Sick Finnish Children: A Local Case

In November 1942 one of the main Swedish newspapers (Dagens Nyheter) published an article with the headline: “One million for the medical care of Finnish war children.” The article refers to the Swedish Government’s decision to contrib­ute financially to the transport and medical care of sick Finnish war children.

Historically, during the interwar years, Sweden had experienced an intensive development of child health care and school health services that led to an improve­ment of child population health and decrease of child mortality. This was part of a broader, more general development in the Nordic countries that marked the first part of the twentieth century, with the Nordic child’s health and body having become the objects of intensive medical surveillance through various health care projects (Andresen et al. 2011; Weiner 1995). The Swedish National Medical Board (Swe. Medicinalstyrelsen) was an important player in various political and admin­istrative initiatives to decrease infectious diseases, like tuberculosis, and to counter further outbreaks through both direct and preventive measures such as improved nutrition and sanitary conditions for poor families with many children (Lundquist 1963). Underpinned by the political visions of the social democratic government, the goal was to combat infant mortality as well as to improve the general health of all children.

Thus, in the light of the success with decreasing mortality rates among newborns and improved child health more generally, Swedish medical experts had acquired an important position in the eye of both the state and the public and consequently assigned important roles in the evacuation of sick Finnish war children.

Many sick Finnish children’s lives could be saved, but this came at a price. The sick war children had very little to say with regard to their situation. The analysis of the local case shows how the transport and movement of sick children were regarded as something obvious and self-evident, in line with the child health politics of the growing welfare state and its mission to save children from physical threats and bodily sickness. The children were perceived as “child objects” rather than “child subjects” (Martin 2011). The children’s own agency and voices were seldom recognized, even though a close reading will demonstrate that there were exceptions.

4.1 Survey and Analysis of Medical Records

The analysis of medical records of sick Finnish war children allows a more detailed discussion of how children were perceived by the experts. The medical records are drawn from a small institution, called Gerstorp, in Linkoping, a town in southern Sweden. Gerstorp was established by a local humanitarian aid movement and was intended for the care of children who had been at the hospital but were not fit to return to their foster family in Sweden or to their family in Finland.

The medical records were based on the traditional format used by the pediatric clinic of the nearest municipal hospital. Formally, they were meant to accompany the children as they moved between different institutions within the county and sometimes even to institutions in other counties. However, a number of records are incomplete in this respect. The Gerstorp archive consists of a total of 105 medical records, which form the basis for the following analysis.

Approaching historical sources like medical case records is ethically challenging in several ways. These records contain important information on children’s lived experiences from their early years, information that is ethically sensitive since it relates to an individual’s personal history and therefore his or her integrity. Many of the child patients may still be alive, and the events and situations in which they were involved can be sensitive for various reasons. In order to protect the child patients’ personal identity and integrity, the material has been approached carefully, and measures have been taken according to the demands of Swedish law, specifically the Ethical Review of Research Involving Humans (the Ethical Review Act). The research procedure in this study has been approved by the Regional Ethical Review Board, Linkoping University (Reg. no. 2012/385-31). The children’s identities have been carefully protected. All names and personal data have been removed from the material, pseudonyms have been used, and personal information that is not relevant to the analysis has been changed.

Firstly, a survey was carried out, in which the children’s recorded age, gender, birth town, family situation, sickness and disease, time of arrival in Sweden, and time of departure, including the number of movements and placements at different institutions during their stay in Sweden, were noted.

All children were stricken by diseases such as tuberculosis (in different forms), diphtheria, measles, otitis, whooping cough, smallpox, etc. Many had multiple infections at the same time. A number of children were also physically disabled, in some cases due to TB infections in their limbs. The survey shows that these children were moved several times between different institutions due to their evolving history of disease. Having four to five placements, in some cases more, during their stay in Sweden was not uncommon.

In the second step of the analysis, a closer reading was carried out, focusing on the construction of children as a specific category. The records consisted generally of extensive medical information and data, with numerous descriptions of the children’s bodies and the various signs of sickness and pathological conditions. Michel Foucault’s account of the medical gaze and the “new turn given to the medical language” in the nineteenth century in The Birth of the Clinic (1973/1994, p. 169) is very apt in this context. The children’s bodily symptoms and signs were reported in great detail, based on both visual and tactile examinations, with images supporting the descriptions. Aspects such as body temperature, eating patterns, and weight recur frequently, while social or emotional dimensions of the children’s situation and condition are very rarely noted.

