I PUBLlC HEALTH THEN ANO NOW I

The Population Health Approach in

Historical Perspective

I Siman Szreter, PhD

The origin of the population THERE IS NO DEFINITIVE

health approach is an historic de- history ofthe population health

bate over the relationship betwee[ approach. m living memor;y, the

economic growth and human health, imp~rmnt epi~emiological research1 B.t . dF th 1 d published dunng World War 11 byn ri aln an rance, e n us- ...

" IR I . d. d I .Jerry Moms and Richard Tltmusstna evo utlon Isrupte popu atlon ..

k d minal od I fISffiVO e as a se m e ahealth and stimulated pioneering ul ti. h alth al .1-5

Mpop a on e an YS1S. or-epidemiological studies, informing ris andTitmuss carefully demon-

the early preventive public health strated that the incidence of such

movement.A century-long process of "individual" aftlictiOllS as juvenile

political adjustment between the rheumatism, rheumatic heart dis-

forces of liberal d~ocracy and prop- ease, and peptic ulcer alI varied

ertied interests ensued. according to changing social condi-

The 20th-century welfarestates tiallS, such as the rate afunem-

resulted as complex political mecha- playment Along with others, they

nisms for converting economic growth sought to widen the scope of tradi-

into enhanced population health. tional public.health beyond.dis- Cartoon from lhe September 1919 issue of lhe journal Amer;can C;ty depicting

H th . f " I' b I" ease prevention toward SOCIal lhe defeat of typhoid fever by lhe large-scale municipal measures of water fil-owever, e rlse o a neo I era di t t. d hl . t. IA . C.ty 191921 247 )me cme, antiClpating to some ex- ra lon an c onDa IODo mencan ,. ;: .

agenda, demgratlng the role of gov- .~ t th hil h fth Lal du;;n ep osop ya e an eemment, has once again brought to Report and the World Health Or- factors such as smoking and hyper- The modem arigins of this de-

the fore the importance of prevention ganization's concept of positive tension but that, it is argued, has bate lie in the late 18th century,

and a population health approach to health.6,7 However, social medicine become too rigid and alI-pervasive, when the fOCllS of discussion was

map and publicize the health impacts never successfully institutianalized partly because af its convenience over the significance of the so-

of this new phase of "global" eco- itself and instead an academic and for the administrative and account- called "diseases of civilization,"

nomic growth. clínical epidemiolagy tended, if ing approach afilie managerial such as gout, respiratory diseases

anything, to diverge from practical regime politically imposed on the and tuberculosis, "hysteria," and

public health work during the health service sector during the neuroses.12 The privileged classes

postwar decades.8 1980s.9-11 However, from a were becoming aware that they

The recent resurgence of the' longer-term perspective, the claims increasingly enjoyed a degree of

papulatian health approach has af each af these methodalogies freedom from some of the epi-

develaped from dissatisfaction can perhaps be helpfully located demics that continued to ravage

with some of the limitatiOllS of a within a muro wider-ranging de- the impoverished fiasses (con-

strongly individual-{}riented meth- bate over the relationship between fumed by demographic historians,

odology, whichhas characterized economic growth and human weIl- who have shown that the life ex-

recent clínical epidemialogy. This being, which provides the histori- pectancy from birth of the upper

is a paradigm that has scored no- cal context for the emergence of a classes first began to exceed the

table successes in identifying risk cancept ofpopulation health. average for Britain after 1750).13,14

3 March 2003, Vai 93, No. 3 I American Journal of Public Health Szreter I Public Health Then and Now I 421

IPUBLlC IEALTH THEN ANO NOW; I

Yet this seemed to bring the rich men such as Dr John Heysham of ated urban growth. There can be

an increased tendency to chronic Carlisle and Dr Thomas Percival of little doubt that part of the reason

and mental diseases of "luxury." WaITington taking a lead, resulting for the resurgence of interest in

Furthermore, the poor remaíned in Joshua Milne's first-ever accu- this approach during the last

as mired in their misery as ever. rate life table (the "Carlisle table") 2 decades has been the epidemic-

What did this portend for the fu- in 1815.18 m the subsequent hands scale health problems once agaín

ture health of civilization? ofWI1Iiam Farr, statistica! superin- unIeashed by unrestrained global

Sovereigns had, of course, long tendent in ~arge of Britain's cen- economic and urban growth.

had a military interest in the rela- suses and vital regis1ration system m England, no such academic

tive populousness oftheir do- from 1840 onwards, life table school ofpublic health medicine

mains; with the rise of mercantilist c comparisons became the scientific emerged (although Edinburgh Uni-

thOUght from the 16th century, gold standard of the Victorian pub- versity was a leading center

they were also increasingly aware lic health movement in its attempts throughout the period). This was

ofpopulation as an index of eco- to publicize the nation's urban partly because already by the

nomic strength. Towns also devel- health problems.19.20 1830s severalleading investigators,

oped an early interest in popula- We can taJk of the emergence such as James Kay Shuttleworth,

tion health, taking various in early 19th-century France of a Thomas Southwood Smith,

measures to contain epidemics.15 disciplinary school of public health WI1Iiam Farr, and, above ali, Edwin

