Ireland's only serious political magazine Monday - Nov 24, 2014

How Ireland got the CRC and exclusive private hospitals The long evolution of our impersonal, centrally-organised, eccentrically-run, consultant-deferential, selfish, non-rights-based regimes for poverty and then health


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By Caroline Hurley.

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Former CRC board members

Poor laws come from Poor Laws.

The English Poor Laws date from the fourteenth century and, though regularly modified, were not fully repealed until 1967.  They mark the beginning of the impersonal, centrally-organised approach to deprivation carried forward to health that is still characteristic, in England – and in Ireland, where universal state-funded healthcare never acquired ascendancy.

Their effects have been far-reaching, though they were more imitated than implemented in Ireland until the 1830s. Charitable institutions, such as leper houses, established in the Middle Ages, had closed along with Henry VIII’s dissolution of monasteries. Little heed was paid to encouragement of local charity until Edward imposed Sunday alms collections from 1551, on pain of the bishop’s admonishment. This “moral suasion” produced such lacklustre results that an act was passed to fine shirkers in the courts. A paupers’ register came with the establishment of an official poor fund; housing was addressed later. Work was arranged for unoccupied adults and children of improvident parents. Relief was supplied to the lame, impotent, blind, and those unable to work. The Undeserving Poor, otherwise known as idle or sturdy beggars, considered able but unwilling to work, were to be whipped through the streets until they repented and mended their ways.

As workhouses were operated voluntarily, local enforcement was haphazard. In 1572, a poor tax to assist the deserving poor was made compulsory. In 1597, every district had to install an Overseer of the Poor,  with the task of calculating and setting the poor rate required to provide for the district’s poor, of collecting and dispensing the rate, and of supervising the parish poor house. The Poor Law passed by an Elizabethan Parliament in 1601 bound together into one legal document these measures. The New Poor Law of 1834 introduced the new administrative unit of the Poor Law ‘Union’ in order to enforce a rigorously and centrally-enforced standard system based around the workhouse. Many commentators agreed that the most significant repercussion of this new philanthropy was how the poor came to be dehumanised, and regarded as inferior and, therefore, the proper object of punishment and control. Suspicion of fault and responsibility replaced the Christian outlook of tolerance and personal charity towards accidents of fortune. Riots didn’t prevent these attitudes hardening, as ideologies associated with moral philosophy were exchanged for those of political economy – that the right response to hunger was labour and not easy alms. Malthus especially blamed poverty on the Poor Laws themselves, as Wilde did, though their conclusions differed. Others faulted factors such as higher prices, and resource and industry declines, for piling misery on misery. Diverse reform proposals never ceased.

Still, this nationwide system did form a welfare safety-net throughout England and Wales. Expenditure on poverty relief, at least until the 1830s, exceeded that of other European countries where the norm was informal assistance and charity, often in the form of domiciliary help bestowed by voluntary agencies and civic-minded visitors, overseen by inspectors of relief. The marked failure of voluntary aid in England directly influenced the mandatory nature of poor laws there – the lack of resources required indoor relief in workhouses to prevent imposture and the avoidance of large numbers of professional staff. Constructing and maintaining workhouses devoured money that might otherwise have been available for individual hand-outs.

In contrast, in Ireland a quasi-feudal system based on landowner patronage of deferential tenants had held sway.  Tacked  on to this  – with the occupying UK government’s civil initiatives – were medieval mores. Up through the eighteenth and nineteenth centuries, nearly all Irish people were of small-tenant-farmer stock, subsisting on large estates mainly owned by English or Anglo-Irish landlords who’d been granted property after armed conquest. Landowners ideally doubled as magistrates or justices of the peace to adjudicate on local issues, act as welfare buffers for the community, represent tenants in parliament and provide education for their children. However, antagonism – sustained due to religious difference and a hangover of bitter disenfranchisement about land confiscated from tenants’ ancestors – fed a vicious circle of absenteeism and mismanagement.

In reality, large landowners rarely rented directly to any of the many small tenants inhabiting the land they received, but would let large areas to middlemen. Several further sublettings down to the smallest unit meant that many transactions went undocumented with little or no right of tenure. Low-paid duty-work for the landlord prevented tenants from tilling their own plots properly which, along with exorbitant rents, left Irish cottagers in more desperate need of subsidisation than any other Europeans.

Central government responded to a rash of agrarian revolt in mid-1780s Ireland by trying to compel landlords to do their duty. Formal structuring of policing, schooling and judicial procedures was instigated, although land-owning magistrates still preferred invoking the Insurrections Acts. Catholics eschewed Protestant-run education, preferring illegal hedge-school classes. Crippling poverty was universally identified as the fundamental Irish problem. After the first Irish workhouse opened, in Belfast in 1756, seven further urban ‘houses of industry’ appeared as if inspired by the single motive to institutionalise away the misery. Poverty as a result of sickness drew more sympathy than the other way round.