The medical gaze constructed a medical child, an image that with a few exceptions dominated the records. A second construction of children, albeit less extensive, was the “transported child.” The medical child and the transported child were both positioned as a “child object.” A third construction of children was present in the records but less obvious: it was an image of children as “beings” in their own right.

4.2 The Medical Child

Medical data filled the main part of the records, with detailed and recurrent information about bodily signs and measurements. Visual information on the child’s body - such as marks on the skin; the form of bones and the skeleton; signs of redness and swelling in the ears, nose, mouth, or throat; measured weight and height of the body; and measured temperature with careful recording of fever peaks - was common. Visual information based on X-ray examination and pictures of the interior of the body was also very common. The results of measurements and observations, including marks on the body, were sometimes noted on a daily basis by nurses and caring staff, while comments and notes by the doctors were taken on a monthly basis.

Another recurring pattern in the records are notes on the children’s daily intake of food and time spent resting as well as the amount of time spent out of bed, sometimes stressing the importance of being outside. Doctors set the medical schemes and regulations for each patient, and nurses and volunteers were respon­sible for seeing that these were followed. Developments or setbacks were then noted in the record. A way to account for positive change was to reference the everyday, allegedly normal status to convey the absence of disease. For instance: “Body fat and musculature ordinary,” “Sinus and diaphragm no rem.,” “In quite decent shape,” “Gen. cond. good, beginning to gain weight again, afebrile,” “Good teeth,” etc. Then, after a time, depending on examinations and symptoms, a doctor in charge would issue new instructions for a further treatment plan.

The language is seemingly concise, with short sentences in passive form without a subject, only predicate and direct object. Determining the child’s age or gender solely by reading the notes was difficult and even more so for a reader unfamiliar with Finnish names. “He” and “she” were rarely used, and the main subject was sickness or disease or, more correctly, detected signs and symptoms.

Another linguistic characteristic of these medical records was the amount of information based on the X-ray images and the visual signs of TB. This was referred to as “strakighet,” which can be translated as “densification,” and the scope of these symptoms was either described or actually visualized in the records. An X-ray image of a girl’s lungs, aged 7 years, was commented on as follows:

X-ray: Sinus and diaphr. no rem. L. hilus still concentrated but is smaller than prev. images and has more dense structure. At adjacent C III under hilus pole a dense spot. The concentration in the previous image that had appeared at the upper hilus pole has greatly regenerated. Densification still remains in a penny-sized area at the upper hilus pole.

Based on the X-ray image, detailed information were added to the record. The expressions “dense structure” and “dense spot” refer to important visible signs of TB, which were carefully examined to detect changes, a decrease being a sign of recovery. Descriptions like the above, full of abbreviations referring to the signs and results of the medical examinations and often supplemented with reproductions of the X-ray images, appear frequently in the records. As mentioned, the language in these medical records is reminiscent of Foucault’s account of a clinical language that slowly began to appear in the nineteenth-century medical literature and mate­rial. In his book The Birth of the Clinic (1973/1994), Foucault argues that it was a question of “opening words to a certain qualitative, ever more concrete, more individualized, more modelled refinement,” including plenty of “metaphors rather than measurements,” “simple operations and sensorial qualities,” and “comparisons to everyday and normal,” designed to introduce “language into that penumbra where the gaze is bereft of words” (p. 169).

In the Gerstorp records, the Finnish war children’s bodies were center stage and their individual ailments and changing conditions were carefully recorded in a language of visual representations and images in ways which created the dominant construction of a medical child.

4.3 The Transported Child

The construction of “the transported child” is clearly present in all records through the careful notations of the movement and transportation of children back and forth between Finland and Sweden, with dutiful information about the dates of arrival and return. The transported child was not connected to medical problems. Trans­portation and movements were depicted as a technical matter similar to the notes on the daily intake of food and medicine and with a few exceptions rarely described as a threat to the child’s health. In some cases, when the transportation concerned a return back to Finland, the transport was discouraged by the doctor, with reference to the child’s poor medical condition. The transfer back to Finland was either articulated as a recommendation or rejected through suggestions to postpone it. For instance: “If the child’s home environment is good, then a return is recommended” or “May return to Finland. Dispensary contr. in 4 mths.” Sometimes the doctor made an issue of the return, such as in the following case of a small boy aged 4 years, who according to the doctor’s notes was “efterbliven” (retarded). The following note can be found in the record:

7/8 -47. The boy is after all retarded. His TB is in remission. Here, one could consider return to Finland, if it is certain that the home is good, or if he can receive care at a convalescent home. The best, however, would be for him to be allowed to stay at Gerstorp. 20/8 -47. To Finland.

