The hygiene measures of the 19th century are usually considered as the origins of modern public health (Rosen 2015; Porter 1994; Flügel 2012). Above all, the catastrophic working conditions in the industrialized cities promoted the spread of infectious and viral diseases such as tuberculosis, cholera, or diphtheria. The expansion of sewage systems, centralised framework conditions for the food industry as well as further general hygiene regulations have brought about the far-reaching containment of many infectious and viral diseases in the 20th century. At the same time, medical institutions have emerged not only to further develop research on individual diseases, but also to advance public education and control of appropriate measures to contain the prevalent forms of disease. Since then, the specificity of public health has been the combination of medical, social, and political expertise involved in the research, development, and implementation of public health interventions. However, they have not only led to the emergence of new medical disciplines and institutions, but also revealed the importance of social movements and political action within the field of public health. In many cases, it is the political struggles in the public sphere that have led to the introduction of new medical and governmental measures. These social movements have taken very different forms over the last 200 years, both in their composition and in their political-ideological orientation. Often they are simultaneously supported by lay people and experts, connected to regressive and progressive ideologies alike, and have an impact on medical as well as political institutions. This blending of different actors, discourses and political positions concerns movements as diverse as the sanitary movement of the 19th century (Rosen 2015, p. 106 ff.; Snowden 2019, p. 184 ff.), the eugenics movement at the beginning of the 20th century (Bashford 2010; Kevles 1985), the women’s health movements (Morgen 2002), the aids activism of the 20th century or the planetary health movement of the present day (Prescott and Logan 2019). Furthermore, it is often difficult to make a clear distinction between top-down and bottom-up changes.

This special issue deals with the interplay of governmental institutions, social movements as well as political and medical discourses with regard to the social dynamics, institutional change and political conflicts within public health since the 19th century. Consequently, the issue is based on a broad concept of public health that does not limit it to state or medical institutions, but also takes into account its roots in social movements and their links to cultural, moral and political contexts. It follows on from literature dealing with the importance of social movements for the emergence and genesis of public health (Hardy 2005; La Berge 1992; Kühl 2013; Kevles 1985; Bashford 2010; Morgen 2002; Hennock 2000; Lewis 1952; Trojan 2011; Hildenbrandt 1992; Huth 2019; Brown and Zavestoski 2004; Deppe 1987; Brown and Fee 2014; Hoffman 2003). Two goals are associated with the following texts. Firstly, they provide specific insights within the history of public health by means of case studies. They use concrete institutions, movements, and discourses to show the different dynamics that the claim to public health care can take on. Secondly, the collection of texts serves to provide a further historical-sociological perspective on the transformation of public health. The texts deal with phenomena over a period of 150 years against the backdrop of very different political, social, and cultural conditions. In the overall view, they make visible how medical, political, and social priorities and problems have shifted and changed over the past two centuries. At the same time, they show the complex dynamics involved in the interplay of medical, political, and social aspects in the context of public health. In this introduction, we will give a brief historical overview of the most important developments in public health since the 19th century. We focus on the development of public health in Germany, even though they often refer to international contexts.Footnote 1 This will frame the individual contributions, each of which will deal with specific subjects through very concrete case studies.

Early forms of medical criticism can be traced back to the ancient writings of the Corpus Hippocraticum (Leven 1997, p. 17 ff.). The discursive roots of their modern forms, however, lie more than a millennium later in the Age of Enlightenment (Leanza 2017, p. 27 ff.). Here, the state institution of the “Medicinalpolicey” emerges alongside a civil societal rediscovery of dietetics. While both discourses broadly aim to maintain the health of individuals through the curation and prevention of disease, their institutional and social locations differ significantly. The “Medicinalpolicey” became a state institution in Germany in the 1770s (Möller 2005). Its explicit tasks of “propagation of the people” (“Volksvermehrung”) and “human ennoblement” (“Menschenveredlung”) (Fuhrmann 2001) through education not of the citizens but of the regents, framed the set goal of population health as a problem of governmental control (Leanza 2017, p. 76). The rediscovery of dietetics emerges in a particularly bourgeois milieu. Less institutionally bound, its discourse revolves more around a social movement that seeks to lead individuals of the lower and upper classes to the path of a healthy and good life. The former through popular enlightenment (Böning 1990), the latter through criticism of dissolute lifestyles (Frevert 1984). Dietetics is a prototypical self-technology. It speaks to individuals rather than about them and it calls for civilized self-control where the “Medicinalpolicey” relies on state guidance. These two health practices, the institutional top-down strategy of the “Medicinalpolicey” as well as the civil societal bottom-up strategy of dietetics, were largely unrelated until their indissoluble intertwining began in the 19th century (Leanza 2017, p. 97). The interweaving of these discourses leads—as the texts in this issue show with selected examples—to constant contradictions and ambivalences in the discursive formation, institutional design, and political orientation of public health.

