Health and Wealth: Studies in History and Policy (Rochester Studies in Medical History, Vol. 6)

HealthandWealthPpbkmech

8/29/05

5:44 PM

Page 1

“These essays are an intellectual delight. They also have profound implications for policy. Szreter arrays persuasive evidence that the preconditions for economic growth include economic and social security that is initiated and sustained by effective governments in collaboration with autonomous civic institutions.” —Daniel M. Fox, Milbank Memorial Fund

“To understand Brazil in the 21st century, study the English city of Birmingham in the 19th. The powerful insight at the heart of this nuanced and highly readable account of health and social change is that the lessons of history are fundamental to understanding the relation of economic growth to health. Szreter compellingly argues that growth, without the development of appropriate civil institutions, ultimately may be harmful.” —Professor Sir Michael Marmot, Director International Institute for Society and Health “Simon Szreter has been prepared to grapple with some of the big issues in history, health and economic growth, and their implications for the present. This book is a vivid and outspoken contribution to the necessary relationship between history and policy.” —Virginia Berridge, Professor of History, London School of Hygiene and Tropical Medicine

Health and Wealth Studies in History and Policy

Health and Wealth

“Health and Wealth is applied history at its most perceptive and most timely. Simon Szreter deploys his profound knowledge of the history of mortality to critique Britain’s welfare policies, and to argue that in poorer countries government provision for pubic health should be developed before, not after, economic modernisation. This book is essential critical reading for policymakers.” —John Tosh, Professor of History, Roehampton University, UK

Szreter

University of Rochester Press 668 Mt. Hope Avenue, Rochester, NY 14620-2731 P.O. Box 9, Woodbridge, Suffolk IP12 3DF, UK

www.urpress.com

Simon Szreter

HEALTH AND WEALTH

Rochester Studies in Medical History Senior Editor:Theodore M. Brown Professor of History and Preventive Medicine University of Rochester ISSN 1526–2715 The Mechanization of the Heart: Harvey and Descartes Thomas Fuchs Translated from the German by Marjorie Grene The Workers’ Health Fund in Eretz Israel Kupat Holim, 1911–1937 Shifra Shvarts Public Health and the Risk Factor: A History of an Uneven Medical Revolution William G. Rothstein Venereal Disease, Hospitals and the Urban Poor: London’s “Foul Wards,” 1600–1800 Kevin P. Siena Health and Wealth: Studies in History and Policy Simon Szreter

HEALTH AND WEALTH Studies in History and Policy

Simon Szreter

Copyright © 2005 Simon Szreter All Rights Reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system, published, performed in public, adapted, broadcast, transmitted, recorded, or reproduced in any form or by any means, without the prior permission of the copyright owner. First published 2005 University of Rochester Press 668 Mt. Hope Avenue, Rochester, NY 14620, USA www.urpress.com and of Boydell & Brewer Limited PO Box 9,Woodbridge, Suffolk IP12 3DF, UK www.boydellandbrewer.com ISBN 1–58046–198–0 Library of Congress Cataloging-in-Publication Data

Szreter, Simon. Health and wealth: studies in history and policy / Simon Szreter. p. ; cm. — (Rochester studies in medical history, ISSN 1526–2715; 6) Includes bibliographical references and index. ISBN 1–58046–198–0 (hardcover : alk. paper) 1. Public health—Social aspects—Great Britain—History. 2. Public health—Economic aspects—Great Britain—History. 3. Social medicine —Great Britain—History. 4. Medical policy—Great Britain—History. 5. Mortality—Great Britain—History. I.Title. II. Series. [DNLM: 1. Public Health—history—Great Britain. 2. Health Policy —history—Great Britain. 3. History of Medicine, 18th Cent.—Great Britain. 4. History of Medicine, 19th Cent.—Great Britain. WA 11 FA1 H434 2005] RA485.S97 2005 362.1⬘0941—dc22 2005018352

A catalogue record for this title is available from the British Library. Designed and typeset by Mizpah Publishing Services Private Limited This publication is printed on acid-free paper. Printed in the United States of America.

For Sam, Ben, Zack and all children past, present, and future

CONTENTS

List of Illustrations Acknowledgments 1 Introduction

ix xi 1

Part I History as Critique: Debating the McKeown Thesis and the Postwar Policy Consensus 2 3 4

5

The Population Health Approach in Historical Perspective The Idea of Demographic Transition and the Study of Fertility Change: A Critical Intellectual History The Importance of Social Intervention in Britain’s Mortality Decline c. 1850–1914: A Reinterpretation of the Role of Public Health Mortality in England in the Eighteenth and the Nineteenth Centuries

23 46

98 146

Part II Historical Studies of the Response to the Public Health Challenges of Economic Growth in Nineteenth-Century Britain 6

Urbanization, Mortality, and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities

vii

165

viii 7

8 9

Contents Economic Growth, Disruption, Deprivation, Disease, and Death: On the Importance of the Politics of Public Health for Development The G.R.O. and the Public Health Movement in Britain, 1837–1914 The Silent Revolution in Nineteenth-Century Government:The Rise of Local Government Expertise

203 242 281

Part III History and Policy: From the Past to the Future 10 Health, Class, Place, and Politics: Social Capital, Opting In and Opting Out of Collective Provision in Nineteenth-Century and Twentieth-Century Britain 11 Health by Association? Social Capital, Social Theory, and the Political Economy of Public Health

