1. Introduction
The socialist states of East-Central Europe were from the start invested in the health of their future generations. As they arose from post-World War II socio-political upheaval, socialist governments postulated intertwined aims for their demographic development: securing sufficient workers to fuel the socialist economy in the future and ensuring the health of their citizens. These aims manifested on all levels: starting from declarations and followed by making health care freely available for working people, supported by creating facilities to guarantee that care was genuinely accessible. The latter was possible only by employing medical professionals who provided care and conducted clinical research. We argue that expert knowledge triggered changes in the understanding of issues critical to population structure and forged continuities in approaching these issues, as demonstrated in discussions of the survival and long-term growth of vulnerable children, a vital topic for demographic development.
Medical expertise about vulnerable children provides an excellent point for analysis because it reveals the workings of modern societies facing consequential challenges in the quest for the health of children who represent the future symbolically and literally as citizens and workers. The definitions of prematurity changed over time, from children born before the full gestation period (and exactly how much before) to children born below a certain weight (and exactly how much below). Irrespective of varying definitions, infants born preterm were susceptible to neonatal death. Experts in East-Central Europe strove to provide care and assistance to premature babies, primarily to reduce the early post-war high rates of infant mortality. They were successful and a sharp drop in infant mortality marked the first decade of state socialism.Footnote 1 This beneficial development, however, had a flip side: many more premature children who would have died mere years earlier now survived, but were vulnerable to illnesses and developmental issues. Questions gradually arose: would these children develop normally and, if not, why? Experts sought to answer these questions by researching the conditions necessary to guide these vulnerable children towards normal development.
In this article, we comparatively trace the changing medical understanding of the long-term development of vulnerable children in four East-Central European countries – Poland, Hungary, Czechoslovakia and East Germany. We selected these countries because they have many similarities: their socio-geographical proximity, which allows for various exchanges; their imperial heritage from before World War I and the period of independence before World War II; and, crucially, their having embarked on the socialist path at the same time. They also have many differences: they had varying degrees of institutionalization (and the dismantling) of the human-science disciplines; there were divergences in demographic development; and they exhibited socio-cultural differences (levels of religiousness, urbanization, industrialization, among others) – all phenomena interacting with health outcomes.
Our aim is to give nuance to the traditional understanding of how socialist societies changed over the decades. We propose to achieve this aim by analysing expertise, which became increasingly important for modern forms of governance.Footnote 2 In socialist countries, medical experts were not mere extensions of political power; their specialized knowledge made them essential for addressing complex issues.Footnote 3 Our previous research showed that experts had significant leeway to advance scientific knowledge, leading to improvements in health care and earning them recognition in international scientific networks.Footnote 4 In other words, when researching how various types of vulnerable people were understood and treated – be they women endangered by pregnancy complications, vulnerable newborns threatened by infant death or children struggling in school as they were not mature enough to follow the curriculum – we saw time and again that in socialist countries, experts often influenced governments and policies. Only in a rare example did we see the opposite: an entire type of policy disappearing as the governments – and thus their priorities – changed. Such policies had reflected an expert-backed proposal to introduce premarital health check-ups to prevent the marriages of unhealthy couples who could pass their illnesses onto their offspring. In this case, the shift to socialism led to finally abandoning the proposal that had been discussed repeatedly in East-Central European countries since the interwar period and even after World War II.Footnote 5
All our research is comparative, so we were able to see that the directionality of experts-to-state-driven change was not a random occurrence in one country but that it was a typical pattern when it came to the health of mothers and the normalcy of children. Building on this research, we want to put our findings of expert-driven change to a further test: can we trace changes in socialist societies in connection with not only medical but also other types of expertise, such as psychological and sociological? Will these different kinds of expertise be similarly important or will they weigh differently at different times? Will the interplay between the state and expertise be the same for all kinds of expertise or will there be differences among medicine, psychology and sociology? In our previous research, which included an article addressing expertise on premature children, we identified the crucial importance of knowledge circulation, both transnationally and across disciplines. Socialist experts drew inspiration from their colleagues on the other side of the Iron Curtain and we show how these exchanges intensified from the 1960s onwards. Were there differences between socialist and capitalist countries in how experts formulated potential problems facing premature children?
We conducted a rigorous comparative analysis of expert writing on the long-term development of premature children, encompassing four countries – Poland, Hungary, Czechoslovakia and East Germany – and covering the four decades of state socialism, and identified commonalities and differences by employing two sets of social science methods: time-sequencing approaches and the sociology of expertise.
First, we compared four countries’ medical discourses about the long-term development of preterm or low-birth-weight children. In each of the four countries, we started with paediatricians, the first line of medical care for children.Footnote 6 We traced how their understanding developed by analysing their professional journals and key monographs. We identified the role of psychologists as influential in this development. We focused on how these experts perceived the prospects of preterm children in general (in other words, whether they would develop normally or experience problems) and also specifically in the mental and behavioural realm (in other words, whether their intelligence and behaviour would develop like that of their full-term counterparts and, if not, what could influence their development). We compared the same types of sources for all four countries. In addition to monographs, we analysed medical and psychological journals.Footnote 7
Second, we looked for trajectories and turning points in our experts’ views. We understand problems as not set but evolving over time. To capture and make sense of their shifting nature, we follow time-sequencing approaches that use reiterated problem-solving, comparing historical times with altering modes of dealing with the ‘same’ issue.Footnote 8 Since each epoch defines problems in a (slightly) different manner and mobilizes various actors to arrive at a solution, one needs to ‘deploy contrasting cases to develop explanations both for period-specific solutions and for differences between periods’.Footnote 9 These cases then connect into a narrative highlighting ‘historical switch points that are followed by more or less durable social regimes’.Footnote 10 Jeffrey Haydu proposed that researchers organize the narrative in time sequences and then show how ‘characteristics or events at time 1 lead to or are transformed into characteristics or events at time 2’.Footnote 11
Such a methodological approach is further developed in Andrew Abbott’s narrative programme of research.Footnote 12 We focus on trajectories and how they form and re-form over time. Trajectories are changed by turning points: defining moments that set events on a (slightly or dramatically) different path. Trajectory can thus be viewed as ‘a relatively stable set of rules governing outcomes’; conversely, trajectories are characteristic of ‘periods in which there was such a stable model’.Footnote 13 Thus, trajectories are causal (causing social consequences) and turning points produce new regimes of causality. We identify trajectories that were characteristic of a (relatively) consistent understanding of the problems (or lack of problems) concerning premature children’s long-term development and turning points that changed that understanding.
As we show, the shifts in expert understanding are enabled by the changing networks of expertise. We employed the sociology of expertise as presented by Gil Eyal. According to Eyal, expertise is best seen as a network in which people, their concepts and devices utilized, or their institutional and spatial arrangements in which they work give rise to specific understanding of problems and potential solutions.Footnote 14 Experts frequently grapple with questions of jurisdiction – defining the boundaries within which they can legitimately apply their expertise – while at other times they strive to link their jurisdictions, recognizing their interdependence. As they forge these connections, their object of study – such as the long-term development of preterm children – inevitably shifts and evolves under their combined perspectives.Footnote 15
We distinguish two turning points marking different trajectories in expert views about how children born preterm will develop. Before the late 1950s/early 1960s, experts saw little amiss with preterm children. Leading paediatricians expressed optimism that these children would catch up with their counterparts within a few years; some doctors even proclaimed that premature children would fare better than ‘normal’ children, potentially owing to the state-of-the-art care that became available at the beginning of socialism. Then, a turning point occurred. The late 1950s were characterized by growing numbers of surviving children and, notably, by the return of a discipline that had been displaced during Stalinist years (up to the mid-1950s). Psychology made an institutional comeback, including – crucially – in medical settings. While some clashes happened, psychological and medical jurisdictions mostly linked, never to be disconnected again. Thus, psychologization in the late 1950s and early 1960s marks the first turning point.