To understand the intertwining of individual and collective health strategies from a genealogical perspective, the emergence of the category of infectious disease is of particular significance. The latter is characterised by the fact that its focus is on collective transmission and mediation processes, thus building a “bridge” between individual and population health (Leanza 2017, p. 97). Once this bridge has been built, individual and collective health, individual and collective prevention and thus ultimately the medically motivated critique of individual behaviour, social organisation and the environment encompassing both, can hardly be meaningfully separated from each other. In this sense Rudolf Virchow identifies not only the unclean environmental conditions, but first and foremost poverty and lack of education as major determinants of the investigated typhoid epidemic (Virchow 1848b). All of this while mordantly criticising the Prussian bureaucracy and the “bondage of the spirit” of the Silesians by church and aristocracy (Virchow 1848a, p. 165). Comparable arguments can be found in the similar investigations of Edwin Chadwick in England, whose “Report on The Sanitary Condition of the Labouring Population of Great Britain” (Chadwick 1842) can be seen as a model for Engels’ investigation on the situation of the working class in England (Engels 1962), as well as Max von Pettenkofer’s somewhat later studies on the spread of cholera (von Pettenkofer 1855).

In addition to the concept of infectious diseases, two other concepts emerged at a similar time that had far-reaching consequences for medical theory and practice. That of social pathology and that of hereditary diseases. As Leanza (Leanza 2017, p. 97) points out, despite all conceptual differences with the category of infectious diseases, they share their bridging position between individual and population health. Consequently, the strands of discourse surrounding them also contribute to the interweaving of top-down and bottom-up arguments and prevention strategies. In this context, the disciplines and movements of social medicine, social hygiene and later racial hygiene, which also followed Virchow, are particularly important in the German-speaking world (Gostomzyk 2018, p. 357).

In the discourse on pauperism of the early 19th century, the connection between “poverty” and “disease”, which had already been made in the late Enlightenment, became general medical knowledge (Flügel 2012, p. 87 f.). In so doing, it takes on an ambiguous character: analytically, poverty is considered as a cause of disease, but on a higher level of abstraction, poverty is seen as a disease itself. Namely, a disease of the social organism or a social pathology. It is this ambiguity in which Rudolf Virchow’s and Salomon von Neumann’s famous definitions of medicine as a social science (Neumann 1847, p. 65) and politics as medicine on a large scale (Virchow 1848a, p. 125) show their effect. Medicine in Virchow’s sense not only takes care of the individual patient, but as social medicine also has the task of combating social diseases in the form of political reforms. Social medicine as a science and the public health care it demands consequently amalgamate the traditional bottom-up strategy of dietetics with the top-down approach of the medical police by elevating the medical profession itself to the authoritative instance of social diagnostics and therapy. In this conception, the social question finds its answer through the scientifically trained advice of the medical experts.

In the second half of the 19th century, the terms social medicine (“Sozialmedizin”) and public health (“öffentliche Gesundheitspflege”) were increasingly replaced by that of social hygiene (“Sozialhygiene”). A terminological shift with consequences: Whereas Virchow had still understood his talk of public diseases (“Volkskrankheiten”) as an abstract term to designate an aggregate of sick individuals, the meaning of “Volkskrankheit” and “Volksgesundheit” in social-hygienic discourse shifts to the designation of the disease or health of a collective subject opposed to that of the separate individuals (Flügel 2012, p. 106). This changed cartography of social reality also allows for a changed assessment: if public health and individual health no longer denote the same condition on different levels of abstraction, but each designate entities of their own kind, the illness of the individual and the health of the people can come into opposition with each other. If the community is now given priority over the individual, sick individuals become threats to public health.