376

12 Public Health and Security in an Age of Globalizing Economic Growth:The Awkward Lessons of History

416

Consolidated Bibliography Index

448 493

345

ILLUSTRATIONS

Figures 1.1 The “Four Ds”: The Contingent Consequences of Rapid Economic Change 1.2 William Farr’s Propagandizing for the Public Health Movement from the G.R.O. 2.1 Punch Cartoon of Lord Morpeth, June 1848 2.2 Water Impurity in London’s Commercial Supplies, The Lancet, 1851 2.3 Life Expectancies at Birth in Major British Provincial Cities, 1801–1901 2.4 “The Battle of the Wards.” Joseph Chamberlain Fighting the 1878 Birmingham Municipal Election 2.5 American City 1919: The Defeat of Typhoid Fever by Municipalities 6.1 Estimates of Expectation of Life at Birth in Provincial Cities in England and Wales, 1801–1901

8 11 27 28 31 33 34 187

Tables 4.1 England and Wales: Standardized Death Rates 6.1 Expectation of Life at Birth in England’s Largest Cities, 1851–1901 ix

104 170

x

Illustrations

6.2 Expectation of Life at Birth in the Registration Districts of England’s Largest Cities, 1851–1901 6.3 Contemporary Calculations of Expectation of Life at Birth in England and Wales, 1801–1850 6.4 Estimates of Expectation of Life at Birth in Scottish Cities, c. 1841 6.5 Estimated Expectation of Life at Birth in Glasgow, 1821–1861 6.6 Estimates of Expectation of Life at Birth in Provincial Cities in England and Wales, 1801–1901 6.7 Probability Distributions for the Population of England and Wales, 1801–1900 6.8 Expectation of Life at Birth in Other Large Cities in England and Wales, 1851–1901 7.1 Estimates of Expectation of Life at Birth in Provincial Cities in England and Wales 1810s–1890s. 10.1 Local Government Expenditure as Percentage of Total Government Expenditure, and as Percentage of GNP, 1820–1999 10.2 Expectation of Life at Birth and Population Size of the Registration Districts in Seven of England’s Largest Provincial Cities, 1851–1901 10.3 Geographic Distribution of Population Living in Each of the OPCS Environments: England and Wales Census Divisions 10.4 Electorate of England and Wales, 1831–1969

172 176 177 179 188 188 191 213

347

350

354 358

Disclaimer: Some images in the printed version of this book are not available for inclusion in the eBook. To view these images please refer to the printed version of this book.

ACKNOWLEDGMENTS

In addition to my co-authors in two of the following chapters, Graham Mooney and Michael Woolcock, with whom it was a pleasure to work, several of the individual chapters reproduce the notices of gratitude to colleagues and friends who gave helpful advice and comments on drafts of the articles that appear here. During the two decades or so that I have been thinking, researching, and writing about the topic of this book, there have inevitably been a great many other students, colleagues, referees of articles, and participants in seminars and conferences—far too numerous to name—who have also provided much stimulating, critical food for thought. I regret that it is impossible to name them all and can only hope that they find this published work provides them with some small recompense for their generosity. I would, however, like to single out for thanks a triumvirate of fairy godfathers at the University of Rochester,Ted Brown, Stan Engerman, and Steve Kunitz, each of whose work and friendship I value most highly and who seem, along with all the staff at the University of Rochester Press, to have conspired to ensure that this collection of essays achieved the collective form it now assumes. I wish also to express thanks to friends and collaborators at the Cambridge Group for the History of Population, those involved in the History and Policy website (www.historyandpolicy.org), the associates of the Von Hugel Institute, Bob Putnam, and participants in the 2002–3 Cambridge Social Capital seminar, and to colleagues and the administrative staff in the Faculty of History at Cambridge and in the Fellowship of St John’s College for continuing, in these ever more pressured times, to provide an excellent environment in which scholarship can be pursued and its practical dissemination can be practiced. I enjoyed an Economic xi

xii

Acknowledgments

and Social Research Council (ESRC) Research Fellowship (award no. R000271041), during the years 2000 to 2002, which enabled this volume to appear by providing the time necessary to complete a number of the chapters published here.

Parts of this work have been previously published as follows: Chapter 2, “The Population Health Approach in Historical Perspective,” was published in American Journal of Public Health 93,3 (2003): 421–31, and is reprinted with permission of the American Public Health Association. Chapter 3, “The Idea of Demographic Transition: A Critical Intellectual History,” was published in Population and Development Review 14,4 (Dec. 1993): 659–701. Chapter 4, “The Importance of Social Intervention in Britain’s Mortality Decline c.1850–1914: A Re-interpretation of the Role of Public Health,” was published in Social History of Medicine 1,1 (April 1988): 1–37, and is reprinted with permission of Oxford University Press. Chapter 5, “Mortality in England in the Eighteenth and Nineteenth Centuries,” was published in Social History of Medicine 7,2 (1994): 269–82, and is reprinted with permission of Oxford University Press. Chapter 6, “Urbanisation, Mortality and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in NineteenthCentury British Cities” (co-authored with Graham Mooney), was published in Economic History Review 50,1 (Feb. 1998): 84–112, and is reprinted with permission of Blackwell Publishing. Chapter 7, “Economic Growth, Disruption, Deprivation, Disease and Death: On the Importance of the Politics of Public Health,” was published in Population and Development Review 23,4 (Dec. 1997): 693–728. Chapter 8, “The G.R.O. and the Public Health Movement in Britain, 1837–1914,” was published in Social History of Medicine 4,3 (Dec. 1991): 465–94, and is reprinted with permission of Oxford University Press. Chapter 9, “The Silent Revolution in Nineteenth-Century Government: The Rise of Local Government Expertise,” is extracted from chap. 4, “The emergence of a social explanation of class inequalities among environmentalists, 1900–1904,” in Simon Szreter, Fertility, Class and Gender in Britain 1860–1940 (Cambridge 1996), 182–237, and is reprinted with permission of Cambridge University Press. Chapter 10, “Health, Class, Place and Politics: Social Capital, Opting In and Opting Out of Collective Provision in Nineteenth and TwentiethCentury Britain,” was published in Contemporary British History 16,3 xiii

(2002): 27–57, and is reprinted with permission of Taylor and Francis Ltd.The website of Contemporary British History is http:// www.tandf. co.uk/journals. This article was also published in: V. Berridge and S. Blume, editors, Poor Health. Social Inequality before and after the Black Report, London: Frank Cass (2003), 27–57. Chapter 11, “Health By Association? Social Capital, Social Theory and Political Economy of Public Health” (co-authored with Michael Woolcock), was published in International Journal of Epidemiology 33 (2004): 650–67, and is reprinted with permission of Oxford University Press.