Following legislation, thirty-nine county infirmaries and dispensaries were opened around Ireland between 1765 and 1841, each staffed by a qualified surgeon. The hands-off approach of hoping local magistrates would deal with outbreaks of famine and fever left already disadvantaged areas even worse off. The timid, advisory General Board of Health set up in 1820, eventually geared into action after the cholera epidemic of 1832 that claimed 19,000 lives, and framed the Government’s more interventionist response to the crisis. Despite evidence of the failure of the Poor Laws in England, the pressure to do something, other than dispatch ineffectual medical experts, led to the enactment of Irish poor laws. Swift appointments of regimental commissioners and the erections of workhouses soon left relief distribution to unsalaried local guardians. The associated rate-levying was pounced on as a possible workable model for a public health system but the perceived cruelty of the Poor Law machine argued against the idea.

However, the re-assembled General Board Of Health saw no option for the efficient delivery of medical relief to the poor from 1847 than close collaboration with the Poor Law system, with its workhouse infirmaries and fever rooms. By the time the Board stepped away again, the overlap was becoming ingrained. Opened to paying patients from 1862, they were often the only services available, especially in provincial areas. Remaining county infirmaries were subsumed by the Poor Law boards in 1898. A workhouse once operated on the site of one of Dublin’s major modern general hospitals, St  James, for example. The Poor Law Commission became the Local Government Board in 1872, one of many examples in Irish oversight of the assimilation of ad hoc administrative solutions, as power leaked little by little from the landlord ascendancy class towards the Irish working classes.

The collection of essays, Medicine, Disease and the State in Ireland 1650-1940 edited by Greta Jones and Elizabeth Malcolm, is an informative resource on these topics. The original names of many general medical hospitals recall their first services to the lowest of the low: termed incurables, wretches, indigents and the infirm. This labelling obviously contributed to demoralisation and abuses: it’s a human habit to conform to official status. By 1735, there were three voluntary hospitals in Ireland encountering huge demand. Private citizens primarily took the initiative to provide such services, usually doctors with some university training, such as Oscar Wilde’s father, William. An ear specialist whose texts are still studied today, his numerous roles reveal a profession trading on contradictory foundations. In place of payment from his impoverished patients, he accepted descriptions of superstitions and folk cures which he recorded and compiled.

This was the milieu for medicine: up to the twentieth century, the best doctors were skilled in bleeding, blistering, cupping, purging and leeching procedures, done whatever the patient complained of at appointment. Not only did these administrations not work, but they often proved positively injurious. It has been observed that exposure to doctors’ methods goes a long way to explaining why a much greater proportion of wealthy victims of typhus fever died in the late part of the nineteenth century  ̶  the poor couldn’t afford medical attention. Apothecaries made up mixtures of herbs and drugs with little or no regulation, as did midwives, whose field of work most doctors considered too demeaning to concern themselves with, though they did co-operate with faith-healing priests. Surgeons still belonged to the guild of barbers.

Doctors generally had the means, the family connections and the education, to make their voices heard over the competition when demanding exclusive authority to treat the sick and, thereby, to avail more of their custom. They largely defined the future of medicine in Ireland in the ‘heroic’ tradition. Another force to be reckoned with was the Sisters of Mercy order of nuns, who set up St. Vincent’s Hospital, the first of several Catholic ventures, in 1834 at a time when Protestants dominated the boards and medical staff of the other voluntary hospitals. These boards secured parliamentary grants and could prove equally sectarian in deciding which patients to admit. The workhouse hospitals were also becoming important public health centres for the educational resources conveniently gathered there. One 1854 report on Dublin’s hospitals queried whether or not medical training was the end rather than the by-product of maintaining these services.

Ever-higher productivity spikes fuelled by the industrial revolution seemed to double living standards with each generation. Notwithstanding frequent steps backwards, growing knowledge of sanitation and cheap cures sustained health gains.

The Poor Laws had originally omitted any obligation on Unions to provide medical care. However, when the number of smallpox cases, which had dipped in the 1850s, flared twenty years later to 3,000 deaths, customary indifference to disease had to go. While Irish medical men had long frowned on the Poor Laws as an English trick executed by power-hungry commissioners to take over independent medical charities, the one hundred and thirty union workhouses were chosen as the locations for vaccination stations. The scheme stalled and lapsed due to social stigma and haggling over medical fees until reform legislation in 1851 imposing central standards also brought hospitals and dispensaries under the Poor Law. The urgency to provide more treatment stations and guarantee doctors’ fees was covered by a further law in 1858, after which demand for vaccination rocketed. The scheme was made compulsory in 1863.