But in the 18th century of pro- and social epidemiology with its Chadwick, had direct access to gov-

gressive Enlightenrnent thought, own journal (still published), An- emment office.25-27 Edwin Chad-

the dual revolutions of republican nales d'Hygrene publique et wick, the éminence gIise of the

liberty and expanding commerce médécine légale, founded in British central state in this period,

in Europe and the Americas intro- 1829.z1-24 The leading figures, aimed at an administrative and en-

duced a new rationalist and demo- such as Parent-Duchâtelet and gineering solution to the problem

cratic agenda lt was increasingly Villermé, careful1y documented of high urban death rates, the "san-

coming to be assumed that the de- the diverging incidence of mortal- itary idea" Believing that miasma-, sirable goal of protection from dis- ity in different districts of Paris, re- the odors of organic decay-were

case should apply, in principie, lating them both to the wealth dif- the causes of epidemic disease,

equally to ali citizens of a nation ferentials of the inhabitants and to Chadwick created a national board

state. Secondly, the even more variation in sanitary faci1ities and of health to supervise the building

ambitious goal of positive health services. They a1so demonstrated of a sanitary infrastIUcture to en-

improvement for humans was be- the poor health of sex workersand sure cleansing fIows of water in

coming imaginable.16 of chi1d workers in the textiles in- and out of large cities.z6.28 But in

Meanwhile, however, contem- dustry. Their research showed that trying to force Britain's towns to

poraries were a1so faced with the for the privileged inhabitants of tax themselves for this purpose,

contradictory evidence that the salubrious areas, the march of civi- Chadwick ran into a politica!

world's first industrial revolution lization was probably a net health firestorm of localist, libertarian op-

seemed to be having anything but gain; but, equally, without careful position, which ended bis career.z9

obvious health benefits for the ma- attention to the regulation of the Two decades later, the Royal Sani-

jority ofthe population. Enclosure market economy and to the living tary Commission of 1869 to 1871

and increasing farm sizes were cre- conditions and opportunities of the found that no provincial cities in

ating rural unemployment while fiasses, economic growth could Britain had yet built the integrated

factory machinery rendered cot- have quite opposite consequences sewers system that Chadwick'stage industry redundant 17 The for the life chances of the populace landmark Public Health Act of

new industrial towns were over- in general. Material progress-or 1848 had intended for them.30

crowded reception centers for des- economic growth-apparently had Until the important franchise re-

titute families seeking work. Previ- ambivalent health effects. forms of the period 1867 to 1884,

ous efforts to devise scientific From its origins, therefore, on Britain's electorate was a "shopoc-

measures of health, pioneered by both sides of the Channel, the racy" of small property holders, in-

Graunt and Petty's politica! arith- population health approach has tent on low national and local

metic ofLondon's 17th-century always been stimulated by con- property taxes. Despite the public

bills ofmortaJity, were now ur- cerns over the human costs ofthe health movement's best efforts to

gently redoubled, with medica! excesses of economic and associ- publicize the appalling extent of

422 I Public Health Then and Now I Szreter American Journal of Public Health I March 2003, Vai 93, No. 3

I PUBlIC HEALTH1HEN ANO NOW f

prevent11ble moItBIity in Britain's

towns, delay and prevarication was ~ ,,1

the order ofthe day.31 This was

not helped by the capacity of key

commercial interests, not11bly pri-

vare water companies, to use the

law to dispute any efforts to force '-them to supply adequare clean -

water, in an era before the germ

theory and rnicroscopic water

analysis had estabIished their sci- ..entific authority.32 There would

seem to be something of a parallel

here with the propensity today of

wealthy tobacco companies and

those dealing in other hannful

products to dispute the evidence of

the negative health effects of their

products.33As today's public health move-

ment has also found, vested inter-

ests and property rights forro a

formidable hydra of political and

legal obstacles to the implementa-

tion of the protective measures in-

dicated by a population healthperspective. Because st1many of SAN A TOI:Y MEA8UllES.

the innovative practices and prod- LORO MORPETH THIIOWING PtA~LS 8t'01lt -ALOtRMtN.

ucts, sanctioned by the criteria of

profitability and shareholdervalue, can never be fully assessed compeIling. We ali know that be- senting econornic advance and in- A Punch cartoon from June 1848 ofin advance for the totality of their fore the industrial revolution, life creased human population den- lord Morpeth, the central govern-h alth. li . th bli "fi b tish d h " . also . d b ment's representative, promoting the

e Imp cations, e pu c was asty, ru an s ort, to Slty, was accompame Y bill for Chadwick's Public Health Act.