1 INTRODUCTION

Questions of health and wealth have been perennial human preoccupations. At the beginning of the twenty-first century economists and social and policy scientists continue to puzzle over this philosopher’s stone. In a world that values democracies, how can we achieve both wealth and health for all, while maintaining our freedoms and the integrity of our environment? The twelve essays in this volume offer an historian’s perspective on aspects of these problems.The essays in Part I cast a critical, historical eye over some of the most influential, general approaches to understanding the relationship between demographic change and economic development during the postwar era.The essays in Part II present original research on relevant aspects of modern British history and offer an alternative interpretation of the principal causes of mortality change consequent on the industrial revolution. The articles in Part III use the historical research presented in the first two parts to address contemporary policy issues and ideas concerning health and wealth. Historical research and the historical perspective can contribute in various ways to the dialogue over wealth and health. One way is by locating historically the most influential theories and models, which guide our

1

2

Health and Wealth

thinking today. This is the method exemplified by the essays in Part I, which use an historical approach to place in perspective current debates over the future of the population health approach and to evaluate critically two highly influential general models of the relationship between wealth and health: the theory of demographic transition and the “McKeown” thesis. (I will describe other research methods when I discuss Parts II and III below.) The opening essay, chapter 2, offers an historical perspective on the population health approach. Many leading practitioners in the fields of public health have become increasingly uncomfortable with the dominant disciplinary methods adopted by epidemiologists over the last quarter century.They have questioned the adequacy of the increasing focus on identifying “risk factors” of individuals’ behavior and on clinical epidemiology to deal with the most important contemporary public health problems. These approaches tend to avoid examination of the wider social, economic, political, and ideological influences, seeking instead to establish direct cause-effect relations at the level of the individual organism, or even at the cellular or molecular level.1 This style of research tends to identify personal risk-factors suitable for treatment by behavioral modification of an individual’s lifestyle or for therapeutic drug interventions supplied by the pharmaceutical industry.The alternative is the population health approach, which seeks to elucidate the nature of differences in average incidences of specific diseases between national populations or large groups.This is more likely to indicate the influence of large-scale, systemic economic, cultural, and structural forces, therefore implying the need for contentious political, legislative, and perhaps global action. I argue in chapter 2 that both approaches are part of a continuous international practice of epidemiological study dating back at least two centuries, each with their respective scientific strengths and weaknesses. The population health approach is intrinsically the more politically engaged, a characteristic which may seem to render it less “scientific” for some. However, an historical perspective shows there are circumstances in which it is the more scientifically appropriate approach to adopt towards problems of disease causation and health promotion.This is particularly the case where rapid economic change is occurring, causing widespread social and environmental disruption of an undesirable kind.

Introduction

3

Thus, the population health approach was pioneered during the industrial revolution era, 1780–1870, as observers attempted to grapple with the enormous scale of insecurities and health consequences created by unprecedented economic and social turmoil and population mobility. I contend that once again, today, in the context of the social and environmental disruptions caused by the acceleration in global economic growth of the last two decades, the population health approach has become of great importance in scientifically detecting the many adverse health impacts of this development. I believe it is vital not to flinch from drawing the politically inconvenient or “radical” policy conclusions that the analysis may suggest. In offering this historical interpretation, as a context for locating the appropriate role and methods of the population health approach today, chapter 2 makes a number of heterodox claims about the historical relationship between economic growth and population health and raises criticisms of the dominant models of demographic change during the post war era. As these perspectives are drawn from the historical research presented in the subsequent essays, I hope that by placing this article with its many summary claims at the beginning of the volume readers will have an early indication of the framework of historical research on which the interpretation is based and can then go on to examine for themselves the more detailed research on which it is based. Chapter 3 examines the historical provenance of the theory of demographic transition. The notion that modern economic growth has invariably been associated with a “demographic transition” of beneficent mortality and fertility declines has been one of the most important ideas in the liberal social sciences throughout the entire period since 1945, endorsed in their plans by many national governments and by all the principal global governance institutions, from the U.N. to the World Bank. It has provided an important part of the justification for the general policy presumption that national economic growth is an invariably and automatically desirable goal and should be encouraged everywhere as much as possible. Furthermore, the apparently logical corollary of demographic transition theory—that economic growth can itself be facilitated by inducing population change—has seen the application of extraordinarily draconian family planning policies by the governments of the two largest nations in the world, India and China.