The baffling truth that tuberculosis was the leading cause of death in nineteenth-century Ireland attracted far less attention until after Koch discovered the guilty culprit, bacilli, in 1882. It accounted for 16% of all Irish deaths in 1904. Even though the disease’s headcount was on the wane combatted by better environmental living conditions, renewed public campaigns for services and education followed the science.

Special sanatoria, dispensaries and notification protocols were put in place, but people resisted compulsory registration and resented the intrusion of professionals into private behaviour. They felt taken advantage of by a canny medical cadre ambitious to politically stamp their marks by overseeing the personal policing of the poor instead of whipping up outrage about their glaring chronic lack of social justice and doing something about that. It was, as Member of Parliament Thomas Kettle astutely commented, less medical and more socio-economic conditions that needed to be improved – for disease prevention. The 1911 National Insurance Act provided for inspectors, capital and privately-subsidised care, even as an astonishing 79% of tuberculosis patients pined away in the workhouses.

Since the Great Famine, nuns had had a significant influence on reshaping Irish society through the infrastructure they developed and fronted in the forms of schools, hostels and a wide range of other charitable services. Except for tending males and births, which was prohibited, they supplied the cheap and biddable labour in hospitals. Their training was something of a mystery: being good women seemed sufficient warrant of experience and ability. Deficiencies in their care, such as wards full of dependent patients deserted by evening-time, were glossed over. Whatever otherworldly qualities they possessed, they liked control well enough to secure the best jobs, often as matrons in charge. They were even allowed to carry out certain medical procedures, and deferred only to male doctors. From the 1900s nurse-training reform couldn’t be put off any longer. Women, overwhelmingly, started choosing the job not necessarily as a vocation but as a way to earn a relatively safe living in hard times.

Poor Law reform began in earnest in 1920 as Irish independence was being won. The whole country-wide scheme, with its imperial imprint, would have been closed down under central order except for local protests against the rationalisation of hospital services. Instead they were reorganised on a county basis, each with one workhouse hospital in best repair, to be retained as the district hospital. Completion of the new underfunded system dragged on through the 1930s even as demand rose due in part to advances in medical treatment and technology. Massive injections of funds from the new horse-racing sweepstakes kept services afloat, albeit if, as concerned politicians noted, in a haphazard (indeed corrupt) way, such that future needs of communities relying on small hospitals was often imperilled. The Board of Assistance, which succeeded Poor Law administration, obliged hospitals to allocate a quarter of their beds to treat the poor but although voluntary hospitals consistently received two-thirds of the monies, they continued to discourage non-paying patient stays.

Catholic bishops called for the preservation of the independence of hospitals under their patronage, now part-funded by their own sweepstakes as well by as the Exchequer, to set their own terms. Some of their demands hampered the expansion of social services such as medical inspection of schoolchildren and provision of more public general beds. The impact was notoriously demonstrated by the resignation in 1951 of the then Minister for Health, Dr Noel Browne, who met with fierce opposition from the Church and doctors closing rank, for proposing the Mother and Child Scheme. These religious limitations retarded progress, especially for women, as much as any other socio-economic conditions such as poor housing.

Already mentioned for his instrumental role in setting up the Irish workhouses, which were the first public-funded services, Dean Richard Woodward compiled in two pamphlets reasons to introduce the Poor Law system to Ireland. Woodward’s grasp of the dynamics of poverty as a function of society was classic, regardless of the parsimonious solutions proposed. Securing permanent funding would prove straitening for governors, but even they resisted a tax on the rich because, after all, “the dispensation results from courtesy, not right”. The first pamphlet outlined A scheme for establishing county poor-houses, in the Kingdom of Ireland, and was published by order of the Dublin Society. The second, An Argument In Support of the Right of the Poor in the Kingdom of Ireland to a National Provision, with its persuasions of the affluent to support the poor, still resonates “by what right did they take upon them to enact certain laws (for the rich comprise the legislative body in every civilised country) which compelled that man to become a member of their society; which precluded him from any share in the land where he was born, any use of its spontaneous traits or any dominion of the beasts of the field, on pain of stripes, imprisonment or Death? How can they justify their exclusive property in the common heritage of mankind, unless they consent in return to provide for the subsistence of the poor, who were excluded from the common rights by the law of the rich to which they were never parties?”.