Only after paediatricians were prepared to see long-term development in psychological terms, that is, as mental and behavioural, could they appreciate non-biological factors influencing preterm children. While medical doctors in East-Central Europe were never disconnected from the developments in their fields occurring in Western Europe and the United States, we identified a growing international knowledge circulation during the 1960s: more experts from more countries were cited by medical doctors in the region. Among the most often referenced was a Scottish paediatrician, Cecil Mary Drillien, whose longitudinal research of preterm children accentuated the social environment, which in her view determined whether these children would overcome the obstacles posed by early birth or low birth weight and be able to start schooling and prosper in educational settings or if they would fall behind their ‘normal’ peers and even become ineducable. This environmental outlook influenced experts in East-Central Europe by the early 1970s, constituting a turning point after which paediatricians assessed conditions that could mitigate or exacerbate the mental and behavioural problems of preterm children. We detail how classed Drillien’s environmental account was and how it was variously employed in each of the four countries. Thus, we analyse how class was deployed in officially classless societies and account for differences among countries.
There were many similarities across the four East-Central European countries we study. However, we argue that the application of medical knowledge was to some extent country-specific, shaped by the interplay with the adjacent human-science disciplines of psychology and sociology. The influence of psychology was largely similar across the four socialist countries – it re-emerged from bans during the Stalinist years and was integrated into clinical settings, which made it possible for physicians to see child development as mental and behavioural. The impact of sociology was much more country-specific: this discipline reflects socio-political situations as these shift within each society. We further argue that specifically the understanding of class, as articulated by each national sociology (or through its silence on the topic), impacted medical expertise on the development of vulnerable infants.
The next section discusses scholarly approaches that address East-Central European sociology, medicine and psychology, both from a transnational perspective and in the context of each of the respective four countries. In the following section, we analyse the first turning point, when experts began to identify a systematic problem with the development of premature infants across the four countries. We then dedicate a section to the second turning point, where state socialist experts, drawing on transnational exchanges, emphasized the role of environmental factors in the long-term development of premature children. The final section discusses how experts understood class and gender, highlighting the differences not only between Western expertise and socialist thought but also among the socialist countries themselves.
2. Transnational historiographies of socialist medicine, psychology and sociology
The transfer of medical knowledge between East and West during the Cold War era was more nuanced and bidirectional than previously assumed. In the early 1950s, the psychoprophylactic method of painless childbirth was introduced from the USSR to Czechoslovakia, though its popularity waned by the end of the decade.Footnote 16 Physicians applying Pavlovian approaches to aversion therapy for homosexuality in 1950s Czechoslovakia demonstrated a more sophisticated understanding than shown in the behaviourist techniques later used in the British Commonwealth.Footnote 17 Contrary to the notion that medical approaches in the Eastern bloc originated solely from Moscow, psychiatry serves as a prime example of diverse influences.Footnote 18
A score of medical advances drew on the cross-Iron Curtain collaborations. Social medicine and public health programmes benefited from East–West exchanges, particularly in combating epidemic diseases.Footnote 19 This collaboration extended to vaccination efforts, as evidenced by the joint work of Hungarian and Western experts in developing polio prevention strategies.Footnote 20 Clinical trials often transcended the Cold War ideological divide, with knowledge sharing occurring between East and West Germany.Footnote 21 This cooperation was also evident in efforts to combat tuberculosis.Footnote 22 In the field of cardiovascular medicine, East German experts maintained a strong presence in the West from the 1950s. By the 1970s, East Germany had adopted a US-inspired risk factor approach to epidemiology.Footnote 23 The late 1950s saw a flourishing exchange between Polish and Western experts on contraception and family planning.Footnote 24 Sexual medicine in East-Central Europe drew inspiration from US therapists Masters and Johnson, developing its own training methods in sexual techniques.Footnote 25
The impact of psychology as a discipline on both society and medicine has been immense. The process of psychologization at the end of the 1950s has been well documented, particularly in socialist Hungary.Footnote 26 The identity formation of Hungarian psychologists was significantly shaped by the reference point of Western expertise.Footnote 27 Work therapy for the mentally ill in Hungary exemplified how domestic pre-war traditions merged with both Western and Eastern expertise to create novel approaches.Footnote 28 The reception of Western psychological expertise varied among Eastern European countries.Footnote 29 In the 1960s, psychological expertise on stress-related issues gained prominence in socialist states, leading to the ‘therapeuticizing’ of society, albeit with some notable differences in practice.Footnote 30 In Czechoslovakia, the care of institutionalized children versus family care reflected both psychologization and Western influences.Footnote 31 While psychology in Poland was marginalized during the Stalinist period, it experienced a renaissance after 1956, establishing significant connections in both the East and the West.Footnote 32 This revival exemplifies the complex interplay of ideological constraints and scientific aspirations that characterized the development of psychology in the Eastern bloc during the Cold War era.
The influence of another discipline, sociology, came to the fore during the 1960s and 1970s. Sociologists in Eastern European countries embarked on empirical research and chose to employ a paradigm of social stratification. First deployed in the West, social stratification was conceived as a tool to rebut the Marxists’ notion of class – and, ironically, Eastern European sociologists flocked to it as the way to understand their societies revamped according to Marxist principles.Footnote 33 The stratification lens allows the study of various groups without necessarily comparing them, let alone implying conflicts. ‘For sociologists, it was not only a way to undertake meaningful empirical research but provided opportunities for subtle criticisms.’Footnote 34 When sociologists became too critical, bans loomed. In Czechoslovakia, sociologists used the results of a 1967 stratification survey to assail the inefficiency of the ‘classless’ system, which resulted in the disbanding of the leading institute of sociology.Footnote 35 In contrast, in Poland, after several sociologists fell victim to political repression in 1968, stratification studies provided a space for studying ‘social differentiation’ that did not challenge the notion of a ‘classless society’ and thus became a relatively safe way to address inequalities. Similar to their counterparts in Poland, East German sociologists did not challenge the ‘classless society’, which allowed them the flexibility to reveal social differences without explicitly using the concept of class.Footnote 36 In Hungary, 1973 marked a comeback of political orthodox forces, which led to the curtailment of the economic reforms of 1968 and the silencing of critical voices in sociology, such as Konrád, Szelényi and Hegedűs. As a result, critical sociology, particularly in its application of class analysis, became marginalized.Footnote 37 Importantly for our research, as we detail later, whenever medical experts in East-Central Europe turned to socio-economic aspects, they did so as part of diagnosing what factors contributed to their patients’ long-term development. These clinicians typically did not care about economic aspects such as the costs connected with long-term care and thus they did not discuss potential consequences for the state.
We detail the turning points in medical expertise on the long-term development of preterm children triggered first by the psychologization of this area of medicine and later by transnational knowledge circulation that brought class more into medical focus.
3. Turning point 1: psychologization – seeing mental issues
In the late 1950s and early 1960s, experts noticed that something was not quite right with preterm children. Twelve per cent of prematurely born children in Poland were diagnosed with mental developmental disordersFootnote 38 and 39 per cent bordered mental retardation.Footnote 39 Prematurely born children in Czechoslovakia were up to three times more likely to have mental defects than their full-term peers.Footnote 40 For Hungary, experts assessed mild motoric and mental retardation in 47 per cent of premature children; 59 per cent had behavioural disorders.Footnote 41 In East Germany, lagging in mental development was simply a ‘well-known fact’ about premature infants.Footnote 42
Before the concern about the long-term mental development of prematurely born children emerged, there was no significant discussion of any potential negative consequences of being born prematurely; experts focused only on physical development or they directly expressed optimism. Such optimism was particularly pronounced in Poland, where key experts on premature infants promised that they would develop normally. Izabela Bielicka, a paediatrician who from the late 1940s designed standards of care for prematurely born infants, argued that they can become ‘fully-fledged citizens’ and catch up both physically and intellectually, around nine months of age, through proper care. She argued, drawing on Soviet experts, that premature infants were not ‘biologically less valuable’, contrary to ‘traditional opinions’.Footnote 43 Similarly, paediatrician Halina Hofman noted that ‘it was not true that premature infants develop more slowly’ and stressed that other factors probably caused mental retardation. To illustrate this claim, she mentioned famous people allegedly born prematurely: Napoleon, Newton, Darwin and Voltaire.Footnote 44 Both Bielicka and Hofman asserted the ‘value’ of premature infants as part of the argument to support the intensive infrastructure development for their care.