health movement inevitably finds cite Thomas Hobbes's celebrated greater susceptibility to disease The legislation is depicted as "sana-

itself in conflict with often-power- dictum. m today's advanced and decreased average population tory" pearls being thrown in vaio byfuI commercial interests. An his- econornies, we alIlive longer and health. It seerns most probable the enlightened national statesmantorical perspective shows that this healthier lives. QED: health has that only with subsequent long- to the unappreciative "swine": the.. th 11 . d b f . ad . did ul .lazy, ignorant, and venal councilors1S owmg to e mUinsil;l1lly am- Improve ecause o econOlDlC term aptation por ation f th t., it. t t t I34 o e na lon s c les, con en o wa -bivalent effects that econornic growth. health recover somewhat m the low in their own filth.

growth has on population health. But the human record in fact early modem period, it was the

shows no necessary, direct rela- econornicffily advanced towns that

ECONOMIC GROWTH AND tionship between econornic ad- had the highest moItBIity rates.35

POPULATION HEALTH: vance and population health, But when we come to the

AN AMBIVALENT rather a more ambivalent and "rnodem" industrial revolution,

RELATIONSH.lP contingentrelationship. During and the development of scientific

the mil1ennia of prehistory, the medicine, isn't everything differ-

It is s1ill commonly assumed skeletal record indicares that it is ent? Well, no. The most that can

that it is a prlmary lesson of his- most probable that each of the pe- be said in favor of modem eco-

tory that the process of econornic riods of q-ansitional shift-from nornic growth is that the wealth

growth automaticffily brings with hunter-gatherer to early settled that it accumulates creates the

it improvements in population agriculture, early to advanced longer-term potential for popula-

health-at least in the long run. agriculture, and then to ancient tion health improvements. But

The evidence would seem to be urban civilization-whi1e repre- whether or not this potential is re-

March 2003. Vai 93. No. 3 I Amer1can Journal of Public Health Szreter I Public Health Then and Now I 423

I PUBLlC HEALTH THEN ANO NOW l

those populations directly affected erated by the processes of eco-

by the transatlantic transforma- nomic growth into increased popu-

tion in economic relations qriven lation health for all. Economiç

by the British industrial revolution growth is an intrinsicaJly disruptive

during the period 178Q to 1870 processo The history of 8Jmost ~

endured a significant negative successful economies of ~e West

health impact. The "d~mographic shows that, in the ab~nce of a suf-

fooprint" of this trauma ~mains ficient political response at botJl

clearly visib;le in the historical rec- national state and local govern-

oro of every o~e of ~e countries ment levels, this disruption will re-

where it has been re~earched, in sult in deprivations, disease, ~d

the form af a generation-long, death-the 4 D's.5o Whi1e eco-

negative discontinuit;y in the his- nomic growth may jJe nece~, it

torical trends of life expectancy, is never a sufficient condition for

infant mortality, or height attain- improved pop~ation health.

ments.36-42 In cases of later indus- In Britain's case, the didcontinu-

tria1iZers, such as Germany;3.44 ity in population health was exten-Austra1ia, 45 or Japan;6 the nega- sive, lasting half a centUIy from the

tive health impacts also occurred, 1820s until the 1870s; it contained

but a little later. Nor were the an epicenter of epidemiological dis-

populations of successful industri- aster during the 1830s and 1840s

a1iZing economies the only afies in the central districts of the new

to suffer in this processo lreland, industrialcities, where expectation

for instance, providing cheap of life at birth plummeted to levels

labor to British and American not seen since the crisis years of

cities and coal fields, was devas- the Black Death (Figure 1).39

tated by a fanrine while the Lon- Significant health improvements

don govemment refused to inter- only began to arrear when the in-

vene in "the market"; the Indian creasing political voice and self-

economy, onthe other hand, was o~anization afilie growing urban

careful1y managed in the interests fiasses finally made itself heard,

of British industry and capital, increasingly ~g actual voting

with little regard for the health or power from the late 1860s on-

livelihood of the Indians.47-49 waI$ (a process not completed

The notion that economic until1928). The civic gospel, orig-

growth can automaticaJly or neces- inating in the nonconformist pul-

sarily deliver rising population pits of Birmingham's more well-

IlIustrations from The Lancet of a1iZed depends entirely on a set of health is a comforting myili, but it heeled congregatiQns, was a bold

water impurity in London's com me r- quite distinct social and political is also an elementary fallacy, re- response from neo-patrician net-

cial supplies. By 1851, the micro- negotiations and decisions on how sulting from imputing sufficient works of families within the newscope enabled water analysts to all d .

k . d . h exactly that wealth IS to be used causation to an underspecified urban elites. It snowb e mto a

ma e precise rawlngs suc as

these depicting the organic con- and distributed. The historical rec- model containingjust 2 variables. social movement promulgated

tents of the drinking water supplied oro clearly shows that the process It is 1rue that to achieve the high throughout Britain's proud provin-

by London's increasingly notorious whereby this wealth is created- levels of population health enjoyed cial cities.51 Recognizing the needprivate companies. Some of these economic growth itself-has no di- today in the West, particularly the for an extensive program of invest-companies' defective systems were1 I .