1768: that’s when he wrote what looks – since there was no chance anyone would do anything about it – suspiciously like an astute articulation of a chronic defence mechanism nursed by the privileged to assuage guilt. Hannah Arendt believed that evil is greatest when human beings are made to engage in senseless motions that render their words and actions superfluous. This ties in with the acceptance of authority that goes with the twentieth century’s embrace of increasingly extreme divisions of labour whereby, according to Wendell Berry, “one does not think to improve oneself by becoming better at what one is doing or by assuming some measure of public responsibility in order to improve local conditions: one thinks to improve oneself…by ‘moving up’ to a ‘place of higher consideration’”. Social experts of the past fifty years have narrated a hegemonic neo-liberal Darwinian prescription for our lives that elevates selfish behaviour and personal exertion in the market above political debate and participation.

Eminent research by Dahlgren and Whitehead into the effects of inequality identified determinants of health beyond the narrow standard focus on age, sex, hereditary and individual lifestyle factors. An individual’s social and community situation, living and working conditions, and socio-economic culture, were also heavily implicated. Alleviating distress then becomes a multi-agency matter addressing relevant risks such as poverty with all its inherent deprivations.

Individuals are often blamed now, without factoring in broader influences, for their own misfortunes, to be patched up with drugs, parenting instruction, brief therapies for positive thinking and self-correction, and jail. Not only is happiness out of reach but unhappiness is unaffordable too. Dan Hind examines the widespread malaise in his book, The Return of the Public: Democracy, Power and the Case for Media Reform. As inequality stretches social distance, citizens who dislike feeling excluded from the advantages of higher status may withdraw in humiliation, in ‘social disparagement’ from the pretence of shared moral responsibility. Those aggrieved fall back on their own private devices and distracting fictions, stripped of public respect by an economic system that needs ever fewer employees on less pay. Resistance endangers careers policed by those in control of the terms of debate and systems of description. Chances to develop collective responses to structural problems shrink.

If income inequality and competitive individualism harm health, research now clearly shows that people flourish wherever ‘social capital’, narrower income gaps and political involvement are enjoyed. Institutional elements retained in such locations would be organic, transparent and allow autonomy  Since sentiments and attitudes are impacted by the surrounding culture they could be better informed to support the equitable distribution of goods. In Frontiers of Justice (2006), Nussbaum argued instead for a capabilities approach based on affording everyone a level of dignity to experience human functioning through organised access to a threshold list of life activities, such as bodily integrity, affiliation, participation in regulating one’s environment and respect for other species. The idea is that, no matter who anyone is, whatever their inheritance, intelligence, looks or state of mind, even animals too, they are entitled to certain inalienable essentials, comforts, opportunities and respect just because they exist.

Enforcing austerity programmes in response to the global financial crises of recent years has greatly increased hardship for those on low incomes, without similar give in the rich who are getting ever richer. This is Russell Brand ‘s  “pre-existing paradigm”. For the first time since World War II, the Red Cross is collecting and distributing food aid in Britain this winter. Soup kitchens have sprung up all around Ireland and are attended to capacity. Waiting lists for public services get longer but cutbacks continue. India did something interesting recently though, introducing a National Food Security Law that protects most of the population against price volatility by giving them a ‘Right To Food’. The proposed global Robin Hood Tax on financial transactions could also rebalance countries towards fairness. These measures turn welfare issues into questions about rights. Nussbaum – and Oscar Wilde –  would probably approve. Now that the poor have had enough of charity  ̶  “a ridiculously inadequate mode of partial restitution, or a sentimental dole, usually accompanied by some impertinent attempt on the part of the sentimentalist to tyrannise over their private lives.”

Society might recognise that the very quality of being alive deserves dignified sustenance without further justification. The overvaluing of status, luxury, productivity, talent, youth and other attributes are dead ends. The final obstacle on the Buddhist path to enlightenment is the temptation to detach into God-like isolated splendour. Verse 18 of the Taoist Te Ching warns that when it takes rules to get people to act kindly and justly instead of being able to trust them to act with natural affection from the heart, hypocrisy sets in and virtue takes flight. In 1890, Oscar Wilde reviewed a translation of a work by Taoist, Zhuang Zi, only to paraphrase its warning about dangers of two-faced good intentions from superior positions. Liberatory and decolonising movements in Latin America are amongst alternatives that offer hope as more realistic interpretations of the world on which to base constructive action. Indeed, conscious reconfiguration of rank and resources in transparent interdependence may yet avert the very collapse of life on planet earth. Jared Diamond, who wrote about this possibility in Collapse, predicted that whether or not this happens depends on willingness to reconsider core collective values, on changes in public attitudes and business practices, and on long-term planning. The quality of being alive shared by humankind depends on the collective. A progressive new order should facilitate an evener spread of goods, restored ecologies, and more health and harmony for everyone.