Similarly, in Czechoslovakia, experts initially shared a positive view of the future development of premature infants. In 1949, prominent Slovak paediatrician Kornel Chmelo published the results of the first research examining 35 premature children’s physical and mental development. Through questionnaires sent to families, he investigated when the child first sat up and started walking, talking, interacting with relatives and expressing needs. Although Chmelo found that these children were delayed in the first years of life, he stressed that after some time they developed normally, stating that ‘our results confirm the well-known fact that premature infants catch up or even surpass others’.Footnote 45 This conclusion was also reached in the 1950s by a team of experts from the Institute for the Care of Mother and Child in Prague, who compared the development of premature and full-term infants during regular check-ups up to the age of three years. When looking at similar aspects as Chmelo, they showed that ‘the group of premature infants as a whole is gradually closing the gap with the group born full term’.Footnote 46 If an infant developed any disorders, the experts explained it to be a result of poor childbirth management.Footnote 47
In Hungary, experts saw the quality of early care as decisive for the positive development of preterm infants. Gyula Surányi, a leading specialist on prematurity in 1950s Hungary, advocated for highly specialized care as provided in his prematurity ward at Tomcsányi úti hospital in Budapest. He argued that children who received such advanced care would develop normally, rebuffing sceptics who saw grim perspectives of physical and mental impairment in preterm children. Surányi challenged his critics for examining children of 10 to 15 years of age who grew up in ‘completely different, much less favourable conditions’.Footnote 48 However, he admitted that a ‘definitive assessment of today’s specialized care can only be made in a decade’.Footnote 49
In 1950s East Germany, the long-term prognosis for preterm infants was not optimistic, but the outlook was not catastrophic either. Based on international literature and their own studies, most experts acknowledged that ‘premature infants lag behind mature infants in physical and mental development in the first years of life; by the end of the third year of life, this deficit is generally not evened out’.Footnote 50 However, irreversible damage ‘is expected in only about every 50th prematurely born child’.Footnote 51
In the late 1950s and early 1960s, experts began to see a systematic problem with premature children. We argue that the reason for that is twofold. First, only in the late 1950s were there any substantial numbers of prematurely born children who lived long enough to exhibit (severe) mental issues in their development. Most countries in the region significantly decreased infant mortality rates in the early 1950s, meaning that children who would have died – many of them premature infants – now survived. The survival rates of premature newborns increased by about half during the 1950s, making long-term development more relevant for medical doctors.Footnote 52 Experts were aware of the improved survival rates, citing them in their papers.Footnote 53 Second, and maybe more importantly, psychological expertise was re-established in East-Central Europe after being suppressed and institutionally scattered during the Stalinist part of the 1950s. Intelligence testing, internationally recognized developmental assessment tools, observation and looking at school performance allowed experts to diagnose developmental and behavioural disorders in preterm children.
In Poland, concerns about the long-term mental development of prematurely born children emerged in the late 1950s, triggered by the re-emergence of psychology as an academic discipline in the post-Stalinist period. Psychological journals started to be published again in 1957 and psychological expertise was integrated into studying various phenomena. The Department of Prematurity at the Warsaw Medical Academy, which had run an outpatient clinic for premature births since 1950, hired a psychologist in 1958 for the first time. In Czechoslovakia, the journal Československá psychologie (Czechoslovak Psychology) was launched in 1957; the following year marked the founding of the Czechoslovak Psychological Society and the first conferences took place in 1957 and 1959.Footnote 54 In Hungary, de-Stalinization brought psychology back to the fore after years of almost complete silence. Signs of re-institutionalization included the foundation of the Psychological Committee of the Hungarian Academy of Sciences in 1958 and the formation of two central journals: Pszichológiai Tanulmányok (Psychological Studies) in 1958 and Magyar Pszichológiai Szemle (Hungarian Psychological Review) in 1960. However, psychology was not reintroduced as an independent discipline at university until 1963.Footnote 55 In East Germany, unlike the other countries, psychology was not drastically shut down in the Stalinist period; medical doctors used psychological tools and indeed the title of the leading journal, founded in 1949, was Psychiatrie, Neurologie und medizinische Psychologie (Psychiatry, Neurology and Medical Psychology). By the end of the 1950s, paediatricians and psychiatrists had expanded the application of psychology to the study of premature children, occasionally incorporating psychologists into medical-led working groups.
The psychological development of the patients in Warsaw was assessed through the study of reactions in the first year of life. The conclusions from these first experiences were published in 1962 and the team of experts, including Bielicka and a neurologist, argued that 12 per cent of the patients had ‘mental development disorders’ and 4 per cent were ‘severely mentally disabled’.Footnote 56 By the mid-1960s, experts were able to develop studies on older children and to use methods applied in psychology to identify disorders. A complex study of long-term physical and mental development was carried out by paediatrician Aleksandra Janus-Kukulska and psychologist Stanisława Lis between 1959 and 1961 on older children aged 3 to 11 years, leading to a series of publications on infants born at 1,250 g or below. They argued that ‘disorders in the development of intelligence are less important than behavioural disorders’, with behavioural disorders described in terms of emotional maladaptation, lack of concentration and anxiety.Footnote 57 Using the Wechsler IQ test and the Gesell developmental assessment for children aged under five years, they established that 39 per cent of the children were ‘on the borderline between normalcy and mental retardation’. This borderline group was cause for concern: 66 per cent presented a range of behavioural disorders and 84 per cent showed emotional disorders.Footnote 58 Almost half of the older children did poorly in school.Footnote 59
In Czechoslovakia, experts disagreed about the mental development of premature children. Psychologist Jaroslava Dittrichová and paediatrician Věra Stanincová in Prague expressed optimism, saying that ‘the foreign literature is increasingly optimistic about the future fate of preterm children, which seems to be related to the improving care of premature infants at birth, after birth and afterward’.Footnote 60 But clinical psychologist Stanislav Langer, who worked with paediatricians in a medical centre in Hradec Králové, noted a higher percentage of mental disorders among premature children. He stressed that experts had not previously paid enough attention to mental development because its disorders typically did not manifest until school age. Based on a group of 107 preterm infants, Langer found that up to twice as many children born in the seventh month attended special school as did those born in the eighth month. Langer was convinced that mental defects were two to three times more common in premature than in full-term infants.Footnote 61 His conclusions, however, became the target of criticism. Dittrichová and Stanincová noted that Langer’s study group was misleading as it consisted only of children attending his clinic and he extrapolated his findings without a control group. Given that the children in his group were aged from birth to 18 months, other experts stressed that Langer could not distinguish a temporary delay from a permanent one. Yet, many articles in the 1960s picked up Langer’s thread, showing that children with a birth weight below 1,000 g were approximately 7 times more likely to attend special schools and 16 times more likely to live in asylums. Moreover, they had more significant behavioural disorders, such as inability to concentrate, lack of interest and poor memory.Footnote 62
Hungarian paediatrician Gertrud Wohlmuth and psychologist Rózsa Fráter turned their interest towards the ‘effects of prematurity and immaturity on later stages of development’ in preterm infants who were ‘rescued at great cost and hardship’. They were specifically interested in intellectual development and behavioural disorders in preterm infants. In a study based on 193 preterm infants, the authors concluded that 47 per cent of the children had ‘retarded motor and mental development’ and 59 per cent developed behavioural disorders.Footnote 63
In East Germany, neuropsychiatrists, pedagogues and paediatricians considered long-term psychological development the central factor to be assessed. From the 1960s, East Germany fostered investigations into children’s neuropsychiatry. The neuropsychiatrist Gerhard Göllnitz led a long-term project addressing the ‘defective child’ that also researched the long-term development of premature infants.Footnote 64 ‘Mental delays’ of premature infants leading to school failure were ‘again and again’ found in East German and international scholarship, as a study led by Hans-Dieter Rösler concluded.Footnote 65
When concerns about long-term development arose, experts typically saw prematurity itself as a problem: once an infant was premature, mental problems such as low intelligence or behavioural disorders were likely to appear. But then experts’ attention shifted.