I. t d b ..rect, necessary posltive lillplica- very low rates of infant and neona- ment m mumClpal health ameru-cear y Imp Ica e y ploneerlng epidemiological research into the tions for population health. Indeed, tal mortality, substalitial econOlillC ties and SOCIal servlCes, this new

major cholera epidemics of the in aImost every historical case, the wealth has been a necessary pre- generation of civic leaders devised

period. firstand most direct effect ofrapid condition. But there have aIso new sources offunding from the

economic growth has been a nega- been many, many other factors massive revenues of local uti1ity

tive impact on population health. necessarily involved, of a social, monopolies.

Thus, the latest historical re- politicai, ideologicai, and cultural Enjoying working-class support,

search increasingly confirms that nature, to convert the wealth gen- this political program was a prime

424 I Public Health Then and Now I Szreter American Journal of Public Health I March 2003, Vai 93, No. 3

'c~

I PUBLlC HEALTIf THEN AND NOW r

hiStorical example of cross-class fàctors regarding local political

brid~g arid linking social capiW leaderi;hip and cross-class al-

(i. e., relationships of respect, 1ruSt, liances.57 Similarly, cwrent devel-

and cooperationJ.52,53 Severa! of opmeilts in the Brazilian city of

those ~paigIÚng in hai-d-fought Porto Alegre demons1rate how the

electora! battles on the hustings, politic'al mobilization of the poor

such ás Joseph Chamberlain in and of cross-class brid~g and

BirminglÍam, were among the linking social capiW can change a

most suCcessful managing direc- city's enviroriment and health58; in

tors of leading global businesses. this .latter case, the change may be

They were assisted by the newly all the more secure than in Surat

coriSolidating cadres of public beca~e of more thoroughgoing

seririce professionals, notably mobilization and participation of

Medical Officers of Health.51,54-56 the poptllation.59By the first decade of the 2 Oth A not diSsimilar pattem is visi-

çentury, major British cities like ble in late 19th-century US history,

Birmingham, Liverpool, and Man- where the franchise was already a

chester were virtually welfare wide one and the more broadlystates in miniature. based middle classes played a (where such reform tended to be Joseph Chamberlain, wearing his

This is not just hiStory. The re- more central role in the sanitarian more exclusively elite and state trademark monocle and occupyingcent transformation in salubrity of., and Urban reform movements, led ledJ:4,44,65 was that the urban mid- lhe moral ".hig~ ground," f~g~ting

..., .lhe 1878 Blrmlngham municipalthe laIge Indian CIty of Surat, hit by medical and other profession- dle classes agreed to greater taxes I t.Th d d fi..5360-64 ., e ec lon. ree eca es a erby plague m September 1994, il- ais.' The net restllt, m the on thelr wealth and property, lhe failed Public Health Act,lustrares many of the same key United States, Britain, and Europe while the working classes often in- Chamberlain led lhe Liberal cau-

cwred increased indirect taxes cus, a highly organized party ma-(thtough their use of monopoly chine, to a series of municipal elec-

47 ~, . al . ch d toral victories on an ambitious46 ~;, ~~_-////~~~ murnClp selV1ces su asgas an I tf f .. d. d . p a orm o CIVIC spen Ing an Im-

45 tramways, for instanceJ to make provement. These programs were to

:~ the necessary hefty investments in be finance~ ~rom lo~g:term lo~ns,42 enhanclng and maintaining the revenue-ralslng municipal semces

j 41 overall urban environrnent This such as gas and water, and rising

>- 40 ' cl d d . d b tax rales on property.:;- Jn u e sarntary systems an pu -Ii;:; 39. I~ 38 lic housing, paved and cleansed j

g 37 roads, and health promotion serv- !'3 36 ices from food msp.ectors to uni- ,li!'i! 35 '

~ 34 versa! education, maternity serv- "~ 33 ices to public baths.5O,62,65-70 1-I 32

31 In an era when self-help, laissez-

; 30 faire, and suspicion of central gov-29 nd Wales emment was still the ideological \L

28' )erage arder ofthe day in the Angio-27

Õ :: N '" ...~ -o ...~ õ: õ Saxonpolities on both sides afilie~~~~~~~~~~o- Atlantic, the central state's role was

Date . ariI xh .ctedprlm Y e ortatory, restri to :

Source, Oerived lram Szreter and Mooney.39 providing illformation about death , !

rates and some financial carrotsFIGURE l-Life expectancies at blrth in major British provincial d .. al .cks- dan mspection sti an even

clties, 1801 to 1901, compared wlth the national aggregate trend. this f B .. thwas more true o ntilln an