4

Health and Wealth

Chapter 3 shows that the rapid postwar rise to preeminence of the theory of demographic transition—and its apparent sanctioning of a commitment to proactive family planning—were both intimately linked to the U.S. liberal establishment’s perception of the emerging threat of communism. During the first decade of the Cold War a fully elaborated liberal orthodoxy on the linked historical relationship between economic growth, “modernization,” and demographic change, along with its policy implications, was constructed as an explicit alternative to the Marxist model of historical change. Despite many critiques and the development of various radical alternatives, this capital-accumulation-centered growth model was not to face a serious challenge to its ascendancy as the common sense of the liberal economics discipline until the postcommunist era of the 1990s.2 Although North American intellectuals and institutions provided much of the driving force behind the elaboration of this postwar liberal academic and policy orthodoxy, it was to the history of British economic and demographic change since the industrial revolution that they turned to seek the most persuasive empirical support for their theories of economic and social change.3 This was for two reasons: first, because of the unusually extensive range of high-quality historical evidence that was available for reconstructing the relevant aspects of Britain’s long-term economic history; second, because it was the original, paradigm case of liberal capitalist industrialization. Thus, W. W. Rostow’s extraordinarily influential general model, published in 1960, The Stages of Economic Growth (subtitled An Anti-Communist Manifesto), which provided a blueprint for how industrial “take-off ” is to be successfully achieved (by attaining a certain savings ratio, i.e., proportion of national income saved for investment), was anchored in his own decades-long research on the British historical case as the main illustrative example.4 Simultaneously with Rostow’s research, during the 1950s, Professor Thomas McKeown, a North American working in Britain, was investigating with his colleagues Britain’s uniquely detailed nineteenthcentury cause of death records. McKeown produced the most influential empirical analysis of the mortality component of the demographic transition (which in 1971 was to be more precisely specified as the “epidemiological transition”5). A series of research articles from 1955 onwards was summarized in McKeown’s best-selling The Modern Rise of

Introduction

5

Population, published in 1976.6 McKeown’s work was an intriguing combination of the radical and the conservative. His thesis was subversive of the claims of one liberal myth, that of his own profession of medicine, which, he argued, had played no more than a minor role in the modern decline of the many communicable diseases. But his analysis supported the liberal orthodoxy of the “demographic transition,” arguing that population growth was principally due to reduced mortality and that this was, in turn, attributable to the direct fruits of economic growth. McKeown claimed that most of the documented improvement in mortality that had occurred in Britain between the mid-eighteenth and the mid-twentieth centuries should be attributed to the growing economy’s capacity to improve living standards, notably per capita food supply. McKeown’s principal policy message was easily understood to be that the health improvements of demographic transition followed automatically from successful capitalist economic growth. The best doctors for improving population health were the economists, wielding their economic growth model of Rostovian take-off for each and every national economy. Chapters 4 and 5 take issue with McKeown’s summary analysis of the British epidemiological evidence. They place the trends, which McKeown derived from the official cause of death data for England Wales from 1850 onwards, in the context of the more recent findings of demographic historians in the 1980s regarding fertility and mortality trends over the previous several centuries, 1540–1850.7 Chapters 4 and 5 point out that the extremely rapid and precocious urbanization of the British population rendered entirely implausible McKeown’s assumption (and that of another historian, Sumit Guha, who came to McKeown’s defence) that the aggregate epidemiological patterns and trends recorded from c.1850 onwards in the official registration records would provide an accurate guide, which could simply be extrapolated backwards to account for mortality history during the previous century and a half. In chapter 5 important research by John Landers and Mary Dobson is cited in support of this point, which has been further confirmed by the more recent work of other scholars, demonstrating that the pattern of age-specific death-rates in the early modern epidemiological regime before the early nineteenth century was very different from that of industrializing Britain.8

6

Health and Wealth

Furthermore, as far as the detailed epidemiological patterns from 1850 onwards were concerned, chapter 4 also shows that McKeown had misleadingly glossed over a number of important anomalies in his own interpretation of the evidence, which, when corrected, produce quite the opposite main conclusion from that which his work was believed to have established. This has profound policy implications, since it means that the careful work performed by McKeown and his team—the statistical analysis of the best historical cause of death data in the world for a large national population—had not, after all, shown that rising real wages and improved nutrition were the primary cause of falling mortality. Instead, McKeown should have been using his enviable communication skills to popularize the message that the British historical epidemiological evidence shows that preventive public health and municipal sanitation measures (though not “high tech” medical science) had the greatest single effect on reducing mortality levels in Britain in the second half of the nineteenth century.9 Chapter 5 reproduces my response to a critique by Sumit Guha of my original 1988 article. It is included here because, in responding at length to Guha, I presented a considerable amount of additional evidence and arguments of direct relevance. In Part II there follows a series of studies that further research the nineteenth-century mortality patterns in Britain and develop a distinctive alternative interpretation of the principal course and causes of mortality change, quite different from the demographic transition model and the associated McKeown thesis.This is a second way in which history can influence policy. Chapter 6 investigates more systematically than previous researchers the curious nineteenth-century discontinuity in national aggregate mortality patterns, which had been unknown to McKeown in 1976 and which represented an anomaly for demographic transition theory. In 1981 the new findings of Wrigley and Schofield (see note 7) showed that a trend improvement in the nation’s health accompanying the early stage of industrialization, which had been in train since the mid-eighteenth century, was interrupted for over half a century, 1811–1871, during Britain’s most prolonged period of sustained economic growth. Focusing on urban mortality patterns, chapter 6 demonstrates that, in addition to the centuries-old “urban penalty” of differentially higher mortality in towns, there was also a further sharp deterioration in the expectation of