4. Turning point 2: transnational knowledge circulation – seeing the effect of the social environment
Experts in East-Central Europe were consistently up to date with international literature on prematurity. They cited many international authors from countries mostly outside of the socialist bloc. The experts in the four socialist countries followed publications by Swedish and Finnish authors, including Arvo Ylppö, the Finnish pioneer in the research on premature infants; they were also familiar with recent publications by British, American and French authors and – less visibly – by West German ones.Footnote 66 Some authors stressed the importance of social environment for the mental development of premature children. Between the mid-1960s and the early 1970s, paediatricians and psychologists in the region noticed the importance of the environment for the long-term development of prematurely born children. Among the referenced international authors, one name stood out: Cecil Mary Drillien.
Drillien was an Edinburgh-based paediatrician who spent her professional life studying prematurely born children. She launched her first longitudinal study in 1953, in which her sample of children born before term and with low birth weight (defined variably but often as 4.5 lb or approximately 2,000 g, and less) grew over time and was systematically compared with children selected by taking the next mature birth from the hospital admission list. Her study sample contained nearly 600 children. In her research, she described the physical growth of the children and focused on their mental and behavioural development.Footnote 67 Drillien noticed two factors crucially affecting how premature children developed in the long term: social class and maternal care.
In assessing social class, Drillien took as her starting point the social class of the father’s occupation according to the classification by the Registrar General. While the Registrar General distinguished four social classes and Drillien’s sample comprised 90 per cent of children from working-class families, the paediatrician decided to merge Social Classes I and II, calling them ‘social grade 1’, and subdivided Social Classes III and IV into social grades 2, 3 and 4. Upon visiting children’s homes, she identified superior working-class homes where the fathers were skilled artisans or held positions of some authority, the mothers managed the household well, the bookcase was well stocked and the parents were interested in education. She titled these homes social grade 2. On the opposite end of the working-class-homes scale were the poor working-class homes, which Drillien called social grade 4; they were typified by a ‘preponderance of mothers of below average intelligence and fathers sporadically employed on labouring work’.Footnote 68 Between these two sat social grade 3; above all was social grade 1, the homes of the middle class. The socio-economic circumstances of a family were reflected in the quality of housing.Footnote 69 Only a tiny fraction of mothers were employed before the child reached two years old.Footnote 70 Drillien blamed institutional care, as ‘attendance at a nursery for the greater part of the first five years cannot be considered the best environment for optimal development’.Footnote 71
Maternal care was seen as crucial for how well or poorly a child developed. Drillien assessed cleanliness; maternal efficiency in weaning, sleeping and toilet training; the mother–child relationship, with siblings and between parents; and maternal health. In Drillien’s evaluation, maternal care or efficiency ranged from ‘very good’ in clean homes where the children were well fed and clothed, enjoyed a sensible routine and a stable environment, to ‘poor’ where care was seen as very unsatisfactory, diet deemed inadequate for growth and health, and children were poorly clothed and dirty and their routines extremely haphazard. Such ‘[h]omes are kept in a state of filth and squalor and relations between husband and wife are often very disturbed’.Footnote 72
Social class and maternal care were largely synonymous for Drillien. Moreover, in her view, class correlated with the mother’s intelligence. Drillien regretted not being able to distribute IQ tests to the parents, ‘but the best estimation possible was made by dividing mothers into social grade’.Footnote 73 Preterm children were three times more likely to be born in poor homes than their middle-class counterparts. ‘The prematurely born children, as a whole, tend to come from an inferior socio-economic level than those in the mature group, and there is no doubt that the intelligence of the parents in the latter group tends to be higher and the home environment more favourable.’Footnote 74 The vicious circle of poor homes–more premature children was compounded by a ‘poor genetic endowment of intelligence’Footnote 75 and closed by a poor outlook that the child’s mental development would improve. In general, increasing birth weight correlated with increasing developmental scores of children across social grades, but still, ‘[i]n the best homes there are very few dull and retarded children, as compared with those of like birth weight from poorer homes’.Footnote 76 Similarly, low-birth-weight children (less than 4.5 lb or approximately 2,040 g) improved more when they had superior working-class or middle-class mothers. For those smallest at birth, the lower their social grade, the more unfavourable development awaited. The children of very low birth weights of 3 lb (1,360 g) and less faced dire outcomes. When reaching school age, half of them ‘were ineducable in normal school for reason of physical or mental handicap or both, [and] one-quarter were dull children retained in the normal school’.Footnote 77 Drillien’s overall argument about children’s mental development prospects could be summarized as ‘[m]ental development is related to the apparent intelligence of the mother and the type of home’.Footnote 78
In behavioural development, maternal handling played an even greater role than birth weight alone, especially in preschool age. During the first years of life, three-quarters of all children across social grades were handled well by their mothers; the exception was the poorest grade, where only a third of mothers were considered efficient enough. When raising low-birth-weight preschoolers, mothers from the top two social grades typically erred by being over-anxious or rigid; average and poor working-class mothers were seen as indulgent or permissive. Upon starting school, the effect of low birth weight rose: as a rule, the lower the birth weight, the greater the behavioural problems. Moreover, the children’s problems increased with decreasing social grade. When comparing a child’s preschool development with after they had entered school, Drillien wrote: ‘Children of over-anxious mothers showed a marked excess of disturbance in the pre-school period, but no more disturbance in school than those whose handling had been satisfactory. … Children subjected to permissive and variable attitudes, physical neglect and absence of discipline showed an excess of disturbance at both preschool and school ages.’Footnote 79 This means that problems typical of middle-class mothers’ handling styles disappeared from their children’s behaviour by early school age. In contrast, those mishandlings typical of poorer mothers continued to reverberate in their children.
Drillien’s approach was rather classed (targeting the lower ‘social grades’) and gendered (singling out mothers and very rarely mentioning fathers). In what follows, we show that while East-Central European experts were influenced by Drillien’s environmental accent, their reception of the class and, to some extent, the gender components differed.
5. Reception of transnational expertise and the social environmental turn: understanding class and gender
Drillien’s studies inspired a range of research in East-Central Europe. Experts considered the same intellectual and behavioural issues as in the 1960s, yet they looked for the explanations in socio-economic factors. Despite increasing interest in the social environment in the 1970s and 1980s, Polish and Hungarian experts followed Drillien’s argumentation to a limited extent; East German experts embraced Drillien’s approach. Czechoslovak experts were the most hesitant about applying a class approach to studying long-term mental development. In this section, we discuss how experts in East-Central Europe created their own approaches to class and gender. These approaches, as we show, were embedded in current sociological discourses about class as well as ideas about gender.
Poland: parental education as the key socio-economic factor
Polish experts on the long-term development of premature children followed Drillien’s publications from the early 1960s, highlighting her interest in socio-economic factors. In a comprehensive literature review paper, Stanisława Lis referenced Drillien’s publications from 1959 to 1961, saying that she established a correlation between birth weight and ‘mental retardation’: ‘According to her, it is caused by defective genetic provision and unfavourable socioeconomic conditions, which have the highest impact on the development of the smallest infants.’ As Lis summarized Drillien’s findings, lower IQ in these children originates in ‘a bad social environment and the poor biological quality of the mother’.Footnote 80 As we already mentioned, Drillien paid attention to ‘poor genetic endowment of intelligence’. Polish experts never considered the second factor, heredity, and thus did not engage in eugenics discourse, but Drillien inspired them to research the impact of socio-economic conditions.
