As governments and societies across the globe endeavour to curb the spread of the COVID-19 pandemic, the economic, political and social significance of hospital structures has likely never been more obvious. Statistics that detail hospital admission rates and chart the health of the patients within the institutions are being used as important mechanisms for gauging the health of the wider populace and the current scale of the epidemic. For all of the data and governments’ commitments to being led by the science, there has been a concurrent recognition that public health measures – of which hospitals form an important part – are a series of compromises between competing priorities. The current pandemic has also afforded a stark reminder that neither diseases, nor their healthcare responses, are experienced equally by patients.
A recently-published volume of collected essays from the INHH conference in Dubrovnik in 2015: Tracing Hospital Boundaries: Integration and Segregation in Southeastern Europe and Beyond, 1050 – 1970, explores the forces which shaped hospitals in the past and reveals that those same tensions surrounding opportunities and experiences of healthcare can be traced back across the centuries. The volume takes as its themes the concepts of integration and segregation and explores these in relation to the experiences of patients and the design and location of hospitals. Many of the essays draw on urban case studies, although Christina Vanja considers the healthcare facilities of eighteenth-century rural Germany and the treatment afforded to those with physical and mental illnesses.
The book uncovers the spatial, social and administrative divisions that were made between patients by class or race, with a vastly different standard of care provided to patient groups. Clement Masakure’s examination of hospitals in Rhodesia in the late nineteenth and early twentieth centuries reveals the intensity of debates regarding access to healthcare which pivoted around race. As he emphasises, these were complex and detailed discussions which affected patients and the nursing staff (who were drawn largely from the black, African population). The perceived danger associated with the presence and movement of Rhodesia’s Asian, ‘Coloured’ and African communities can be identified in earlier centuries in debates about the appropriate place for women in Renaissance Dubrovnik. The language of immorality or contagion was deployed in order to restrict the visibility of the city’s female population and prompted concern about households or institutions which lacked sufficient male oversight. In the same city, the foundlings (or orphans) which were accommodated in one of the city’s early hospitals faced financial hardship and, often, social ostracization. Throughout the period covered by this study, parts of society have been distinguished as particularly worthy of care or vulnerable whilst others have attracted fear, criticism or blame and these distinctions have informed healthcare policy and hospital structures directly.
Separation between patients was also often made on the basis of medical diagnosis. In the premodern period, dedicated institutions were developed to accommodate sufferers of leprosy, as explored vividly by Anna M. Peterson and Annemarie Kinzelbach. During the late nineteenth and early twentieth centuries in Italy, pellagra sufferers constituted a significant proportion of the patients within asylums. David Gentilcore and Egidio Priani consider the impact of hospital admission, treatment and discharge on patients by drawing on a rich database of patient case studies. During a similar period in Britain, the place of burn sufferers prompted reactions ranging from fear to compassion, which were used to justify separate structures and spaces for care. Jonathan Reinarz’s essay traces these debates alongside changing perceptions of burn injuries and the most effective forms of treatment which eventually necessitated the development of multi-disciplinary medical teams. In twentieth-century America, the place of chronic illness was a source of official oscillation and debate. George Weisz charts the dynamics of the economic and social forces which have shaped attitudes towards the long-term ill. The picture that emerges from the volume is of changing attitudes to illnesses and their patients: sometimes perceived as victims but at other times implicated as a drain on communal resources or a threat to their wider communities.
Hospitals locations and design have long been influenced by ideals beyond health. David Theodore examines the influence of efficiency and cleanliness which shaped the Friesen Concept Hospital, drawing on technologies of automation in order to shape the movement of objects, patients and staff within hospitals. Valentina Zivković uncovers the frequently-interwoven dynamics of charity and healthcare, tracing the issues of symbolic space and movements through what she terms the ‘sacral topography’ of premodern Kotor. The decisions regarding where to situate hospitals and how to use the internal space is often driven by considerations beyond what might be narrowly termed ‘medical’.
As a whole, these essays reveal the changing boundaries around and within ‘community’ or ‘official’ hospitals, which reflected altered purposes of the institutions. In the past, many groups had limited access to hospitals or were believed to require segregated spaces if not dedicated institutions. The language and justifications of such policies undoubtedly changed but a recognition of the vital ways in which hospitals were shaped by their political, economic and social contexts might encourage us to ask questions of our contemporary public health policies which probe at the experience of different groups within our communities and, in particular, to raise the profile of those in society whose opportunity for, and experience of, healthcare is limited.