Introduction

7

life at birth in Britain’s industrial towns and cities during the latter stages of its industrialization, c.1825–1850. Quite to the contrary of the demographic transition model, industrialization resulted in a sharp rise in mortality for precisely that part of the population most directly involved in the modernization of the economy and of social life in general. Although the life expectancy of industrial urbanites subsequently recovered somewhat in the 1850s, it was still no better at the beginning of the 1870s than the relatively deficient level (well below the national average) obtaining in the 1820s. Only in the last three decades of the nineteenth century, a hundred years and three to four generations after the economy began to experience the rapid growth rates of Rostovian “take off,” did the health of the urban populace finally appear consistently to draw absolute gains from the nation’s vastly increased flows of wealth, such that by the beginning of the twentieth century some cities were becoming almost as healthy as the improving national average. In order to explain the specific chronology of this complex pattern of mortality change, chapter 7 investigates in greater depth the thesis of the importance of social intervention as laid out in chapter 4. Drawing on the work of many other historians of central and local government and of public health, I argue that, although the celebrated Health of Towns movement in the 1840s and the Sanitary Idea had, indeed, resulted in the famous, first-ever national Public Health Act in 1848, national legislation was nothing like as important for the population’s evolving health fortunes as the provincial politics of “voice” in local government affairs. The population health of the heaving towns and cities, receiving wave after wave of migrants seeking work in the multiplying factories, was primarily in the hands of its local government authorities throughout the whole of the nineteenth century. The savage deterioration in life expectancy during the second quarter of the nineteenth century was due to the failure of both unreformed and, after 1835, nominally “reformed” municipal corporations to mobilize collective political will to tax themselves sufficiently to invest in the necessary measures to improve their deteriorating urban environments. Jealous protection of the right to local self-government in towns run by and for small businessmen and shopkeepers anxious to keep the local rates bill as low as possible, along with a dominant national ideology of minimal government intervention and free markets, ensured that the 1848 Act was

8

Health and Wealth

Fig.1.1 The “Four Ds”:The Contingent Consequences of Rapid Economic Change.

Disruptions: Social Environmental Cultural Ideological Administrative Political Deprivations: Entitlements and Capabilities Diseases:

Physical and Psychological

Deaths

only used selectively over the next decades. Outside the capital, British citizens had to wait until the 1870s before the national government legislated a set of mandatory public health duties on all local authorities, although even then much discretion remained in local hands. Chapter 7 also proposed that British history illustrated a general thesis of “the four Ds”: that industrialization, or indeed, very rapid economic change in any context, entails disruptions, and, ceteris paribus, consequent deprivations, diseases, and deaths. Figure 1.1 depicts the general thesis of the “four Ds” in graphic form. It indicates that, if left to its own devices, the multifaceted disruptions of rapid economic growth will necessarily produce deprivations among many of those who experience it. In the absence of appropriate remedial responses, such deprived persons will contract diseases which may, in turn, increase the incidence of premature death, if not addressed adequately. However, the thesis of “the four Ds” is not quite as gloomy a prognostication as at first sight it appears. Figure 1.1 shows dotted lines between each of the “four Ds” to indicate that this is a contingent, sequential model offering conditional predictions.The history of many countries experiencing rapid economic growth for the first time indicates that the model’s grim unfolding beyond the first “D “of disruptions is not necessary and inevitable. Societies affected by rapid economic growth can devise the means to protect themselves from serious deprivations occurring in their population; or, if not, they may still find sufficient resources

Introduction

9

to prevent the deprived from suffering from debilitating diseases; or, if not this either, they may yet take sufficient action so that the diseases of the deprived do not cause extensive premature death. But if they do none of this, “the four Ds” will unfold to their lethal conclusion. In Figure 1.1 the political dimension of the first “D” of disruption is in italic because history indicates that this is the most crucially important issue. British history demonstrates that because rapid economic growth disrupts societies politically, it is all the more difficult for them to formulate the kind of effective social and administrative responses needed to avoid deprivations and the further consequences of diseases and death. Of course, part of the reason why they are disrupted politically is that so much else is simultaneously at stake. Morality, culture, social habits, ideas, and ideals, as well as so many aspects of the physical environment, are all typically under challenge during periods of rapid economic growth.This may be why it is hard to find examples of any national populations, before the availability from the 1940s of highly effective and relatively cheap medical technologies, whose health trends have not been negatively inflected by the industrialization of their own national economy or of the markets on which they depended.10 Although local government was key, chapter 8 investigates one important, but easily overlooked, way in which central government in Britain did, however, provide a form of leadership and continuous contribution to the Victorian public health movement throughout this difficult mid-nineteenth-century period.The Office of the Registrar-General, set up in the first year of the young Queen’s reign in 1837 to keep a civil record of all individuals’ births, deaths, and marriages (primarily for property registration and inheritance purposes), was immediately and somewhat fortuitously hijacked by the nascent public health lobby. By the beginning of the 1840s the Registrar-General’s Office had also captured the administration of the decennial census as part of its duties, so enabling its innovative Statistical Superintendent,William Farr, to provide England and Wales and each of its 630 Registration Districts with accurate information on comparative mortality patterns—a vital intelligence resource still lacking in most of the world’s poor countries today. Though debarred from acting on this knowledge by the self-denying liberal ideology of non-intervention, the central government, through the analytical activities of the General Register Office, nevertheless pumped out

10

Health and Wealth

a ceaseless flow of propaganda from the 1840s onwards. Farr never tired of finding new ways to measure the comparative death rates of different parts of the kingdom and to communicate as graphically as possible the central message that a massive waste of preventable mortality was occurring in most towns and cities, an example of which is reproduced in Figure 1.2. Nevertheless, as chapter 7 shows, this information campaign, by itself, was unequal in the short term to the task of swaying the pennyconscious petty bourgeois ratepayers of urban Britain to vote against their perceived financial self-interests and to endorse significant municipal spending on their sewers and streets. However, an important widening of the municipal electorate in 1869 transformed the political arithmetic.With the respectable working-class enfranchized for the first time, this new political voice was successfully harnessed to support a new agenda of expansionist municipal activism, with Joseph Chamberlain’s Liberal caucus in Birmingham pioneering the new municipal politics of “gas and water socialism,” as its opponents dubbed it. As E. P. Hennock demonstrated, in his foundational research on this subject, the powerful ethical code driving this program was provided for Chamberlain by a handful of remarkable, nonconformist Birmingham divines, who had been literally preaching a “civic gospel” for many years before 1869.11 Now, with the changed electorates of working-class voters (who did not pay local rates), there was no longer the barrier of brute, petty bourgeois self-interest to prevent the ideals of the civic gospel from inspiring a political reality. The interpretation offered here, therefore, is that it is provincial local government politics that should rightly occupy center stage in the causal story of mortality change in nineteenth-century Britain. National politics and central government was also an important driver when it legislated significant constitutional changes for the towns, as in 1835 or 1869. But it was municipal governments that had most influence on the health fortunes of the urban population, both when they failed to act in the 1830s and 1840s and when, energized by the civic gospel and a proactive municipal rivalry, they eventually did begin to act in the 1870s. The nascent public service professionals increasingly employed by municipal councils, and the relations of both of these with the changing character of social capital—the civic associations of working men and of

