Médicos Titulares and Municipal Malfeasance: The Local History of Public Health in Restoration Spain, 1904–23

Beginning in the second half of the nineteenth century, European states increased their interventions in public health through a combination of direct intervention and the regulation of municipal or provincial authorities. Constrained by budget insufficiencies and with a strong tradition of municipal autonomy, Spanish efforts tended to favor the regulation of municipal affairs over direct intervention.  This strategy of balancing municipal autonomy with state regulation is reflected in the 1904 General Public Health Instruction, which significantly increased state oversight in the hiring, separation, and payment of médicos titulares, doctors hired by municipalities to provide medical service to the poor and serve as local public health authorities. This increased regulation exacerbated tensions between médicos titulares and those municipalities particularly jealous of their autonomy.  Municipal reactions to these regulations can be analyzed through the numerous complaints made by médicos titulares about municipal behavior.  An analysis of these complaints quantifies the divergence between the regulations and actual conditions on the ground and demonstrates significant geographic and chronological variations in municipal compliance. Establishing a stable and uniform public health regime through the enforcement of municipal compliance was a slow and difficult undertaking, which was complicated by deficiencies in the regulations themselves and a political culture that favored negotiation through personal and political ties over uniform regulations. Examining the changes in municipal compliance over time contributes to our understanding of the experiences of medical professionals, local public health, and the political and administrative problems facing the Spanish Restoration state.