regency Council. Policy on the public health care system transformed from an ad hoc model of addressing pressing issues and individual problems to a model of implementation of a clear public health care policy and establishment of firm legislative foundations in this field. *** The central theme of this book is the creation of a state public health care system in Croatian lands under Habsburg rule, specifically in the Croatian-Slavonian Kingdom and the Military Frontier in the 18th century, and particularly in its second half. I examine the theme primarily through the prism of the function of the state and public administration in the age of enlightened absolutism, understanding that state concern for the functioning of a public health care system was part of a broader process of state establishment as we know it today. The focus of my research is on public health care regulations, laws and other regulations, which refer to a broad range of affairs linked to the state’s health care policy. While analysing these legislative and public acts, I attempted to ascertain 348
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motives for their drafting, the influence of individual public servants and officials on their contents, the mode of their implementation and – sources permitting – their effect. I attempted to view these enactments not merely as a fait accompli but also as regulatory guidelines often clashing with the reality in the territory in which they were supposed to be implemented. For this reason, based on archival sources, correspondence, travel books and other contemporary writings, I attempted to find elements pointing to the feasibility or unfeasibility of implementation of individual provisions and define the basic factors of success of reforms in the field of public health care. The 1770 General Norm in Health Care Issues – the basic piece of legislation regulating the public health care system in the Hungarian part of the Habsburg Monarchy which exerted considerable influence on designing a stable, proto-modern system of public health care, as well as on all future regulations – is the focus of this analysis. The Norm was, in some parts, drafted on the basis of earlier pieces of legislation and for the first time regulated two major fields of public health care in the Monarchy. On the one hand, the Norm provided for responsibilities, means of admission and qualifications of all physicians, surgeons, pharmacists and midwives serving in the territory of the Monarchy and especially those who were paid from the public budget. On the other hand, the Norm clearly regulated operations of the sanitary cordon system on the border with the Ottoman Empire. The management and personnel of quarantine stations on the border were provided with detailed instructions as to the procedure required during quarantine for people and goods entering the Monarchy from Ottoman areas. Given its importance and the fact that the Norm laid foundations for future legislation on the public health care system, the Norm is published here in its integral version, for the first time in its Croatian translation. In addition to the Norm which was most influential in the establishment of the public health care system in Croatia, I also recognised a Supplement to the General Norm in Health Care Issues from 1773 (implemented in Hungarian lands in 1778), as well as two instructions for county physicians and surgeons from 1785 and 1787 respectively, all published here in their Croatian translations. All these enactments were primarily administrative rather than medical handbooks and the objective of their adoption was to establish a formal framework for the functioning of the public health care system. Since the enactments in themselves do not reveal a great deal if taken out 349
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of the context of the circumstances in which they emerged and conditions in which they were implemented, the purpose of the book is to provide and explain the context of their adoption and implementation. To this end, Chapter 1 of the book, Protagonists of Public Health Care Policy: State and Theoreticians of State, presents ideas underlying the emergence of a state structure, which are essential for understanding the role of the state in the period of enlightened absolutism, as well as theoretical foundations underlying the involvement of state institutions in the public health care domain. Importance is attached to theoreticians of cameralism – in Austria, particularly to Johann Heinrich Gottlob von Justi (1717-1771) and Joseph von Sonnenfels (1732-1817), who distinguished themselves as agile promoters of the view that the state’s care for the good health of its population is at the same time an investment in its own resources. Considering that both of these cameralists were very close to circles and political decision-making centres in Vienna, the conclusion is that their ideas were regularly reflected in formal provisions in public health care legislation. Chapter 2, The Institutional and Legislative Framework of the Public Health Care System, presents the institutional system of the Habsburg Monarchy and particularly the institutional system in Croatian lands, which played a crucial role in the implementation of public health care measures. In addition to presenting the necessary framework in which this institutional system developed, the analysis focuses mostly on the development of institutions specialised in public health care. Four basic