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Teemu Sakari Ryymin, Smitte, språk og kultur: tuberkulosearbeidet i Finnmark, Oslo, Scandinavian Academic Press/Spartacus Forlag, 2009, pp. 368, Kr 298.00 (paperback 978-82-304-0044-9).
In simple terms, the history of tuberculosis in Norway, as in other western countries, is the whiggish tale of the reduction of the country's most frequent killer in the late nineteenth century to a nearly insignificant affliction by the 1960s. This transformation was not achieved without effort. In 1900 the Norwegian parliament adopted the world's first national tuberculosis law, and for the next half-century the fight against tuberculosis dominated Norwegian public-health policy. Aspects of this campaign have been described before, but Teemu Ryymin's well-informed work is the first comprehensive account and a valuable addition to the international literature. Its principal theme is that health-care policies in general are a function of their medical, political, administrative, and economic context. A second theme, embodied in Ryymin's focus on Norway's northernmost county of Finnmark, is the tension between national and regional contexts. Between 1900 and 1950 Finnmark had the country's highest mortality rate from tuberculosis: roughly twice the state average. The county was poor, sparsely populated, and, most importantly, inhabited by considerable numbers of ethnic minorities whose language and culture differed greatly from those of ethnic Norwegians. Ryymin's thematic concentration results in two parallel presentations that reflect the decentralized administrative reality of Norwegian public health down to c. 1950: an analysis of the medico-political bases of national policies on the one hand, and an examination of local practices on the other.
The Norwegian anti-tuberculosis campaign followed a succession of four overlapping prophylactic strategies that reflected the development of national and international medical knowledge about the disease's aetiology and epidemiology. The 1900 law was founded on the principle that tuberculosis was a highly contagious disease whose spread could be controlled only by a neo-quarantinist strategy of identifying infected persons and isolating them, by compulsion if necessary, in care-homes or sanatoria. In the early 1920s new research revealing widespread latent infection, especially among children, provoked a shift to a preventive strategy that focused on reducing individuals’ predisposition to the disease by strengthening their bodily resistance. The reorientation was reinforced by the general spread of social hygienic measures such as housing reform. In the 1930s doubts were increasingly cast on the theory of latent predisposition, while the international economic crisis reduced public finances and compelled a retreat from the social-hygienist approach. Following the tireless advocacy of a group of younger doctors, a third preventive strategy emerged. It focused on eliminating the sources of tubercular infection by early identification using radiology (from 1935), isolation, and active, even aggressive, surgical intervention. The strategy's apogee came during the Nazi occupation: in 1942–43 the compulsory controls of the 1900 law were sharpened and extended to chest X-rays for adults and tuberculin tests for children. After 1945 a fourth prophylactic strategy developed that combined the three preceding approaches: legislation in 1947 essentially repeated the wartime laws and extended the compulsory principle to BCG vaccination; at the same time the new Norwegian welfare state generally emphasized the social-hygienic approach to “national health”. By 1963 the anti-tuberculosis campaign's success was so complete that the venerable National Association against Tuberculosis changed its name to the National Association for Public Health.
The sections on Finnmark document how these different strategies played out in practice: the building and placement of care-homes and sanatoria, obligatory tuberculin testing of schoolchildren and the construction of boarding homes for pre-tubercular children, obligatory X-ray examinations, and BCG vaccination. Of particular interest is the changing relationship between public-health policy and ethnicity, or national identity. For decades the ethnicity of the Sami and the Kvens was regarded as a disruptive factor: their lifestyles, especially traditional Sami housing, were considered essentially unhygienic and their languages were ignored in public-health work. Since the 1950s, however, the Sami language has been increasingly adopted in programmes of health education, and public-health authorities have made special efforts to bring Sami women into their activities. The incorporation of ethnicity in Norwegian health care came too late to have much effect in the struggle against tuberculosis, but the experience of this campaign in Finnmark played an important role in transforming Norwegian policy towards ethnic minorities.