In the context of this debate and under the influence of statutory health insurance, which had been in existence since 1884, social hygiene became institutionally anchored in the early 20th century. In 1905, the Society for Social Medicine, Hygiene and Medical Statistics (“Gesellschaft für soziale Medizin, Hygiene und Medizinalstatistik”) was founded under the leadership of Adolf Gottstein and Alfred Grotjahn (Gostomzyk 2018, p. 358), and in 1913 Max Mosse and Gustav Tugendreich published their influential manual on the social condition of diseases as an early compendium of the social hygienic research programme (Mosse and Tugendreich 1913). In the latter, the socio-critical impetus of social hygiene is inscribed in its disciplinary self-understanding. Because socio-hygienic research draws attention to the pathogenic effects of cultural and social life, they state, it simultaneously raises a serious charge against culture and society (Mosse and Tugendreich 1913, p. 21). Alfred Grotjahn, probably the most important figure in the establishment of social hygiene in Germany (Baader 2010, p. 757), rejects the reifying talk of public health as an entity of its own kind, however maintains the shift in values outlined above.

Hereditary diseases as a central theme of eugenics enter the discursive field alongside infectious diseases and social pathologies as a further focus of social hygiene. With this step, the demand for an almost complete hygienic penetration and racist classification of social life becomes part of the public health discourse (Leanza 2017, p. 167). Mental hygiene, housing hygiene, sexual hygiene, food hygiene, industrial hygiene and school hygiene are just some of the fields the social-hygienic program aimed at especially after the First World War (Moser 2002, pp. 52–67). In this context, Alfred Grotjahn’s Social Hygiene Seminar in Berlin can be understood as a laboratory from which the theoretical tools were supplied that made the political transformation of the public health system of the Weimar Republic possible in the first place (Baader 2010, p. 768).

The enormous influence of the Grotjahn School on social hygiene goes hand in hand with the increasing significance of racial hygiene (“Rassenhygiene”). The latter owes its name, its institutional and its intellectual existence in Germany decisively to the writings and work of the economist and physician Alfred Ploetz. In 1904, he launched the influential periodical “Archiv für Rassen- und Gesellschaftsbiologie” and founded the first Society for Racial Hygiene (“Gesellschaft für Rassenhygiene”) (Weingart et al. 1992, p. 189 ff.). His primary goal was to avert a civilisation-induced reversal of the ‘survival of the fittest’ through an exuberant protection of vulnerable groups. His eugenic treatment bases the nation (“Volk”) as a reproductive community on marriage and reproductive licenses issued by doctors to prevent ‘degenerative’ and promote ennobling tendencies in the ‘hereditary material’. The individual interests of society members should be subordinated to the current and future common good in the sense of a “generative ethic” (Schallmayer 1909), so that their individual lifestyles become health- and family-oriented. Newborns are to be medically examined before they are granted a license to live by the legal means of a granted citizenship, and welfare state measures are to be abolished as hindering factors. In other words: The whole of society is to follow the regulatory agenda of a genetically arguing and racist prevention regime.

These arguments coincide with the eugenic movement in the Anglosphere, which was largely initiated by Francis Galton. Galton defined his new science of eugenics in a lecture given to the British Sociological Society of London and later published in the American Journal for Sociology as follows: “Eugenics is the science which deals with all influences that improve the inborn qualities of a race; also with those that develop them to the utmost advantage.” (Galton 1904, p. 1) Analogous to Ploetz, he assumes a counterselective effect of the Industrialization. In order to counteract this deterioration and, moreover, to achieve an improvement of the race, eugenics would first have to be established as an academic discipline, then gain general recognition and finally, “be introduced into the national conscience, like a new religion” (Galton 1904, p. 5). He adds: “[Eugenics] has, indeed, strong claims to become an orthodox religious tenet of the future, for eugenics co-operate with the workings of nature by securing that humanity shall be represented by the fittest races.” (Galton 1904, p. 5) In view of the consensus outlined above, it is not surprising that, despite the nationalist pathos of the eugenicists and racial hygienists, the first international eugenic congress was held as early as 1914. A second and a third followed in 1925 and 1932, and even as late as 1947, the first general director of the United Nations Educational Scientific and Cultural Organization (UNESCO), Julian Huxley, attributed a high degree of urgency to those projects that would improve “the average quality of human beings […] accomplished by applying the findings of truly scientific eugenics” (Huxley 1947, p. 37 f.).