Introduction

11

Fig. 1.2 William Farr’s Propagandizing for the Public Health Movement from the G.R.O.: Graphic depiction of the extent of preventable mortality occurring in Liverpool in 1841.

Source: 5th ARRG, pp. 50–51 (PP, 1843, XXI), reproduced in Eyler (1979), 136.

women as well as the middle classes—were all integral parts of a burgeoning provincial social movement. Indeed, as Table 10.1 in chapter 10 shows, by 1905 this wave of municipal activism had resulted in a situation whereby local government expenditure actually exceeded that of central government in absolute terms, for the first and only time in modern history. Between 1875 and 1905 it was provincial municipal governments, not central government, that were much more likely to make significant innovations in the provision of social, medical, and preventive health measures. In this period, national government intermittently stepped in to generalize certain best practices that had already been locally pioneered and road-tested, and increasingly provided grants-in-aid, but rarely led the way. For instance, the vitally important system of compulsory infectious disease notification was pioneered by the city of Bolton in 1877, well over a decade before it became the subject of national legislation and, as chapter 9 points out, it was the city of Bradford that first employed a School Medical Officer, well over a decade before the national government created a system of school medical inspection.

12

Health and Wealth

Chapter 9 presents another dimension of the importance and influence of the public health movement. There has been a pronounced tendency in the historiography to portray the New Liberal administration, elected in 1905, as the most important source of government activism in the history of social and health policy before 1939. Its legislative record was certainly a sharp contrast with previous decades of relative torpor on “social problems” in Westminster, which were seen as the small beer of local politics beneath the dignity of the Empire’s legislature.After 1905 the New Liberals rapidly created a number of important, centrally organized and tax-funded services, such as old age pensions, free school meals, school medical inspection, labor exchanges, and a national insurance scheme. However, it is also acknowledged by historians that a significant part of this new thinking in central government, especially in the field of health policy, can be traced to the outcome of the famous Inter-departmental Inquiry into Physical Deterioration of 1903–4. Certainly school medical inspection, free school meals, a new notification-of-births act, and recognition of the importance of infant and maternity services all came directly from the recommendations of this Inquiry’s Report. Chapter 9 examines key aspects of the proceedings recorded in this official document to show how the testimony of medically trained officials, with detailed local knowledge built up in their practical work in the cities over the previous several decades, strongly influenced the Inquiry’s conclusions. Without this contribution, the national government’s subsequent turn towards a more proactive direction of national domestic health and social policy in the decade before the Great War might have been forestalled. Government policy might either have remained in limbo or even taken the radically different path of social segregation and possible sterilization of the poor favored by the leading exponents of the new science of Eugenics, whose claims regarding “racial” hereditarian deterioration had initially been taken very seriously by the 1903–4 committee of Inquiry, as its title indicates. Chapter 9 agrees with previous historians’ estimates that the 1903–4 Inquiry was an important juncture in the history of the nation’s social and health policy. National government policy and leading-edge scientific theory and debate came into direct contact at this forum. It was a pivotal moment of intellectual contest when the competing claims and interests of evolutionary science, conventional morality and religion, preventive public health principles, concepts of social stratification, and

Introduction

13

early educational psychology were all being evaluated together in an official enquiry, making the story a particularly complex one to reconstruct. This is perhaps one reason why the crucial importance of the provincial public health contribution, with its strong roots in municipal local government practice, has not been sufficiently appreciated before in determining the outcome of this Inquiry and its influence on subsequent national social and health policy. The essays in Part III offer a balance of emphasis somewhat different from those of Parts I and II. Most of the earlier essays present various forms of historical research on key theories or events and processes that influence our historical understanding of the causes of mortality decline in Britain and, in so doing, carry implications for contemporary public policy discussions. Conversely, the essays in Part III are constructed primarily as explicit contributions to the discussion of various contemporary policy concerns.These essays are attempts to mobilize the specific value of the historical perspective and of already published historical research to make a distinctive historical input to current policy debates and issues. Chapter 10 was originally conceived as a contribution to a collection of essays on class inequalities and health, seeking to place the famous Black Report of 1980 in historical context.12 It takes a relatively longterm perspective, supplementing the research on mortality change in the nineteenth and early twentieth centuries offered in the chapters of Part II, with a survey of certain key aspects of mortality patterns and public policy during the course of the subsequent twentieth century. Chapter 10 argues, first, that dynamic interactions between class and “place,” typically operating in English communities through the processes of residential segregation, need to be more fully recognized in research on the relationship between inequality and health. The most exacting historical research recently completed has established that residence in different kinds of local environments or “places” c.1900 had a greater influence on mortality among the very young than the class status of their household and their parents.13 Second, chapter 10 puts forward an interpretation of a larger-scale sense in which “place” interacted with class in modern British history. It argues that long-term regional effects have had profound influences on the political demography of the nation, which have to be taken into account in explaining the historical