Doctors do in some cases clearly reject the idea of sending the child back, due to ongoing infections or sickness, while in other cases the recommendation is condi­tional: “If the child’s home environment is good, then a return is recommended.” But often, despite the recommendation, the final notes in the records are most often the following: “Return to Finland (date).”

Table 1 Timeline of different placements in Sweden

The construction of the “transported child” is noteworthy in the way the trans­ports and movements are consistently presented as obvious and self-evident mea­sures, with no hesitation or discussion about the child's relation to, or dependence on, his or her social environment. The child's relation to parents, families, or staff is never brought up; only the dates of leaving or arrival, and medical condition of the child in the light of returning to Finland.

As mentioned above, children were moved four to five times during their stay in Sweden, irrespective of age. The timeline below (Table 1) shows the transfers of a 3-year-old Finnish boy. This boy was born in October 1944 and was moved to Sweden a year later, arriving in October 1945. Though the war was over by then, in the case of sick Finnish war children, the activities continued until 1947, when the Swedish Government decided to withdraw budget support.

To begin with (which is not noted in the record), we can assume that he stayed in a quarantined institutional arrangement for a couple of weeks before being placed at a sanatorium for children in Linktiping, which entailed various visits, including examinations at a Linktiping hospital. This boy, aged 18 months, then stayed at a convalescent home for a year before being moved to the Gerstorp children's home in July 1947, where he stayed another 6 months before being transferred back to Finland.

The decision to place a child, in this case a very young child, in the hospital because of a disease or sickness, was not unusual during this period in either Finland or Sweden. In Finland, tuberculosis among children was common, and in the fight against it, so-called cottage hospitals had been initiated for children without parents (Laurent 2012). Sending children to hospitals for longer periods of time was regarded as an important step in the fight against disease and child mortality in the Nordic countries during this period.

Against the backdrop of the Nordic state's ongoing fight against poverty and ill health, the placement of children in institutions and hospitals was self-evident and accepted by the involved parties on a formal level. Previous research has shown that parents resisted demands to place their children in institutions, but that this was carried out as silent resistance (Areschoug 2000). The norm was to obediently follow the advice of experts, far from today's demands on both children and adults to actively participate in their own care.

In the scientific community, articles problematizing the placement of children in institutions had begun being published. In 1946, the same year the little Finnish boy was being moved between different institutions in Sweden, American psychiatrists Rene Spitz and Katherine Wolf published an article in the journal The Psychoanalytic Study of the Child (Spitz and Wolf 1946). The article described a case of so-called anaclitic depression in a hospitalized child, which was discussed in relation to the separation from parents and a familiar environment. Similar approaches to children and institutions were found in the work of child psychiatrist John Bowlby, who wrote about the situation of orphans in postwar Europe and its social and psychological consequences (Bowlby 1951).

In the Nordic context, such an approach was not present at the time of the war, and in Sweden Bowlby's argument against institutional care in the postwar years was rejected by Swedish child experts (Zetterqvist Nelson 2009). The frequent arrivals and departures of sick Finnish war children to and from Swedish hospitals and institutions for sick children were presented in a taken-for-granted way, without any kind of problematization (Foucault 1988; see also Bacchi 2012). Placing a sick child in a hospital or institution for a longer period was a taken-for-granted measure by both Finnish and Swedish medical experts at the time. In the particular case of Finnish war children, the transnational dimension of evacuation across nation-state borders did not seem to change the underlying assumption held by those involved: transport to Sweden was in the sick child's best interest. The medical discourse created a sick child object, whose bodily condition demanded medical interventions and measures, while social and relational dimensions were more or less absent in the notations and descriptions of the sick war children. However, there were some exceptions to this.

