Who Cares about Care?

Should trained physicians prescribe medicines to the poor free of charge? This question gripped the membership of London’s Royal College of Physicians in the 1690s and inspired Samuel Garth’s (1661-1719) satirical, mock-heroic poem The Dispensary (London, 1699).

The question pitted apothecaries against physicians in their respective efforts to make a living in London’s competitive medical marketplace at the end of the seventeenth century. In response to increasing commercial competition, the College proposed that its members (physicians) give free advice to anyone identified as poor by City officials (including servants) and then build a public dispensary at the College’s hall in Warwick Lane where those patients could purchase medicines based on that advice at cost. The hope was to undercut the prices for medicines offered by apothecaries, who recently had begun to encroach on the business of many physicians especially among non-elite sufferers. The dispensary was opened in the spring of 1698, the first of its kind in London. Despite some success in attracting patients, some physicians remained unhappy with the arrangement (as did most apothecaries).¹

Across six cantos, the physician Garth, who supported the dispensary, mocked all sides but especially ridiculed the physicians, his peers, who opposed the dispensary. The poem reaches its climax, at least in terms of action, with a street fight between apothecaries and physicians outside the dispensary where syringes and broken phials are used as weapons by the combatants.

The poem was a huge success at the time, seeing three editions published in 1699—the Folger holds a presentation copy of the third edition—and eight more during Garth’s lifetime. It continued to be reprinted regularly during the eighteenth century. The dispensary closed in 1724, but nearly a half-century later a new dispensary movement would take hold in Britain concerned with the issue of medical care for the poor.

Debates like this one from the end of the seventeenth century about the parameters of care for those characterized as the lower sort are not particularly uncommon. What the argument over the dispensary does do is emphasize that such debates were (and are) fundamentally about labor and remuneration. What is owed to the precarious people who provide the, often uncredited and under-compensated, labor that underwrote the long-distance commerce, warfare, and resource extraction of empire? Versions of this question can be found throughout art, policy, correspondence, sermons, commercial documents, and newspapers—nearly everywhere. Then, as now, such questions are an important part of lived experience and suffuse society; and, from my perspective, remain unresolved today.

Across the eighteenth-century Anglo-Atlantic world different expectations of care structured the health practices of institutions organizing the labor of large groups of people, namely soldiers, sailors, servants, and the poor. These categories might be familiar, but versions of care were also provided for enslaved people, prisoners, and refugees. The kinds of care (and ideas about care) practiced in these institutions depended on medical ideas and the desire to prolong life but also moral judgements about deservingness, practical labor needs, budgetary concerns, and racial thinking. They could also be contradictory or barely salutary at all.

These disparate ideas eventually coalesced into a modern conception of care work. Of course, this was a historically contingent process, one rooted in the early modern period before there was a single definition of care. This is the focus on my new book that I am working on as a Virtual Fellow at the Folger this spring. The book illustrates how bureaucrats and social reformers in an era of empires built an entire care economy upon institutions that were both punitive and palliative. Sometimes this was in concert with caregivers and other times against them. Key to my analysis are British naval hospitals, prisons, charity hospitals, sugar plantations, and refugee camps at a time when, I’ve found, new ideas about health, bodies, and medicine were yoked to the management and upkeep of precarious populations of people.

For example, Wood Street Compter (founded in 1555) embodies the ambivalence that typified care in such spaces.² The compter was part debtors’ prison and part holding pen for a wider range of transgressors including religious dissidents. London featured several by 1600 which featured prominently in plays by Ben Jonson, John Cooke, and others throughout the seventeenth century.³ On the one hand, Wood Street Compter was a punitive place designed to confine people; but on the other, it was also a place of care visited daily by a physician. Pregnant women gave birth at the compter. A local apothecary provided personalized medicines regularly for inhabitants. Boys from a compter could be sent to the Marine Society to prepare them for a career in the Royal Navy. The ties between labor and care were thick and complex.

Wood Street Compter and other institutions were caught up in the British dispensary movement that brought a new attention to the health of the laboring poor in the last quarter of the eighteenth century. One of the leaders of this movement, John Coakley Lettsom (1744-1815), a physician, gardener, tea enthusiast, and prison reformer, contributed his services to the Wood Street Compter alongside his work at the nearby Aldersgate Street Dispensary, the first dispensary of this movement founded in 1770.⁴ Many of Lettsom’s tracts on dispensaries and medical reform are available electronically through the Folger and illustrate some of the changing ideas of this period.

In contrast to the goals of reformers and philanthropists, care often looked differently from the perspective of patients and caregivers for whom it was personal, intimate, and often traumatic. Consider the nurses employed at hospitals and prisons across Britain. What must they have thought or felt as they earned a wage changing the bandages of an impaired sailor? Or picture the home caregivers supporting those wounded sailors after they were discharged with often permanent or life-changing impairments. Care and compensation for it shaped the interpretation of disability. Enslaved women filled caregiving roles on sugar estates across the Atlantic Ocean. Barbados, for example, featured an early dispensary for the care of Bridgetown’s urban poor funded by the very physicians who attended enslaved men, women, and children on nearby plantations, often marginalizing the important work performed by enslaved midwives and healers.

These are only some of the tensions that constituted care in the eighteenth and early nineteenth centuries and that form the foundation of our own care economy today. Tenderness can occur, but so can precarity, exploitation, and violence; often intentionally and simultaneously if we take a historical perspective. Fewer records remain of that side of the story—the voices of many caregivers are fleeting if they can be accessed at all—which raises pressing questions about how we tell those stories and maintain a range of perspectives in our work.