14

Health and Wealth

shifts in support that have occurred for social exclusionary and social inclusionary welfare and health policies. The period of industrialization saw a profound shift in the population balance of England and Wales, with the agriculturally richer south losing its long-standing numerical dominance. In 1700, 70 percent of the population lived in the south. By the beginning of the decade in which two acts of parliament, in 1918 and 1928, granted universal suffrage, the 1921 census registered the fact that over 60 percent of this predominantly urban and proletarian electorate now lived in the north and midlands. Chapter 10 argues that, ceteris paribus, the disposition of a propertyowning electorate has tended towards opting-out of expensive, collective measure of welfare and health provision, whereas it has been in the interests of the propertyless poor to support such policies. The preponderantly southern electorate of property-owning ratepayers, which dominated British national politics until the twentieth century, returned national governments committed to minimal taxation and welfare measure. However, the inexorable demographic rise of the north and the belated enfranchisement of the propertyless, resulted in the gradual shift to a politics of social inclusion and spending on collective measures of social security, health, and welfare. Initially this was expressed only in municipal politics in the midlands and the north, but from the beginning of the twentieth century increasingly national politics also succumbed to this influence, as chapter 9 documents. Furthermore, in the special circumstances of class rapprochement prevailing after the nation’s fight for survival in World War II, this culminated in the election of the political party of the north, the Labour party, to national government and the institution of a new, collectivist national approach to welfare and social security, with the creation of the welfare state. The problems of persistent class inequalities in health, investigated by the Black Report in 1980 and continuing to exist today, are then placed in this interpretative framework. The 1945–80 welfare state did in fact achieve substantial reductions in absolute (but not relative) inequalities in overall health and income. However, paradoxically, it was this very success of the collectivist welfare state and full employment policies of the postwar era—in delivering enhanced security, relative affluence, and the possibilities of property-ownership to an increasing section

Introduction

15

of the working-class—that created the political opportunity for the New Right to launch an electorally successful appeal for the return to a politics of “opting out” of the expensive measures of collective state provision, now that the electorate was once more, as in the mid-nineteenth century, dominated by the interests of small property-holders. Chapter 11, coauthored with Michael Woolcock, presents an historically grounded contribution to the academic and policy debate within the public health field surrounding the innovative concept of social capital. The essay offers an attempt to grapple with the concept’s definition and its theoretical and policy implications in the context of its application to modern British history.The fundamental insight of social capital theory is that relationships are resources, or at least potential resources. The resource value of any given relationship may vary from the nugatory, if for instance the relationship is merely a cursory exchange perhaps even devoid of eye-contact, to the all-important and all-consuming (as between lovers, for instance). However, the vast majority of social relationships fall between these two extremes, creating and maintaining varying degrees of mutual identification, trust, obligation, and commitment. Most individuals most of their lives are interacting with others and engaging in relationships in a variety of linguistic and physical contexts, which are themselves embedded in various local and national cultures and histories. Social capital theory offers the possibility of being able to study the way in which potentially important social, economic, and political resources are generated and maintained by these diverse relationships, which are structured by political contexts and by emergent networks and norms of different kinds. It has been applied empirically by Robert Putnam to argue that historical variation in the forms of social capital has had both highly positive and negative effects on the political, the economic, and the physical health of communities, states, and whole nations. In Putnam’s most substantial contribution to date, Bowling Alone, he recognizes two distinct genera of social capital, bonding and bridging.14 Bonding social capital networks are formed by those for whom an important element of their participation is the assertion of members’ social similarity to each other and the exclusion of other social groups, such as Britain’s interwar suburban tennis clubs.15 Bridging social capital refers to voluntary association among those who perceive themselves to be unalike—such as Putnam’s American bowling league teams in the

16

Health and Wealth

1950s where blacks and whites played in the same teams even in the decade before the civil rights movement. Bridging social capital is the more unusual and the more valuable kind of social capital for a democratic polity. In the public health field, there is a vigorous contemporary policy debate among leading social epidemiologists which is reviewed in chapter 11. It is argued there that the concept of social capital can be helpfully reformulated to distinguish “linking social capital” as a third form in addition to Putnam’s bridging and bonding forms. The concept of linking social capital enables those studying social capital to include in their analysis relationships and networks that are established across formal, institutional power gradients, such as when individuals encounter officials of central or local government—the police or social and medical workers—or representatives of the media, of religious bodies, of commercial corporations, or of N.G.O.s in today’s poor countries.These are all crucial areas of interaction where the history and current practice of public health are concerned. Chapter 11 then provides a condensed review of nineteenthcentury British mortality history, arguing that trends in linking social capital—reflected in the relative responsiveness of elected local government to the needs of the urban poor—tended to move in tandem with related shifting balances between bonding and bridging social capital. Thus, the civic associations, religious sects, and voluntary associations of early nineteenth-century British society embodied a relatively exclusive ethos, generating a plethora of institutionalized bonding social capital. In fact, with the urban crisis of the 1830s and 1840s came the first glimmerings of a long-term reaction to this social exclusionism. From its foundation in 1847 George Dawson’s Church of the Saviour in Birmingham provided a paradigm and leading case of a new emphasis on linking social capital. Dawson insisted that there would no exclusive creed demanded of his congregation. His gospel was that the entire city should be approached as a corporate body, of which his church was a microcosm, and that the city’s elected authority, its Council, should be the core of this spiritualized “city as church.”16 Dawson was in effect proposing an ethical transformation in the purposes to which the town’s social capital should be put, entailing cross-class cooperation. Perhaps not surprisingly, it took nearly three decades before Dawson’s novel message,

Introduction

17

the civic gospel, began to be more widely influential, eventually catching on in other cities once a successful pathway had been pioneered during the mayorship of Joseph Chamberlain in the 1870s, summarized thus by his most recent biographer: Chamberlain had accomplished a great deal as mayor of Birmingham.The policy that he worked out combined industrialists and their associates from the professions, including the leading Nonconformist ministers, together with organised labour, in an alliance which addressed palpable needs of the town and established guidelines for future civic action.17