Two types of arguments come to dominate the eugenic and racial-hygienic discourse which distinguish it from the social-hygienic discourse. Firstly, the meaning of the concept of health changes fundamentally. In both German-speaking and Anglo-Saxon discourses, the understanding of health is moving from the shaping of individual or collective lifestyles to the conscious shaping of the very evolutionary process that generates both individuals and collectives (Weingart et al. 1992, p. 139). The health of the individual is thus no longer measured only by its contribution to the health of the recent collective but must also satisfy the superhuman agency of the cross-generational process of evolution: it must be ‘fit’ in the ‘struggle for survival’ and ‘better’ than its preceding generations to be considered truly ‘healthy’. Secondly, especially in Germany, the concept of race (“Rasse”), in the spirit of Galton, increasingly takes on the role of a key ideological and socio-ethical concept.

The establishment of the World Health Organisation (WHO) after the Second World War led to a shift in this public health discourse (Kickbusch 2003, 2006). In its constitution ratified in 1948, the WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). Accordingly, the goal of public health care no longer lies in the treatment and therapy of already existing diseases, but in comprehensive health promotion, which is intended to prevent the future occurrence of diseases. Even though the topic of prevention was already of importance for society’s approach to health in the 18th and 19th centuries, it is now acquiring even more prominent significance (Leanza 2017). The Ottawa Charter adopted by the WHO in 1986 finally marks the transition from the “old” to the “new” public health (Petersen and Lupton 1996; Rosenbrock 2001; Baum 2016). The focus is no longer on the spread of infectious and viral diseases, but on the increase in chronic diseases such as diabetes, obesity, or cardiovascular diseases. The drastic increase of such metabolic diseases in the course of the 20th century is attributed to increased life expectancy, the expansion of the consumer industry, changed working conditions and other cultural, economic and social structural changes. At the same time, health inequalities have also increased with the intensification of other social inequalities (Hurrelmann and Richter 2009). The “new” public health focuses on measures of primary prevention, which look at the structural conditions and connections of the emergence of health problems in society as a whole. This restructuring is also a consequence of the re-evaluation of the services of the “old” public health. Although the development of medicines and vaccines in the first half of the 20th century led to a sustainable containment of many infectious and viral diseases, further decisive impulses for improving the social situation came from non-medical measures (Rosenbrock 2001).

This shift towards governance under the sign of the ever-present risk of disease in every individual has led to an immense expansion of public health action, not unlike the above mentioned penetration of society by hygienic measures: “By focusing not on individuals but on factors of risk, on statistical correlations of heterogeneous elements, the experts have multiplied the possibilities for preventive intervention.” (Petersen 1997, p. 193) Public health care is no longer oriented towards reactive containment of already existing infections and diseases, but towards active prevention with a view to the risks of future health impairments. The “new” public health sees itself as an approach with a changed image of man. While the “old” public health considers individuals as passive recipients of disciplinary and regulatory measures, the “new” public health sees them as active shapers of individual health measures. This enlarges the potential circle of addressees of people who are already ill, since the prevention of diseases also affects those who are considered healthy under consideration of all conceivable standards. In the age of “new” public health, all people, not just specific groups, races or classes, live with the risk of falling ill.