stages in the development of public health care institutions are defined. The first stage is the development of permanent anti-epidemic protection as part of the model of the primarily preventive policy of approach to public health care. This was followed by the development of institutions and hiring of medical experts in public health care administration, on which the entire system would rely in the final stage of the institutional development of the public health care system. A Station on the Way to Christian Europe: The Sanitary Cordon covers the process of emergence and organisation of the sanitary cordon on the border with the Ottoman Empire – institution which was of great importance in anti-epidemic protection both of Croatian lands and the entire Habsburg Monarchy. As a follow up to Chapter 2, this chapter analyses the organisation of the sanitary cordon in detail. The quarantine station as the basic health care station of the cordon is examined as an 350
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important aspect of state administration over public health care and an important factor in the every-day life of individuals in transit (mainly merchants) or those who lived nearby. Although during the 18th and up to the mid 19th century, the cordon was often an object of criticism for its cumbersome organisation and high costs and as a major impediment to trade between the Habsburg Monarchy and the Ottoman Empire, it is concluded that the cordon accomplished an important function of necessary compromise between public health care requirements and the economy and that, in the end, its operations largely contributed to curbing plague epidemics in Central Europe of the time. The following chapter, Medical Education: Continuity and Reform, is devoted to opportunities for medical education in the Habsburg Monarchy. The development of an educational system for those who wanted – and in the end were allowed to – to practice medicine in the Monarchy is in my view an important factor for the development of the public health care system, primarily since the quality of treatment was defined as imperative, and practitioners who were not skilled were ever less tolerated. The analysis focuses on the School of Medicine at the University of Vienna which was reformed in the mid 18th century, when it became a referral centre for studying medical sciences not only in the Habsburg Monarchy, but also in the broader area of Central Europe. Reorganisation of studies, introduction of practical training and above all strict control by state institutions and a strong feeling of responsibility of the School’s staff established a system which was then applied to other medical schools of the Monarchy, and academic education became systematic and mandatory for all who aspired to a legal medical practice. In the context of reorganising higher education, special attention was paid to the establishment of new chairs – for instance, a chair in obstetrics or veterinary medicine – and their influence on the education of physicians, surgeons and midwives who later worked at the local level. Furthermore, an important landmark in medical training was the establishment of higher schools of surgery, whose matching organisation at the time showed a tendency towards equalling the academic title of surgeon to that of doctor of medicine – among which the Academy of Medico-Surgery Josephinum in Vienna should be highlighted. The chapter Physicians, Surgeons, Pharmacists and Midwives in the Service of the Public presents and analyses individual (traditional) types of medical practitioners. Traditional conventions in their work are 351
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juxtaposed to new conditions defined by the state and new public health care legislation, and it is questioned to what extent existing medical practitioners, in particular in Croatian lands, were prepared to conform to new conditions. Especially emphasised is the importance of their education and quality training for performing their service. Their status as public servants is analysed: in the context of their public obligations and rights, the status of their professions is compared to the general trends in the development of public services of the time. The chapter further examines to what extent the practices in use in the area of the Monarchy could be applied to Croatian circumstances. Greater mobility of medical personnel in the region, their higher level of education and considerable involvement of the state in public health care and disease prevention contributed to – both directly through a targeted involvement of state institutions and indirectly – to a more dynamic flow of new medical ideas and scientific achievements, and an atmosphere of progress ensured better acceptance of these ideas and achievements by the general public and professional personnel. The final two chapters cover in more detail public health measures implemented by public institutions and public servants, necessarily in interaction with the population. Chapter 7 covers hospitals in the broader sense of the word – hospitals, xenodochia, almshouses and sanatoria, as well as other institutions intended primarily for the poor and only then for the sick. To what extent this was possible based on available material, the situation of these institutions in the Croatian lands under Habsburg rule is presented, with an emphasis on the financial component of their maintenance. In the context of the development of hospitals, emphasis