The Politics of Health and Citizenship: Historical and Contemporary Perspectives

Health has been defined as a basic human right and also, in most of the welfare states in the Western as well as in the former communist world, as a civil right. The Preamble to the Constitution of the World Health Organisation drafted in 1945, states that '[t]he enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.' And article 25 of the Universal Declaration of Human Rights, proclaimed by the United Nations in 1948, reads: 'Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including […] medical care.' No matter whether such rights are explicitly laid down in constitutions, in other (social security) laws, or in the administrative regulations of the welfare state, in many countries health and disease have become an affair of the state as well as an important constituent in the exercise of democratic citizenship. The welfare state provides medical care for individuals - at least for its residents - according to their needs, not because of who they are or what they possess, but because they are citizens with equal rights. Access to health care is an aspect of democratic citizenship: it is considered, not just as a favour or a commodity, but as a right.
In fact such rights and provisions reflect long-term historical developments: next to poverty, (ill) health was one of the first social issue targeted by the emerging intervention state in the nineteenth century. As part of the discourse of human rights in liberal-democratic political thought, the notion of health as a right can be traced back to natural law in Enlightenment philosophy and the principles of the American Declaration of Independence (1776) and the Déclaration des droits de l'homme et du citoyen, proclaimed by the revolutionary French National Assembly in 1789. In the course of the nineteenth and twentieth centuries, medicine and politics became mutually entwined to an increasing extent. Health care has become a substantive and increasingly visible issue in democratic as well as authoritarian and totalitarian politics. Most national health care systems in the West, although organised in different ways, epitomise the principle that all inhabitants have an equal right to health care according to need and that its costs are shared equitably. Apart from inevitable biological distinctions between individuals, everybody should have equal opportunities for health.
The relation between health and citizenship, however, is far from self-evident and uncontested; it is fraught with complications and ambiguities. The idea that medical care is a human and civil right is easily formulated in the abstract, but it runs into difficulties as soon as practical implementation is at stake. Health cannot be construed as an absolute, legally enforceable right, like freedom of speech or religion, universal suffrage or fair trial. A human or civil right to health cannot be guaranteed for the simple reason that, in spite of the considerable advances of modern medical science and technology, individual health and disease are still, to a large extent, a matter of nature and fate. Governments can at best provide the conditions that put individuals on a more or less equal footing with regard to chances for health. However, as long as the necessary means, such as money, medical knowledge, and an adequate health care infrastructure are lacking, this right will be an illusory promise. The realisation of health as a human right has to be fought for and requires resources, solidarity, social responsibility, a long-term perspective, and the effort to resolve difficult questions and conflicts of interests.