The emergence of “new public health” is associated with immanent contradictions that continue to strongly shape the practices and discourses of public health today. The calculation and regulation of risks goes hand in hand with the claim to change both the active prevention behaviour of individuals and the socio-ecological conditions of their behaviour. In many health-relevant fields, however, the question arises to what extent individual decisions to act, or societal structures should rather be taken into account. An example of this is the discussion surrounding high-sugar products. In most industrialised countries, no separate tax is levied on beverages and food with a high sugar content, although a close connection between a high-energy, sugary diet and the development of metabolic diseases such as type II diabetes, cardiovascular diseases or tumours has been proven (Hotamisligil 2017; Christ et al. 2019). Politically and socially, however, the question arises whether structural measures against the food industry promise more success than public health campaigns that motivate healthier eating behaviour. Closely related to this is the question of the relationship between private and public prevention. On the one hand, it seems certain that individual health promotion bears fruit directly if it initiates processes of change in the areas of fitness, nutrition, and lifestyle. In terms of active care and primary prevention, the subject of the “new” public health is now oriented towards the virtues of resilience, empowerment, and self-determination. On the other hand, measures of structural prevention in education, transport, and urban planning or in the energy and food industry could enable even more far-reaching improvements for the field of health.

The promotion of personal responsibility and lifestyle changes hides the danger of stigmatisation and intolerance of large population groups. Strict monitoring and control of individual behaviour may result in a strong stance against those who are “unable or unwilling” to follow basic norms of health and well-being (Petersen and Lupton 1996, p. 179). In the most extreme cases, these stigmatisation dynamics can become structures of discrimination in their own right. In some cases, it must even be asked whether the supposedly medically justified health measures do not themselves rather have their origins in historically longer-standing contexts—as for example Sabrina Strings argues regarding the racially motivated “fat phobia” towards black women (Strings 2019). Even if the sheer racism of racial hygiene and eugenics has lost all its power today, there is still a danger of discrimination against minorities against the background of an ambitious public health policy for society as a whole.

This leads us back to the social movements as the focus of this special issue. In the 21st century, the relationship between individual and collective prevention remains unresolved. In this respect, the measures and concepts of new public health uphold not only the high political and moral standards of the WHO, but above all reproduce the dilemmas and contradictions associated with the political perpetuation of the neoliberal and conservative health policies since the 1980s (Kühn 1993). Social movements remain caught in the dilemma of standing up for the empowerment of those affected on the one hand, but acting within the framework of complex, powerful structures on the other. Even in the age of WHO, they are not immune to becoming entangled in dynamics of discrimination. In addition, the new public health is confronted with challenges that the public health of the 19th and 20th centuries could only begin to imagine. Climate change, rising social inequality or the densification of urban spaces confront public health with new problems, the extent of which can hardly be surveyed by individual institutions, movements, or discourses. This special issue therefore allows us to look back at conflicts and developments that may resurface in a different form under these new circumstances. The texts move between historical and sociological perspectives. A study of the history of public health and its social movements requires both in order to gain a better understanding of the developments of the past two centuries. For this reason, the special issue sees itself as a fluid and dynamic dialogue between historical and sociological approaches.

The first essay of this public issue starts before Chadwick, Virchow and von Pettenkofer, through their investigations and writings, established the inseparability of individual and population prevention and before social reform prevention measures entered the agenda of public health care. Sophie Ledebur begins her study in a period when the scientific question of the origin, spread and proper management of infectious diseases was just emerging. State reactions to diseases and epidemics were still predominantly characterised by medical police measures, and liberal dietetics practised disease prevention through popular education. Ledebur deals with undercover, illegal prostitution in Berlin in the 1820s to 1870s and the discourses, institutions and social movements surrounding syphilis. She describes how the critical reflections on the denunciation systems of the medical police for the prosecution of chains of infection and the unrelated emphasis on personal responsibility for health led to a discourse on state health policy. In this discursive field, she particularly elaborates the difficult balancing act between the individual attribution of responsibility to the women and men involved because of their ‘lewd’ behaviour and the collective attribution of responsibility to the state for a lack of educational opportunities, inaccessible health care for poor people and social decay. As Ledebur shows, the example of women affected by syphilis can be used to study how health policy increasingly shifted from a strategy of class- and gender-specific repression and persecution to cross-class preventive measures in the course of the 19th century. Dealing with prostitution thus stands for the development of the first health policy measures of prevention in the middle of the 19th century. However, it is precisely in the knowledge of not knowing, in the uncertainty, that health policies ultimately find legitimacy for new measures and regulations. At the same time, the restructuring of health policy is taking place against the backdrop of a cultural struggle over state toleration of prostitution.