Note. Britain's industrial cities were signilicantly less healthy than the national average at of the United Smtes.19,20,61,71,72 Inthe beginning 01 the 19th century. Thereafter, they were plunged into an abyss 01 high both countries, the role of munici-mortality during the 1830s and 1840s, which prompted much social comment and a ' .Royal Commission on the Health olTowns during the 1840s. There was some recovery in paI govemment was cntical. Else- :the 1850s, but no real improvements above the levei 01 the 1820s until the 1870s and where, on the crowded continent '

the era 01 "the civic gospel" and municipal "gas and water socialism:' of Europe and in Japan, nationalI

iI

March 2003, Vai 93, No. 3 I American Journal of Public Health Szreter I Public Health Then and Now I 425

1 PUBLlC HEALTH THEN ANO NOW I

security fears and imperial rivalries into enhanced bodily health and the auspices of the neoliberal

had already been conducive to a ever-increasing longevity for the "Washington consensus," a relent-

more precocious interest on the majority of their citizens, resulting less overemphasis on the promo-

part of the state in both the quality in the highest average life ex- tion of free trade and rapid eco-

.and the quantity afilie nation's pectancies in the world. nomic groWth, first and foremost,

supply of manpower-famously so Indeed, the Swedish historical and even ai the expense of gov-

in the case of Bismarck's innova- case is in a sense the exception emment investment in welfare

tive, early German social insui'ance that proves the rule. Industrializa- and health seÍ"vices. To understand

legislation afilie 1880s, the efli- tion carne very Iate in the 19th how such a misleading "common-

ciency of Japan's miIitary medi- centliry to Sweden, and it appears sense" position could have be-

cine;6 and the French state's poli- to have avoided the worst conse- come sodominant, we need to re-

cies aimed at promoting high birth quences of the "4 D's." However, viewbriefly the main ideas that

rates after its defeat in the Franco- this was because Sweden was a continue to inform that consensus,

Prussian war of 1870 to 1871:3 state that had been careful1y mon- insofilr as it relates to population

Eventual1y, also motivated by miIi- itoring its population health since health issues.

tary fears, the early 2Oth-centliry 1749, and it was used to working From the outset of the postwar

British state underthe "New Liber- through devolved, local initiative, era, the overarching theory of de-

ais" began to enact Bismarckian- an administrative necessity in such mographic transition always

I style, central1y funded measures a large country of scattered settle- stro:ngly implied that economic

, aimed at improving the health and ments. Sweden passed compre- growth alone was the ultimare

I physique of its uman industrial hensive public health legislation in source of benevolent demo-

work-force:4 Even the OS federal 1874, at exactly the same time as graphic change. According to this

govemment final1y followed suit in Britain's important second Public theory, nations one after anotherthe New Deal and post-World Health Act. 75 But in Sweden's have moved from the undesir-

War 11 era. case, this was in anticipation of, able, premodern "high-pressure"

j ~ For the liberal, democratic in- not following the ravages of, in- equiIibrium of high birth rates

dustrialized nations, the 20th cen- dustrial urban growth. Thus, in and high death rates to the more

tliry has exhibited a substantial Sweden, as in the 20th centliry eflicient and rational "Iow-

embedding and institutionalization more general1y, economic growth pressure"regime of low vital

of a widening range of mainly was careful1y politically reguiated rates, exempIified in the modern-state-oIganized and tax-funded and managed-in a devolved and ized West 76,77 Economic growth

, preventive health, educationai, not centralized fashion-to ensure is posited as the beneficent motor

i and social services, which be- that population health was im- force standing behind a1l this. It

1 tween them consume a substantial proved, not compromised. effected reductions in mortality

proportion of the growing national by increasing per capita incomes

income. It has been these exten- FORGETTlNG HISTORY: and food supply and by placing

sive"welfare states" that have pri- THE WASHINGTON ever-greater resources in the

marily provided the crucial mech- CONSENSUS hands of increasingly scientific

anism enabling these societies to and professional medicine, facili-

continue to experience relatively The importance and difliculty tating the release of mankind

rapid rates of economic growth of this extraordinary political and from the historic burden of infec-

throughout long periods of the administrative achievement of cre- tious disease and poor nutrition;

20th centliry, while minimizing ating effective welfare instifutidns, transition theory posited that fer-

the disruptive impacts on people's so as to consistently convert raw, tiIity decline then followed in re-

livelihoods that rapid economic intrinsically disniptive economic sponse to increased chi1d survival.

change necessari1y entails. Where growth into enhanced population The postwar international

welfare principies have been most health for the majority afilie ciu- public health, family planning,

thoroughiy institutionalized and zenry, have been profoundly un- demographic, and development

devolved (in terms of their man- derestimated, if not completely ig- communities took it as their hu-

agement), as in corporate Japan or nored, in the policy priorities of manitarian mission to bring about

universalist Scandinavia, these so- the international development or- this demographic transition in as

cieties have succeeded in rou- thodoxy of the late 20th centliry. many other countries as possi-

tinely transforming such growth Instead, there has emerged, under ble.78 From the end afilie 1950s,