This interest in socio-economic factors developed slowly. Polish studies from the 1960s mentioned socio-economic factors only marginally and in very general terms. However, in one study, published in an international journal in English, Lis and Janus-Kukulska concluded, referencing Drillien’s 1964 monograph: ‘A relationship was observed between developmental achievements and the family’s socioeconomic status. In most cases, good achievements were connected with good socioeconomic status.’Footnote 81 This discrepancy between Polish and English publications on the same research might indicate that the researchers avoided talking about socio-economic factors while addressing a Polish audience.
Indeed, talking about socio-economic factors and addressing class was problematic in 1960s Poland. Reflecting on the history of Polish sociology and the conceptualization of class, David Ost argued that while critical theoretical analysis of class emerged after 1956, radical application of class analysis became politically repressed. Sociologists developed studies on working and living conditions, yet they needed a theoretical legitimization.
That was the aim of Włodzimierz Wesołowski’s pathbreaking 1966 work, Classes, Strata and Power, which became a valuable resource for empirical sociologists throughout the Soviet bloc. … Wesołowski argues that while nationalized ownership means that class conflicts do not divide socialist societies, goods, jobs, income, prestige, life chances, and even ‘political influence’ are still distributed unevenly, leading inescapably to dissatisfaction, typically addressed to the state.Footnote 82
Stratification peaked in the 1970s.Footnote 83 Anna Zawadzka showed that while during the 1960s sociological research on class and lifestyles approached class differences as undesirable, in the 1970s social stratification began to be depicted as something functional, along with an affirmative view of the dominant role of the intelligentsia.Footnote 84
Stratification studies and the normalization of class differences impacted how medical experts addressed socio-economic factors in their research. In the 1970s, Lis and Janus-Kukulska published a new series of publications in Polish that discussed all the studies conducted from the late 1950s, shifting the attention towards socio-economic factors. In a 1974 literature review article, Janus-Kukulska argued that new studies provided evidence that the consequences of being born premature could be overcome.Footnote 85 This was when Polish experts started to analyse socio-economic conditions in greater detail, following international literature where – as they argued – ‘almost all researchers’ stressed the importance of these conditions.Footnote 86
Polish authors differed in their approach to socio-economic factors from what they had read in Drillien’s publications. They considered the education level of both parents, whether the mother worked outside the home and the housing conditions. In the state-socialist Polish context, in which most mothers were employed full-time, the assumed model of the family was of two earners, and women were expected to combine working with motherhood and childcare. Making education at all levels accessible to women, and their consequential advancement in the professional realm, was a crucial and omnipresent aspect of the socialist discourse about gender.Footnote 87 Lis argued about the impact on premature children’s development of interrelated factors: parental education, housing and material conditions.Footnote 88 In her 1979 book on children born prematurely, she analysed the education of both parents (elementary, secondary and higher), occupation, housing conditions, the number of children in the household and the parents’ evaluation of their economic situation, since she claimed that income was not a useful indicator. She concluded that parental education was the factor that best reflected socio-economic differences among families.Footnote 89
Thus, parental education became the main criterion of socio-economic differentiation for Polish experts. Lis concluded that it affected the IQ of prematurely born children and therefore the probability of ‘mental retardation’ (meaning intellectual disability defined by low levels of intelligence).Footnote 90 In one of her studies, almost 86 per cent of intellectually disabled children had ‘poor socioeconomic conditions’.Footnote 91 In all the groups she studied and summarized in the book, which included two groups of prematurely born children (smaller and bigger) and one group of children born at term, parental education mattered for the children’s IQ levels. The better educated the parents, the higher the IQ levels of their children. Nevertheless, average IQ levels in groups of premature children were still lower than those of full-term children of parents with only elementary education, which led Lis to conclude that there must be other factors beyond socio-economic ones.Footnote 92 Furthermore, behavioural disorders that had worried experts since the early 1960s were found to be unrelated to socio-economic conditions or children’s intelligence. Janus-Kukulska and Lis found that most children had favourable socio-economic conditions, but this did not prevent behavioural disorders.Footnote 93 According to them, what mattered for various forms of behavioural and emotional disorder were the family-related factors such as conflicts or poor parenting styles.
While the importance of socio-economic status for the IQ levels of children partially resembles Drillien’s argument, Polish expertise was not similar to hers concerning the gender aspects. According to Janus-Kukulska and Lis, the level of both parents’ education mattered. However, what was discussed was whether the mother worked outside the home. Although the experts initially did not argue that this factor mattered for the child’s development,Footnote 94 in her book Lis claimed that ‘in the groups of premature children, worse socioeconomic situation was compensated with mother’s care and better family situation’. She assumed that non-working mothers ‘could secure better care and upbringing conditions’.Footnote 95 At the same time, Lis discussed the (non)working mother factor together with the ‘upbringing situation’, thus shifting the attention from socio-economic status to family-related factors. Following this line of thinking, premature children could benefit either from the better educational level of the mother or – if that was not the case – from her full-time commitment to childcare.
Polish experts widely discussed factors related to the quality of family life from the early 1960s, such as ‘parenting attitudes’, ‘family conflicts’, ‘atmosphere at home’ and ‘broken family’, yet those were not associated with socio-economic make-up. Regarding parenting styles, they argued that children whose parents were either ‘overprotective’ or ‘rejected’ them and children who were raised in ‘broken’ families were more likely to develop social and emotional disorders.Footnote 96 Studies showed that these factors were not connected to socio-economic status, unlike in Drillien’s approach. As an exception, Lis observed that high parental education correlated with ‘emotional instability’, but this remained a marginal remark.Footnote 97 Importantly and in line with broader contemporary expertise on upbringing and parenting styles in Poland, which accentuated a new model of engaged fatherhood, experts considered the parenting of both mothers and fathers.Footnote 98
Hungary: between class analysis and stratification studies
Hungarian paediatricians researching the long-term prospects of preterm children turned to Drillien’s research in the early 1960s to make an explicit connection between the impact of socio-economic factors and the future mental development of low-birth-weight infants. Alice Benedikt, head paediatrician at the state-of-the-art Schöpf-Mérei Hospital for preterm infants in Budapest, looking at ‘mental defects’ among other factors, acknowledged a higher likelihood of preterm children coming from ‘poor social conditions’ without further clarifying it. However, Benedikt was adamant in claiming that ‘proper care and treatment’ in specialized prematurity wards could overrule any social disadvantages and help ‘a large proportion of these children to become practically full human beings’.Footnote 99 The influential study by Wohlmuth and Fráter in 1965 did not follow the optimistic belief in the decisive role of infrastructure and medical professionals. The authors, looking at intellectual development and behavioural disorders in preterm infants, engaged thoroughly with Drillien’s research, which inspired them to devote ‘special attention to family and social conditions’ once the preterm children reached school age.