In his text, Andreas Neumann deals with the question of how the women’s movement was perceived by the early eugenic movement of the German Empire. Within the framework of a discourse analysis, Neumann looks at the interpretation of women’s emancipation in eugenic journals between the 1890s and the First World War. While analysing the views offered in major periodicals, the text highlights the antagonism between anti-feminist as well as feminist eugenics and the progressive women’s movement at the beginning of the 20th century. The national conservative faction of the eugenic movement analysed the emancipation of women within the framework of a cultural-critical view as a social regression and decline, whereas the feminist eugenicists tried to ennoble the race through their emancipatory movement themselves. Neumann’s analysis shows the political ambivalence of both, the women’s and the eugenic movements, their constant interactions and confrontations with each other and the social criticisms which are uttered to defend as well as to denigrate the women’s movement from a eugenic perspective.

Sung Un Gang’s text explores the discourse on cinema attendance in Korea in the 1920s and 1930s. Public and medical debates during this period discussed medical and psychological reasons why young, educated women should be advised against going to the cinema. Drawing on a rich corpus of media and journal articles, Gang shows that the Korean eugenics movement interpreted cinema and theatre as symbolic expressions of the health-endangering tendencies of romantic love. Thus, discourses on sexuality, marriage and reproduction based on Confucianist moral concepts were transferred into eugenic debates. Gang thus opens up a perspective that highlights intersectional entanglements of culture, health and colonial politics. While sexuality education was sufficient for men, tougher measures such as the enforcement of body checks and hygiene certificates were demanded for sex workers and single women. Gastronomic and cultural venues such as pubs, theatres and cinemas were assigned to a hwaryugye (“demi-monde”), considered as “shameful places” where STIs and viruses were spread because hygiene and health could only be maintained in the private sphere of marriage. Gang shows that compulsory physical examinations for the so-called kisaeng women and sex workers led to a continuation of class- and gender-specific surveillance and prosecution without any progress in health policies. He argues that the dichotomy between pro- or anti-Japanese movements dominating current research on colonial Korea is undermined precisely in the case of eugenic biopolitics. This illustrates the complexity and multi-layered nature of the eugenic movement in the early 20th century, even in a non-European context.

According to the genealogy outlined above, the subject of Pierre Pfütsch’s essay is located in the discursive field of new public health. It deals with health education in the 1970s in the Federal Republic of Germany, especially the emergence of gender as a target group-specific and thus health-relevant category. In particular, Pfütsch focuses on the implicit and explicit communication and constitution of societal gender concepts and role models in health policy brochures and measures. He reconstructs the shift in discourse from the construction of women as health literate and men as health illiterate family members, to the research driven addressing of men and women as different target groups for distinctive interventions. This conceptual change takes place against the background of and sometimes in confrontation with the women’s movement, which demands a transformation of social structures, gender concepts, and public health policies. While writing the history of this episode, the article illustrates how the individual-centred behavioural prevention of the “Bundeszentrale für gesundheitliche Aufklärung” (“Federal Centre for Health Education”) moves in the field of tension of critical social movements—especially the women’s movement—and political demands, how it tries to mediate both with each other and is thus itself subject to institutional as well as ideological change.

Dimitras Kostimpas and Hella von Unger deal with the concept of “structural prevention”, which has been used by the “Deutsche Aidshilfe” (DAH) since the 1980s to legitimise its civil society commitment. Behind the concept is the attempt to build a bridge between institutionalised health policy and civil society AIDS support. To this end, the DAH reinterprets the concept of prevention. Structural prevention does not fit into the common distinction between primary, secondary and tertiary prevention, but refers to indirectly addressing health issues in the lifeworld of self-help networks and local communities. The aim of the concept is to include the perspective of those affected without allowing the resulting independence from medical discourses to become an antagonistic attitude towards institutionalised science and politics. Prevention is understood as political work going further than mere education and medical treatment. Kostimpas and von Unger thus deal with a historically significant caesura with regard to the importance of social health movements in the second half of the 20th century. The HIV/AIDS activism of the 1980s and 1990s shows how, for the first time in post-war Germany, new paths were taken with a view to changing institutionalised health policy. The concept of structural prevention thus reconciles the concern for political emancipation with the idea of an institutionally controlled policy of health promotion and prevention.