426 I Public Health Then and Now I Szreter American Journal of Public Health I March 2003, Vai 93. No. 3

~I PUBLlC HEALTH THENAND NOW I

,

they found themselves the benefi- United States, fertility fell before this time McKeown's intelpreta-

ciaries ofplentiful resources for morta1ity.85.86 tion received endorsement from

these activities from Western gov- In addition to transition theory, an inIIuential intermediary, Robert

emments and from US philan- the separare bistorica! epidemio- Fogel, the Oricago-based Nobel

thropic foundations, as the Cold logica! research of Thomas laureate in economics, in bis initial

War rivairy with the world's com- McKeown on Britain's detailed bistorica! anthropometric work (on

munist states intensified:9-81 civil registers of deaths for the pe- trends in heights and weights).90

Demographic transition theory riod after 1850 has been very in- The strategy of the neoliberal

was, in fact, the projection onto fIuential in giving sustenance to Washington consensus was to

earlier bistory of the seemingly the view that economic growth maxin1ize the scope for free mar-

miraculous experience of the gen- has a directly benevolent effect on ket economic growth, reducing ali

eration in the West who carne to population health. McKeown is govemment-provided, tax-funded

maturity in the interwar decades rightly celebrated as a great icono- public services, including free

of the 20th century. They and clast, who accurately aimed an im- health and aIlied social servires.

their children were the first gen- portant blow at the status and McKeown had supposedly shown

erations to truly benefit from the power of clínica!, scientific medi- these to be of far less value than a

multiple life-preserving and thera- cine, which he saw as abrogating booming economy where health

peutic practica! app~cations of far too muro of the nation's re- improvements were concerned.

the sequence of profound late sources to its own professional Larger ideologica! and geopolit-19th-century scientific break- agenda. 87 McKeown conclusively ica! forces were clearly at play

throughs upon which modern demonstrated that medica! science here. The rising ascendancy of the

medical science is based: evolu- could not have accounted for New Right benefited political1y

tionary theory, germ theory, mi- more than a tiny fraction of any from a widespread practica! disen-

croscopy, bacteriology, and nutri- improvement in morta1ity that had gagement from policy issues dur-

tional physiology.56,82 occurred before the 1930s, when ing the 1980s by the intellectual

But as a theory ~ account for sulfonanrides and antibacterial left, which became preoccupied

morta1ity change in the 2 previ- agents finally arrived. with more abstract issues of philo-

ous centuries, the demographic McKeown's work, however, also sophica! relativism-"postmod-

transition theory rested on slen- had the effect of further reinforc- ernism." ane of its most influential

der historical evidence.83 The rig- ing the simplistic economic deter- figures, Michel Foucault, focused

orous historica! demographic re- minism of demographic transition bis relativist assault on both the

search of the Cambridge Group theory. This was because he ex- authority of medicine and the le-

for the History of Population and plicitly demoted public health gitimacy of the nation-state and its

Social Structure (analyzing data medicine-which he termed "mu- "ofticial" forms of knowledge,

from hundreds of English parish nicipal sanitation"-to a lowly sec- through an exanrination of the

registers dating from the 1540s) ond place, an aIso-ran in bis ac- 19th-century bistory of its treat-

has conclusively shown that for count, while concluding that ment of insanity and the proce-

the key case of England, it was improved living standards, notably dures of the clíniC.91,92 With, its

not, after ali, declining morta1ity rising nutrition, had been prima- suspicion of "the state," the capac-

that was primarily responsible for rily responsible for most morta1ity ity of the postmodernist position

the massive population growth reduction before the 1930s.88,89 to provide a política! challenge to

during the period 1750 to 1850 This left the impression of an even the agenda of the New Right has

but rising fertility brought about more direct link between econom- been rather 1imited, especially as

by falling age at marriage.14,84 In ics and health than in classic tran- one of the legitimating rhetorics of

Britain, morta1ity did not fali sig- sition theory, which had assumed the market is to extol its capacity

nificantly until1870, two decades that medica! science aIso per- to offer unlimited individual

after the industrial revolution was formed an essential role. "choice." The anti-authoritarian,

completed. In fact, the demo- McKeown's message was highly relativist left and the radica!liber-

graphic transition, as a general convenient for the neoliberal as- tarian right have thus concurred,

theory, has been refuted time and cendancy within the field of eco- for rather different reasons, on a

again-for instance, it has long nomics during the late 1970s and vision of an anarchist utopia.

been known that in the 2 sub- 1980s. Johansson has pointed out McKeown's intelpretation was

stantial cases of France and the the significance of the fact that at taken by the New Right as mean-

March 2003, Vol 93, No. 3 I AmericanJournal of Public Health Szreter I Public Health Then and Now I 427