With the establishment of the Sociology Research Group at the Hungarian Academy of Sciences in 1963, Zsuzsa Ferge and András Hegedűs developed a sustained critique towards persisting social inequalities in contemporary society despite its reorganization according to Marxist principles. They rendered the Stalinist model of ‘two classes and one stratum’ outdated for sociological analysis, increasingly employing principles of stratification to evidence their critique.Footnote 100 Although sociologists had started to highlight social inequality in a society envisioned as egalitarian, Wohlmuth and Fráter acknowledged the importance of environmental factors only by using an unspecific formulation of ‘unfavourable surroundings’ without providing a definition of what they understood by socio-economic conditions. Interestingly, while they often had intimate knowledge of the family situation, they did not systematically examine the relationship between environmental factors and the long-term mental prospects of preterm infants.Footnote 101
The introduction of liberal economic reforms in 1968 evoked a redefinition of social structures and inequalities in sociological research beyond the Marxist principle of class struggle.Footnote 102 Leading sociologists, most importantly Zsuzsa Ferge in her book Társadalmunk rétegeződése (Stratification of Our Society), began to systematically examine society along different types of occupational groups. Accordingly, a person’s income, housing and level of education would therefore define his or her position within a system of division of labour.Footnote 103 While Ferge used a stratification model based on work-type groups to show the distribution of social inequality, by the beginning of the 1970s Hungarian paediatricians had widely acknowledged Drillien’s findings about the impact of socio-economic factors as a possible avenue for understanding the long-term prospects in preterm children. However, most experts did not produce systematic studies in Drillien’s spirit. Korányi and his colleagues, exploring long-term ‘physical and mental development’ in very-low-birth-weight preterm infants, explicitly recognized the importance of parental social status and education. Surprisingly, though, they did not include corresponding research categories as their ‘material would have to be completely revamped’.Footnote 104 Only by the end of the 1970s did Korányi, together with psychologist Erzsébet Csiki, interrogate socio-economic conditions more closely. Specifically, they examined the mother’s education, marital status, living conditions and per capita income. While they provided precise numbers for every category, they did not connect their findings on the socio-economic background of their preterm infants with the prospect of the children’s long-term development in their conclusion. Instead, they claimed to have controlled socio-economic factors only randomly. Even more peculiarly, they concluded that the children’s socio-economic situations were ‘probably average’.Footnote 105 Thus, Hungarian medical experts shied away from drawing conclusions based on their findings related to socio-economic factors, most possibly reflecting the change in the overall climate towards the study of social inequality after many leading sociologists, including Szelényi, Konrád and Hegedűs, were censored in 1973 as a result of the party’s ideological shift to orthodox, that is, pre-1968, interpretations of society.Footnote 106
During the last decade of socialism, Hungarian paediatricians further de-accentuated socio-economic factors. Vekerdy and his co-researchers – although not explicitly referring to Drillien’s argument on the importance of socio-economic factors – stated at the beginning of the 1980s that ‘after the perinatal period, the fate of preterm infants depends primarily on family and social conditions’. While the authors classified social conditions as poor, average and good, they did not specify which concrete factors were measured.Footnote 107 However, in a long-term study starting in 1977, the same authors came to a somewhat different assessment regarding the impact of socio-economic conditions. They concluded that perinatal events primarily determined intelligence levels in very-low-birth-weight infants; the influence of the socio-cultural background, specifically maternal education and family social circumstances, was ‘less pronounced’.Footnote 108 Paediatrician Barkó and his co-authors supported the shift in perspective marginalizing socio-economic factors. Their study, published in the same year as Vekerdy’s, concluded that school maturity in very-low-birth-weight infants was more decisively affected by the infants’ birth weight than by their mothers’ education.Footnote 109
While Hungarian paediatricians still considered socio-economic factors but found them increasingly negligible, psychologist Magda Kalmár focused on the relationship between socio-economic status (SES) and mental development in preterm infants. By doing so, Kalmár brought Drillien back into the scholarly discussion and followed much of her recent research. After Kalmár identified that parental education affected the IQ of preterm infants, she embarked on a different research project using the families’ SES, including parental education, occupation and income, very much in the fashion of stratification studies still pursued by sociologists at the time.Footnote 110 Like Drillien, she concluded that SES substantially impacted the IQ levels of preterm children and their school success, without being a stand-alone indicator.Footnote 111 Ultimately, Kalmár revived the socio-economic angle and stressed its relevance for these children during the last decade of Hungarian state socialism when social differences increased dramatically owing to the growing legalized Second Economy.Footnote 112
Like Drillien, most Hungarian experts understood the mother’s role as equally impactful. Nevertheless, they distinguished her mental levels via education and not – like Drillien – via a class-informed IQ estimate. However, experts related income levels and housing to both parents without making gendered differentiations. Kalmár and her colleague used SES with both parents but related a dynamically developing SES to parenting styles only in the mother’s case.Footnote 113
In the late 1980s, when the Second Economy was in full swing, interest in how parenting styles and SES intersect peaked. Indeed, human-sciences experts observed a change in parenting styles in three-quarters of Hungarian families, with one or both parents working in the Second Economy, leaving less time for the upbringing of their children.Footnote 114 Given the dynamics of societal change, sociologists assessed a ‘dual model’ of society in which quasi-market principles coexisted with state redistribution, profoundly affecting the fabric of Hungarian society.Footnote 115 In this vein, Kalmár measured the impact of parenting styles and SES on the IQ of pre- and full-term children. Interestingly, the effect of the Second Economy was more profound in full-term children. Mothers of families who experienced a dramatic improvement in their SES after the child’s birth showed a decreasing quality of parenting, negatively impacting the child’s mental development. However, Kalmár did not make the same observation for mothers of preterm children who, in the vast majority, were continuously devoted to their children independent from their SES. Unlike Drillien, who assumed a direct correlation between class status and IQ levels, Kalmár stated that the psychological effect of being a mother to a preterm infant most likely triggered a parental attitude that was beneficial to the child’s mental development, such as being ‘accepting, reasonably authoritative, [and] quasi-democratic’.Footnote 116
East Germany: the re-emergence of class and the importance of ‘educated’ working mothers
In East Germany, experts cited Drillien since the 1960s, but it was not until the 1970s that her works triggered an interest in the importance of socio-economic factors. In the late 1950s and early 1960s, leading paediatrician Eva Schmidt-Kolmer argued that the long-term development of preterm infants was ‘irrespective of the environment’ as there was ‘no longer a significant difference in the standard of living between workers and employees in the GDR [East Germany]’.Footnote 117 A decade later, studies recognized that the socio-economic environment had a more decisive effect on development: the delays seen in premature and low-birth-weight infants might be understood differently ‘if one considers that these children are more often born out of wedlock and grow up in an unfavourable environment’.Footnote 118 Experts did not dispute the presence of some developmental delays, but they wanted ‘the problem of late sequelae in premature infants to be understood as a purely social one’. Drillien stimulated this change of focus; experts accepted her correlation between ‘the social environment and behavioural disorders’ and lower IQ.Footnote 119
In East Germany, the turn to social environment factors was also a reaction to a pessimistic discourse that partially drew on Drillien. As East German paediatricians noted, Drillien highlighted that only a third of very small infants ‘would be able to complete elementary school satisfactorily’. Also, ‘Drillien expressed the opinion at that time that the survival of small premature children would lead to an increase in the proportion of damaged children’. As a reference expert, she fuelled a concerning question ‘repeatedly raised by colleagues from other disciplines, medical students and outsiders’ regarding the development of premature infants: ‘if we continue to reduce infant mortality …, do we not have to reckon with an increase in the number of damaged infants who would have died without this therapy? Are we not imposing additional burdens on our society with the necessary care for those affected, which we would have avoided through higher infant mortality rates?’Footnote 120