is placed on the importance of “medicalisation” of hospitals and development of clinical hospitals linked to academic education. These were primarily hospitals associated with the University of Vienna and Trnava/Budapest, which exerted strong influence on the organisation and work of the first modern hospitals in Croatia which were founded in the following decades. The final chapter entitled The Concept of “Medical Police” deals with two major aspects of the role of public institutions in preserving the health of the population. One of them is the introduction of medical topography and statistics, which emerged as a result of the obligation of sending regular medical reports by public surgeons, physicians and health commissions, as well as based on a number of enquiries by central authorities about the current status of 352
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health and health protection on the field. The second aspect returns once again to the theoretical approach based on the ideas of Cameralism and Enlightenment. These are primarily ideas on the realisation and concepts of the so-called medical police propagated in Austria by authors such as Justi, Sonnenfels or Johann Peter Frank (1745-1821). Their ideas were found in many provisions enacted by Habsburg rulers in the late 18th century – especially by Joseph II. An important aspect of the success of public health care reforms by the end of the century was public awareness with the view to, on the one hand, promote preventive measures against diseases and, on the other, increase the general public’s awareness on the importance (and irreplaceability) of quality medical care provided by educated medical practitioners in the public service. Enlightenment, with its zeal for learning and faith in progress, and enlightened absolutism giving opportunities for implementing ideas of the Enlightenment were, in my view, the key factors in the initial development of the public health care system in this area, which during the second half of the 18th century, given the strong involvement of rulers and intellectual public, acquired the outlines of a proto-modern state system. The process of medicalisation set in, and the Habsburg Monarchy of enlightened absolutism was a true “medical empire”, based on a rational order in the public health care system. The development of the public health care system in the Habsburg Monarchy kept pace with time and many regulations were at the same time innovations and became models. Considering that as late as the mid 18th century, there was no mention of any form of state public health care system in the Monarchy (except for preventive measures at the border), and that in the 1770s there was an already “established” system, such an undertaking can be deemed extraordinary. On the other hand, considering the continuing problem that monarchies in the early Modern Age had with implementing provisions at the local level where, traditionally, political structures of the estates were much stronger, it should be emphasised that the public health care system was successfully implemented in all lands of the Monarchy almost parallely to the system established in Vienna as the centre of political power: in Vienna, a model was established which, in just a few years, was implemented elsewhere. The issue of the population’s health was indeed understood as a public issue, and regulation of public health care was understood as exclusively positive and useful. To be sure, there were differences in the way how individual provisions were accepted. 353
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The mere pace of their adoption as well as persistence in their repetition demonstrate that the Court in Vienna had high expectations but they did not everywhere fall on fertile ground. This is especially noticeable in the Croatian-Slavonian Kingdom, which was politically and socially still stronger oriented towards traditional links. Changes were difficult to take hold here – due to financial and social circumstances which were quite different from those in the place where the provisions were adopted but also, very often, due to inertia of social structures, which, in this dynamic period of history, often demonstrated only poor abilities for quick adjustment. This, however, did not mean that reforms failed: reforms in public health care system were fully adopted here as well, however they lagged behind in time for a transitional period which was necessary for the changes to be perceived not only as useful but also necessary. Enlightened absolutism in the Habsburg Monarchy positioned the state as the main protagonist in the development of the public health care system, and the enlightened ruler accepted the role. Therefore, since that time, it is possible to speak of a state public health care system which – more or less successful – has been further developed to this day. Let us conclude with the appropriate words of Johann Peter Frank, author of “A System of Complete Medical Police” who, believing that his work would be either completely useless or always useful for all people, expressed the following view: “I hold that, admittedly, interests of the state change from century to century depending on the changing circumstances of their neighbours and the course of time. However, the foundations of health and the steadfastness of citizens, their longevity and their healthy reproduction will never be liable to changes.”
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