I PUBLlC HEALTH THEN ANO NOW I

ing that "It's the economy, stupid"; and relations of mutual respect health and hygiene98 (for reviews,

to reduce global mortality, the and support-are both crucial. see references 69,99, and 100).

number one priority was to pro- However, it should be noted that

dure as muro economic growth as after the acrimonious dismissal of THE POPULATION HEALTH

possible. Concerns over the distri- the World Bank's controversial APPROACH TODAY

bution of material wealth were pa- chief economist, Joe Stiglitz, who

pered over by fi-ee market apolo- openly attacked the neohbera! Epidemiologists and public

gists' taIk ofthe "trickle-down" Washington consensus polires of health policymakers are engaged

elfect-a surprisingly casual no- the previous decade,96.97 the in a reappraisal of the models that

tion, lacking theoretical elabora- bank's 2002 report appeared to they use to investiga te health

tion or empirical confinnation. display less enthuSiasm for this problems. They have argued that

Saro Preston, the doyen of US de- emphasis. methodologies have often been

mography, launched a timely The tragedy of ali this is that, too narrow: "medical care is but

state-of-the-art, cross-national sta- during the last 2 decades of one of many socioeconomic 'insti-

tistical demonstration to refute this structural adjustment and condi- tutions' (e.g. income maintenance,

aspect ofMcKeown's case, arguing tionality, there has never been social security, education) that af-

that medical technology, in the any strong historical evidence for fect health."IOI There has, in fact,

forro of public health, had been of believing in either the demo- always been a significant stream

most importance in enhancing life graphic transition theory or the of important work since Morris

expectancy, especially in the 20th McKeown thesis view that maxi- and Titmuss-such as that by Gra-

century. Ris analysis, however, mizing economic growth can it- ham, Susser, Marmot, Syme, and

was powerless to stem the ideolog- self produce health benefits. A Berkman-that has explored the

ical flood tide in the economics discriminating evaluation of the wider social and cultural sources

profession.93.94 historical evidence indicares, of epidemiological variation.1O2 A

Poverty reduction and welfare quite to the contrary, that without number of large compilations of

~ as priorities disappeared from the a strongly interventionist role for new research have recently ap-

intemational development agenda local govemment, supported with peared that begin to suggest a re-

for an entire decade, in favor of the resources of the central state, tum to this line of investiga-

"structural adjustment programs" economic growth wiIl seriously tion.1O3-106 Furthermore, a range

and "conditional" loans, which compromise population health. of important editorial and opinion-

slashed public spending and serv- Many who have accepted fonning contributions are now

ices in the evangelical belief that McKeown's thesis stiII do not real- calling for a disciplinary genera!-

fi-ee markets could best supply ize that he never presented any ization of the new approaches and

most goods and servires. Only in positive historical evidence about for muro greater environmental,

the 1990s, thanks principally to food and nutrition in British his- ideological, and global political

the influence of Amartya Sen's tory. By contrast, ali the historical awareness on the part of the pub-

concepts of entitlements, capabili- work reviewed here has carefully lic health discipline.1O7-1I5

ties, and functionings,95 did ex- shown, through primary source At the beginning of the third

plicit ethical concerns about the documentation, that a complex miIIennium, massive disruption

health and welfare outcomes of and continually expanding range due to rapid and relatively unreg-

economic growth reemerge with of social and political interventions ulated economic growth is once

the launching of the United Na- has been vital in securing wide- again upon uso A wide-ranging vi-

tions Development Program's spread health benefits from the sion wiIl be needed to produce

human development indicators. roere accumulation of material the compellingarguments from

A further significant step has wealth. This includes watering, ethical first principies and the ef-

been the recognitionin the World sewerage, the sealing and cleans- fective strategies and policies that

Bank's World Development Report ing of roads, better housing, regu- can core with the health chal-~ for 2000/2001, Part 111, and in lation of the urban food supply lenges it poses. Such a new alter-

eê severa! associated World Bank and environment, enhanced social native synthesis, embracing ethics,

publications entitled Voices of the security measures, the provision of politics, the importance of social

Poor, that empowerment-the po- widely accessible health servires, capital, human security, the eco-

litical voice of the world's poor- and the fostering of a more demo- logical and biological sciences,

and social capital-social networks cratic spread of knowledge about and new approaches to economic

428 I Public Health Then and Now I Szreter American Journal of Public Health I March 2003, Vol 93, No. 3

I PUBLlC HEALTH THEN ANO NOW I

affairs and their measurement, ap- overzealous application of free these same institutions' acquies- .-

pears to be emerWng, one that ac- market policies can even uninten- cence to rising global social in-

knowledges that market economic tionalIy commit "the perfect equality and environrnental dam-

growth may not, in and of itself, crime," removing the epidemiolog- age, exemplified by the OS

be the prime mover of alI that is ical evidence of the health prob- president's unilateral abandon-

of vaIue, especialIy where health lems it creates. It is a primary duty ment of the Kyoto Protocols on

is concerned.95.116-131 The public ofthe international public health climate change.137

health field and epidemiological community to insist on the contin- The population health ap-

science therefore need to be for- uing right of alI citizens to be reg- proach may have a particularly

mulated as a population health istered and counted and the duty important role to play in demon-

approach, capable of engaging of alI govemments to colIect and strating and sensitizing public