The notion that vulnerable children could be seen as a ‘burden’ was largely absent from other socialist countries and remained marginal in East Germany. Nonetheless, even this minor eugenics-like phrasing prompted a reaction from East German paediatricians, who countered it by emphasizing the primacy of socio-economic factors and the potential for vulnerable children to overcome their challenges. A working group of paediatricians from Rostock, led by Karl Dietrich Wagner and Hans Eggers, contradicted the ‘burden’ discourse and Drillien, stating that, especially in bigger premature infants (over 2,000 g), a ‘normal intellectual performance was increasingly diagnosed’.Footnote 121 Indeed, in further studies Wagner found ‘surprising’ the capacity of premature children to catch up and show normal development later in their lives.Footnote 122 In parallel, paediatricians like Eggers, who was head of the ‘social paediatrics’ department in Rostock, started looking at the children’s environment. In the 1970s and 1980s, East Germany launched neonatal programmes and conducted studies, most of which recognized the ‘increasing susceptibility of at-risk children to the social milieu’.Footnote 123 In 1984, a study led by Wagner on the development of premature infants concluded that ‘by the 6th year of life the social factors were of greater importance for the intellectual development of the children than the organics’.Footnote 124
In various studies carried out after the 1970s, experts foregrounded socio-economic factors as a risk to the long-term development of premature infants. In the first two decades of East Germany, class was addressed only obliquely. However, as recent scholarship has shown, when social inequality increased in the 1970s, there was a ‘re-actualization of the class theorem’, which led sociologists to address social stratification more directly.Footnote 125 Sociologists overtly indicated the differences among peasants, workers and the intelligentsia and stressed substantial differences within the working class.Footnote 126 These changes were reflected in the medical field, where experts took on class and foregrounded how low parental education, poor housing conditions and low per capita income hampered the child’s intelligence development. Those factors had a compounding effect, meaning that they could significantly aggravate the condition of being premature. As a study led by Bernhard Meyer-Probst showed, premature infants growing up in a socio-economic environment with some of these factors had an IQ nine points lower than the average by the age of six.Footnote 127 Most studies agreed that ‘unfavourable social conditions can intensify the consequences of biological risks’.Footnote 128
East German experts highlighted that Drillien looked at the ‘intelligence of the mother’ as a key factor in long-term development. They complemented this approach with a classification proposed by Czechoslovak perinatologist Zdeněk Štembera that included factors where the socio-economic and gender aspects intersected. To identify the harmful social factors, experts departed from an ideal of ‘an intact family with the corresponding level of education of the parents’ – having a well-educated mother and father.Footnote 129 The father’s job did not count, but the mother’s ‘unskilled labour’ was a risk factor. The highest risk was if the children had a ‘dissocial mother’; risks were similar, though slightly lower, if the mother was unmarried or did not have a secondary education.Footnote 130 Unlike Drillien, a comprehensive study led by Eggers addressed both maternal and paternal education and concluded that their influence on long-term development was similar and not decisive. However, an alcoholic mother was much more damaging than an alcoholic father.Footnote 131
Poor parenting, either authoritarian or dismissive, was listed in Štembera’s classification; East German experts understood poor parenting as both gendered and classed. Eggers’ study showed that, in relation to at-risk children with developmental delays, ‘tensions in the family, also due to upbringing disagreements, occurred much more frequently …. The living conditions of these children and the housing comfort are much worse; the parents feel subjectively more burdened. They have less time for their child’, so the children ‘are more likely to have behavioural problems’. Low socio-economic status, including poor housing conditions, negatively affected parenting styles. The study also singled out women as the study considered ‘the burden of the mother at home’ – in other words, women out of the workforce or housewives – as detrimental to children’s behaviour.Footnote 132 In East Germany, there was a clear discourse promoting women’s participation in the labour force, with working mothers celebrated as the ideal representatives of socialist society, as studied by Donna Harsch.Footnote 133 While stay-at-home mothers were not condemned, medical studies indicated that they had a higher incidence of premature labour than working mothers.Footnote 134 These challenges were not solely gender-based but mostly socio-economic: housewives generally had lower educational levels than working mothers. Consequently, stay-at-home mothers in East Germany were considered a negative factor for children’s upbringing. Experts considered both low parental education and growing up in an ‘incomplete family’, which in most cases meant a household run by a ‘lone mother’, as a risk factor.Footnote 135 As the socio-economic environment had a decisive influence, growing up in a positive one generated a ‘compensatory effect’, permitting children to overcome developmental deficiencies,Footnote 136 a generally favourable prognosis confirmed by further studies.Footnote 137
Czechoslovakia: conflicted relationship to class and the re-emergence of gender
Although the Czechoslovak experts were familiar with Drillien’s publications, the information they drew from them differed considerably from that of other countries in East-Central Europe. They turned to her research in the mid-1950s, citing her 1948 paper that dealt exclusively with the physical development of premature infants. This attitude never changed. Even in subsequent decades, when Drillien discussed the influence of the family environment and parenting styles, Czechoslovak experts referenced her regarding somatic development only. This different reflection of Drillien’s publications was related to the low interest of Czechoslovak medical doctors in socio-economic factors and the greater emphasis on the physical development of preterm infants.
We argue that Czechoslovak physicians shying away from anything resembling class during late socialism, when expertise in neighbouring countries was considering socio-economic determinants of infant health, was a unique development in the late-1960s sociology in the country. Czechoslovak sociologists undertook an extensive survey in 1967 under the leadership of Pavel Machonin that uncovered incongruences within society along the axes of education, work complexity and income. While income distribution, in general, was rather flat, Machonin noted another feature: status inconsistency along those three axes. Jan Drahokoupil argued that Machonin was critical of status inconsistency – for example, manual labourers who had lower education, low work complexity, yet relatively high income – while the ‘class system was defined by a high degree of status consistency, which was not what he observed in Czechoslovakia’.Footnote 138
Machonin’s research team was tasked with studying social stratification; they worked alongside three other scientific groups researching other key aspects of a socialist society – such as a centrally planned economy, the impacts of the scientific and technological revolution, and the development of a political system.Footnote 139 These four research teams identified rigid and dysfunctional features of socialism, and their findings fuelled the Prague Spring reforms, which were overthrown by Soviet-led tanks in August 1968. As Machonin called for adjusting the social structure towards greater status consistency, in other words, towards a hierarchy resembling a capitalist class system, he was fired and his team dispersed in 1969.Footnote 140
In this light, the sustained disregard for socio-economic aspects, exemplified by the work of prominent Czechoslovak perinatologist Zdeněk Štembera, starts to make sense. In his 1973 book on risky pregnancies, he admitted that foreign literature extensively discussed the effects of poor economic conditions on families and the issue of single mothers. When looking at income levels, Western authors divided pregnant women into five basic groups, which, Štembera was quick to add, did not apply to Czechoslovakia ‘both as a result of the small salary differences in these groups and as a result of increasing the lowest salary threshold’.Footnote 141 Moreover, he concluded that these socio-economic factors were difficult to assess in Czechoslovakia because systematic studies were lacking. However, when he re-published the book on risky pregnancies in 1979, it was a slightly different story:
A deeper analysis of the causes of risky pregnancy and identification of individual risk factors revealed that it is not only biological factors that adversely affect perinatal mortality and morbidity, but also various social factors. Western authors have included them under the common term socio-economic factors, which captures well the most important non-medical risk factors in a class-divided society. We rightly assumed that the risk factors thus defined had lost their importance in a socialist society and therefore, received little attention in the context of the study of risky pregnancies in previous years. Gradually, however, it is becoming apparent that even in socialist healthcare, the care of mother and child cannot be removed from the overall social events (společenské dění) and that their interrelationships must be studied much more intensively and in a broader perspective than before.Footnote 142
As the decade after the tumultuous Prague Spring passed, it became gradually possible to use the lens of class again. Curiously, together with class critique, gender scrutiny emerged. In 1973, Štembera had not seen single mothers as a significant problem in Czechoslovakia because women had access to legal abortion since 1958, significantly reducing unwanted pregnancies.Footnote 143 His view shifted when, in 1979, he newly identified single mothers as a risk factor occurring relatively frequently, as data showed that even though about 6,000 abortions were performed annually, nearly 14,000 infants had been born out of wedlock in 1974.Footnote 144 As Štembera’s scepticism about a classless society took root, the traditional gendered narrative about the dangers of unmarried motherhood returned.