4.4 An Agential Child Subject

Children's individual actions and responses to social interaction were seldom recorded in the medical documents. Commonly, the medical discourse ruled out information about children's actions, wishes, and opinions. Constructions of child agency and subjectivity, however, were not completely absent. The medical records also contained dispersed minor notations of children's actions, which can be interpreted as signs of child agency (Gagen 2001). Such instances created gaps and breaches in the dominant medical discourse. In most cases these notations convey an explicit problematization: “not possible to get an x-ray,” “wets bed every night,” and “cries a lot.” Otherwise, they conveyed an indirect form of problema- tization, pointing out that there had been problems: “now calm,” “this time not crying,” and “now much nicer.” Such short notations provided an image of chil­dren's subjective responses to the medical regimen and procedures. They protested, they asked for something else, they were probably homesick, or they were in pain and other different expressions of the patients as “child subjects” (Martin 2011). But obviously, such behavior or reactions were not deemed important in relation to the medical mission and were mostly omitted.

However, one exception to the mostly negative responses to the children's wishes, protests, or other expressions of subjectivity was found. The medical record of a girl aged 11 years contained one example of a positive response from the medical staff to the girl's individual wishes. In the final section of her record preceding a handwritten note of transfer to the Gerstorp children’s home, the doctor states:

Can only with hesitation be transferred to conv. home, but in consideration of her fairly nervous constitution and above all the wish to accompany her peers to the conv. home, she may however be transferred. She should maintain sanit. regimen and be kept under strict watch.

The way the doctor refers to the girl’s “fairly nervous constitution” in combi­nation with her “wish to accompany her peers” demonstrates an alternative approach to the dominant medical approach. In this short note, the girl is given the status of a (human) being with her own wishes and longings. The doctor also allows this consideration to overrule his medical judgment concerning her TB condition, which is not yet completely cured, and lets her continue with her friends to Gerstorp. This example is an exception but provides a hint of how the doctors and nurses also attended to other aspects of the children’s lives, even though this was not normally considered worth noting in the medical records.

4.5 A Local Case: Concluding Discussion

This local case study demonstrates how the medical approach to the sick Finnish war children arriving in Sweden during and right after the war was anchored in government health politics, with the National Medical Board as a driving force behind the development and medical doctors - pediatricians - as the main child experts. The medical doctors were not only involved in the evacuations of sick Finnish war children but also important agents in the planning of evacuation schemes. Medical examinations of all children arriving in Sweden presupposed a high involvement of medical expertise. For the sick children, whose reception and care was deemed an explicit concern for the Swedish state, an administrative system was available, with preadapted forms for medical records and test results, as was a structure for state-supported budget and funding national health care services. This was a system that had advanced as a result of an extensive population health politics in Sweden, which among other things meant fighting infectious diseases and high infant mortality. In the 1930s, the decade preceding the reception of sick Finnish children, the health politics had successfully reduced child mortality and fewer children were stricken by infectious diseases.

The local analysis showed that the evacuations of sick children presupposed a view of children as objects rather than subjects, even though there were exceptions, in which child agency was recognized. The vision of evacuating sick children from one nation to another was easily combined with the medical mission to treat and cure children’s bodies and to save lives, or put differently, the construction of the transported child was built on a similar foundation as the medical child. Both contained a similar image of children as small plants, requiring good soil and a favorable climate. The horticultural metaphor implied seeing bodily growth and bodily health as primary, and it was the child's material environment that was considered important, drawing on factors such as nutritious food, warm clothes, and clean and hygienic living conditions. The accurate recording of individual chil­dren's location and movements across borders and institutions was not only an administrative challenge to record children's whereabouts, it was decisive from the perspective of saving lives and to reduce child mortality as articulated within a developing national health politics.

A benevolent reading of the local case recognizes the good will and humanitar­ian effort to save sick Finnish children by the Swedish state and NGOs. According to standards of the time, the most prominent experts were mobilized - the pedia­tricians and their scientific medical knowledge and practice. And many children returned to Finland in better physical shape and cured from diseases. A more critical reading sees the powerlessness of Finnish families, both the children and their parents, who were left with no other choice than to follow the instructions and advice of those in charge - either in Finland or in Sweden. Children were not only separated from their family and siblings, they were also separated from their cultural and linguistic context and placed in and moved between hospitals and institutions with little or no influence over the situation. The Swedish and Finnish state involvement in the transportation of sick children limited the opportunities for the involved individuals to make their own decision and have a say in the matter; particularly, the children were highly exposed to circumstances beyond their own control.

5