\with these related global, ecologi- publicize con-ect, comprehensive opinion to the epidemiological

cal, and local problems. vital statistics on alI persons within early warning signs of important,

In these circumstances, the first, their borders. though gradual, environrnental

essential duty of public health epi- The irony of the long-term his- and ecological changes that mani-

demiologists is to measure and tory of economic growth, the fest themselves oniy at the popula-

publicize the dimensions of dam- marcl1 of science, and the expan- tion levei. An epidemiological ap-

age being dane to the health of sion of markets is that, as we be- proach that prefers to focus oniy

populations. This activity is an es- come ever more independent on individuais' bodies, lifestyles,

sential informational prerequisite from the vagaries of untamed na- and personal risks is less likely to

for mobilizing public opinion, and ture, so we have become ever detect and correctly diagnose the

it tugs as sharply as possible on more intimately interdependent causes of the early effects of these

the consciences of the poweJful on ourselves, on the consequences gradual changes in the world's liv-

elites, making cIear to them the of our colIective actions, and on ing conditions. There is, therefore,

human costs of the wealth accu- the enormous, complex network much researcl1 that needs to be

mulation from which tltey believe of relationships that we call "the dane today from a populationthey profit It is precisely this role market" 136 That interdependence health perspective. .

that a highly committed, smalI set is now more evidently global in

of public health practitioners, in scope than ever. The series of About lhe Authorboth central and local govern- speCtacular national financial s~ Szreter is ~th St John '5 Co~, Uni-

velmtyofCombridge,EngiandHeLSaOO ",i'" C"ment, played m Bntaín durmg the cnses that charaCtenzed the ro-editorofwww.histmyandpolicy,org. li'(",;,

mid-19th-century era oflaissez- 1990s and that show no sign of Requestsfor 7I!prIiIts shou/d be sent to ~:1;~Jf'ilffaire.19.20,132.133 abating as much as the events Sinwn Szreter, PhD, StJohn's Coaege. Com- '()!(!I,;, bridge CB2 1 TP, United Kingdom (e-mail:

ane of the most unfortunate and still-reverberating sequelae of srss@cam,ac.uk),

consequences of the Washington September 11 th, have made this 1his artide lM5 aa:epted Odober 17,consensus policies of structural ad- painfully obvious. 2002,

justment imposed on less ad- However, far more insidiousA k wI d nts. b thre lI ..C no e grne

vanced econOmIes has een a ais to our co ectlve seClll1ty nm aI1icle was completed while lhe au-

weakening of essential state capac- and health are posed by the con- Ihor was an Economic and Social Re-jty to colIect reliable vital statistics tinuous and accumulating social semm Council (ESRC) fellow (award no.

. th . ai . ali d . tal ROO027104l). covenng e most margm sec- mequ ty an enVlronrnen The aI1icle benefited from lhe many

tions of the population-child degradation produced by unregu- helpful comments of Theodore M, Brown,workers, low-paid workers, black lated free market growth; these Elizabelh Fee, Daniel Fax. Daniel J, Fried-

., man, John Lyndl, Steve Kuni1z, Johnmarket workers, mIgrants, may, m the long nm, be even Powles, GeOIge Davey Smith, Barbara

refugees, and remate nu-aI com- more devastating to global popula- Starfield, and lhe 4 anonymous journalmunities. These are the very peo- tion health. There is a stark con- referees,

pie who are paying the principal trast between the highiy energeticR f.,e erenceshealth pnce for the global market response of the world s power 1 M . JN T'tm RM Ep'd 1-.oms, 1 uss .1 enIlO

economy's "successful" growth elite-in the form of the actions of ogy of juvenile rheumatisrn. Lancet, JuIy " " -

rates, achieved through share- the International Monetary Fund, 18, 1942:59-65,holder capital's ceaseless searcl1 the White House and the Penta- 2. Monis JN, T1tm= RM, Heallh and, ..social dlange, I: lhe recent history offor the lowest labor, production, gon-to some of the more V1Slble rheumatic heart disease, Medical Officet:

and fiscal costs.134,135 Thus, and acute political disruptions and August 26, September 2 and 9,1944.

March 2003, Vai 93, No. 3 I American Journal of Public Health Szreter I Public Health Then and Now I 429

I fIU8l1CflEALTH THEN ANO NOW I

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March2003, Vai 93, No. 3 I American Journal of Public Health Szreter I Public Health Then and Now I 431