Although Czechoslovakia did not focus on socio-economic factors as intensively as the other countries in the region, several studies were published over the years in which experts investigated a connection between environment and child development. In the early 1960s, experts noted that the mental development of a premature infant was greatly influenced by the social and family environment in which the child grew up, as well as the intensity of parental care.Footnote 145 A poor family environment, at this time associated with parental alcoholism or divorce, also determined a child’s school performance. Experts noticed that children from good family environments were able to achieve good results in school and concluded that ‘our attitude towards low birth weight children must not be pessimistic or even nihilistic, since their school performance can be satisfactory in 50 to 70 per cent [of cases] if the environment is good and stimulating’.Footnote 146 However, a good family environment did not necessarily mean the presence of both parents; as a 1967 study showed, even single mothers or widows could take good care of their children, who quickly caught up with their peers.Footnote 147
In the 1970s, this line of research was abandoned. It re-emerged in the 1980s, following the problem of single mothers mentioned by Štembera. At this time, experts clearly did not share the optimistic view of single mothers from the late 1960s. On the contrary, children with delayed mental development and lower IQs were associated with dysfunctional or incomplete families, in other words, with divorced and single mothers.Footnote 148 The mother’s level of education also became a source of worry, starting in 1979 when Štembera noted that low maternal education was much riskier for the child’s development than low paternal education.Footnote 149 Mid-1980s research showed that 51.6 per cent of children with psychological deviations had a mother without a high school diploma.Footnote 150 However, other experts did not reflect this gender aspect and considered the low education of both parents to be problematic.Footnote 151
Socio-economic factors were more widely discussed in Czechoslovakia in the 1980s when research revealed a higher incidence of mentally delayed children in the lower social classes. The most extensive research on this issue was published in 1980 by psychiatrist Miroslav Vichnar, who identified 34 of a group of 70 children as ‘social cases’. This category included incomplete families, families with low per capita income, poor hygienic conditions, malnutrition, child neglect or abuse, and families with alcoholics, delinquents and parents constantly changing their residence. Often, several factors were present in one parent. Children from these socially poor conditions had lower IQs, poorer school performance and behavioural disorders such as truancy, aggression, cheating, lying and even stealing. Many children attended special schools. Vichnar came to a similar conclusion as his colleagues in the 1960s: ‘There is a noticeable influence of the social environment since many children from good families can attend elementary school even with below-average aptitude if brought up properly.’Footnote 152 Vichnar and other Czechoslovak experts stressed the importance of parenting style for the future development of children as they found connections between children’s ability and neurotic reactions and wrong parental attitudes towards them.Footnote 153 They agreed that premature infants developed normally under medical supervision, so the parenting style should be the same as for full-term infants.Footnote 154 To differing extents, all the East-Central European countries were swayed during the 1970s by a social-environmental outlook underscoring class when it came to assessing the long-term prospects of premature children.
6. Conclusion
When the future is at stake, embodied by the health and prosperity of children, societal values shine through the debates. In the example of vulnerable children born preterm, diagnoses formulated by clinical experts show the changing values of modern societies. We highlight here how socialist societies of East-Central Europe, via their medical doctors and psychologists, wrestled with inequalities that socialism set out to undo: those of class and, to some extent, gender.
Analysing the expert discourses on preterm children’s development over the four post-World War II decades following World War II, we identify across East-Central Europe common shifts and differences, the latter mainly pertaining to each country’s differing interpretation of class within the broader array of human sciences, especially in late socialism. We argue that the common shifts were triggered by shared turning points. The first turning point was brought about by the re-institutionalization of psychology after Stalinism; since the late 1950s and early 1960s, psychology informed medical perspectives on the ‘mental’ development of preterm children with its tools, such as IQ tests, and vocabularies of disturbed behavioural and emotional growth. Importantly, this first turning point would not have been possible without a precipitous drop in infant death in the early to mid-1950s, which meant that many vulnerable children survived – and by the end of the decade, they were old enough to be diagnosed by psychologized clinical expertise as delayed or disturbed in their mental development. Before this first turning point, paediatricians did not see any problems awaiting preterm children; in fact, some leading experts claimed that these children would develop better than children born on time. After this turning point, ‘mental’ issues could not be unseen.
The second turning point was inspired by international knowledge circulation. Interestingly, in the medical area we studied, we found little trace of Soviet influences; we did notice cross-border exchanges within the region, though. We identified an outsized impact of one British paediatrician: Drillien. Drillien’s longitudinal research on the (mental) development of premature children triggered a wave of interest among paediatricians in East-Central Europe: in the early 1960s, Polish and Hungarian experts detailed Drillien’s findings and Czechoslovak experts cited her early findings on somatic growth; by the early 1970s she was widely cited by East German doctors. Most consequentially, international research allowed the East-Central European experts to see the effect of the social environment that Drillien thoroughly addressed. In her view, class ultimately determined how preterm children developed: lower ‘social grade’ families could not provide adequate housing or wherewithal, and lower social grade mothers were not intelligent enough to stimulate their children or consequential enough in their upbringing to right behavioural problems. How could such a classed approach be taken up in ‘classless’ societies?
There are considerable differences among the countries in our study in the ways that clinical experts employed class and understood its effects – the reasons make sense in light of divergent developments at state socialism’s midpoint, in other words, in the late 1960s and early 1970s, and how those were reflected by local sociologies. Polish clinicians noted class only marginally when writing about the development of preterm children in the 1960s; with the popularization of stratification approaches in sociology in the 1970s, and with a more positive view on social differences, clinicians seriously considered selected class markers, such as education, to be important for children’s mental development. East German clinicians paid no heed to class in the 1960s and local sociologists wrote about class only indirectly. When sociologists focused on class differences openly in the 1970s, clinical experts began to see their importance; by the 1980s they embraced the view that class had a compounding effect on vulnerable children. Hungarian paediatricians noticed correlations between poor social environment and poor mental outcomes of premature children in the mid-1960s, exactly when sociologists started to engage in class-based analysis. Since class analysis in sociology was censored in mid-1970s Hungary, we suggest that this shift in discourse affected medical studies that had started before this break but were concluded only after: detailing class markers, yet making no conclusions as to how these affected vulnerable children. Only in the 1980s did clinical research become openly critical when social discrepancies caused by the growing Second Economy were reflected by leading sociologists. The situation in Czechoslovakia was peculiar as its clinical research in the 1970s remained utterly silent about anything resembling class. When a large sociological study was published in 1969 criticizing the inefficiencies of a classless society, it met the atmosphere of quashed reforms of the Prague Spring; the authors of this research were fired from their posts and their institute was banned. We suggest that in the decade that followed, Czechoslovak experts in clinical disciplines were careful not to allude to class; when a leading paediatrician did so in 1979, it was only in a very circumspect fashion. Thus, we suggest that the clinical views of class that we detected in the expert writings in East-Central Europe align with understandings that were prevalent within the human sciences at a given time and place. Nevertheless, expertise in the four countries never became as classed as Drillien’s approach.
Gender was also an important feature after the second turning point, when experts looked closely at the social environment. While mothers were studied more often in terms of the time they devoted to their preterm offspring and the nourishing environment they provided, fathers were always part of the picture: their education and the income they brought, together with their wives, were seen as salient for their families. While the father’s role in upbringing was not emphasized, experts subsumed paternal participation under the ‘parenting styles’ deemed crucial for children’s prospects. While maternal failings were seen as detrimental, experts also underscored the obstacles to their emancipation when their preterm child required heightened care. Unlike the British context described by Drillien, state socialist expert discourses were significantly less gendered.
We showed that socialist medicine was connected to the transnational networks of knowledge circulation throughout the post-war period, with the impact only growing over time. Importantly, we argue that medical knowledge was shaped by the adjacent human-science disciplines, such as psychology and sociology, which changed medical views of the long-term development of premature children. Ultimately, we understand these changes as indicative of shifts within socialist societies over the four post-war decades.
Acknowledgements
This research was supported by the Czech Science Foundation, EXPRO grant agreement GX21-28766X.
Competing interests
The authors declare none.
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