Finally we turn in the last essay of Part III to reconsideration of the pressing policy issues of health and wealth in the world’s poorer countries today. Can the study of the history of Britain when it, too, was economically less developed be of any value in giving practical pointers for the policies that should today be prioritized in these very different times and places?18 Britain’s history, I argue in chapter 12, indicates that today’s developing societies require the social resources flowing from a combination of three state-sanctioned institutions in order that their populations can survive the rigors of rapid economic growth without succumbing to the “Four Ds.” These three institutions are: a universal system of civil, legal registration for all individuals from birth to death; an effective nationwide social security system; and the constitutional or legal guarantee of the key autonomous civic institutions of elected local government, freedom of association, and a free press.The skeptical counter-argument that would be mounted, by for instance proponents of the Washington consensus view, would be that these three institutions are “unrealistic” luxuries that poor, developing countries could not possibly afford until after they have developed economically. Or, there is the “Malthusian” argument: that these institutions are misguided distortions of the free market—notably the expense of a national social security system—that can only stymie, not promote economic growth. However, chapter 12 points out that in the case of England (and Wales) most of these institutions, notably including the social security and registration systems, came into place during the centuries preceding the industrial revolution and so should properly be understood to have been causes, not consequences of the world’s first successful industrialization. Thus, in the only single case in history in

18

Health and Wealth

which industrialization and market expansion happened spontaneously— in Britain—it did so with the assistance of these key institutions, not in their absence; and the industrializing population’s health experienced a mortality crisis only when the long-standing social security system—the Poor Law—was effectively dismantled in the 1830s. Throughout this book I argue that mortality trends and turning points in modern British history have primarily been driven by the politics of changing ideologies and institutions; by central and—especially—by local government intervention (or its deliberate absence), along with the interaction of these factors with changing civic institutions and various forms of voluntary association. Impersonal economic forces, such as gradually rising real wages and improved food consumption, certainly played a significant part, but this was much more a general, background contribution. Both of these factors, for instance, had been improving gradually since at least 1815, yet they were apparently powerless to prevent the urban mortality crisis of the 1830s and 1840s. Only later, once cities had politically committed themselves to a cumulative upward rate of investment in improving their collective environment and health services, could gains from rising private incomes also manifest their healthenhancing potential. Rapid economic growth throws up disruptive challenges to health. A detailed examination of British history shows that the resolution of these health problems was not supplied simply by economic growth itself and the passing of time, but required purposive human agency, inspired by collectivist ideals, mobilized through particular kinds of social capital and issuing in politically negotiated interventions in specific local contexts, as well as in national legislation. In effect the essays in this volume provide a detailed national case study that supports the general thrust of the policy lessons recently expounded by Peter Lindert, derived from his impressive, international historical and comparative econometric study (although the history of health policy was largely excluded from Lindert’s work).19 On the basis of this evidence Lindert has argued that it is the political voice and the active devolution by the central state of much social policy, such that its administration is in the hands of more responsive local authorities, and not simply the extension of democracy per se, that has been crucial in determining international historical patterns of social spending.Wealth and health ideally should go together, but

Introduction

19

history shows that any polity needs a rich endowment of institutional and civic resources for its citizens to be able to achieve this ideal. Throughout the late twentieth century the populations of the world’s poorer countries have been encouraged by their own governments, by institutions such as the IMF and the World Bank, by transnational corporations, and by the consensus of liberal public opinion to believe that their futures will be best served if their economies can follow as quickly as possible the same path of industrialization and commercial modernization that all the world’s developed societies have experienced. They should therefore enter the world’s trading markets without delay and engage in market economic exchange as vigorously as possible. However, this book suggests that history would counsel a more circumspect and cautious approach. Many of these societies have already been subject for many decades to the disruptive influences of rapid global economic growth, as subordinate parties to the world’s international trading system, and some have been experiencing the four Ds in their full force during the last two decades. The study of history indicates that in the twenty-first century there should at last be recognition that incentives and finance should be given, as a matter of priority, by the World Bank, the U.N., and other N.G.O.s to enable the world’s poorer countries to establish the foundational social institutions needed to withstand the buffeting of economic transformation. These institutions comprise state-sanctioned systems of individual citizen registration and social security, elected local government, and a free press, and the removal of any possible legal barriers to the growth of voluntary civic associations. All this will take time, of course, and that is the final and most general policy lesson of history implicit in all the essays here. The efforts to encourage development in poor countries since World War II have never been remotely realistic in their visions of the time scales involved in economic and social change. Five-year projects are deemed to constitute farsighted planning horizons by governments and N.G.O.s working in the development field, but this is out by a factor of about five! Quarter-century units of time—approximately a human generation—would be more appropriate as the minimum timeframe to work within and in which to expect “results” from any serious development strategy or policy intervention.The impatience of such policy means national interventions and national agencies are privileged,

20

Health and Wealth

with no time for the more devolved forms of local self-government to be encouraged instead. Most of the world’s currently successfully developed societies took this more gradual and locally devolved route and they took at least two and often three or four generations to accomplish the transformation from an agrarian to an industrial economy, even then suffering significant trauma on the way. The world’s poorest societies today need to be allowed at least the same time-frames for their provincial institutions and civic associations to mature, to give them the capacity to cope with the disruptions that the pursuit of wealth in the world’s economy entails.

Notes 1. McMichael (2001), 265–71; Beaglehole and Bonita (1997). 2. This has been the challenge of “new growth” or “endogenous growth” theory: Romer (1994);Temple (1999). 3. Smelser (1959); Rostow (1960). 4. Rostow (1948); Gayer, Rostow and Schwartz (1953); Rostow (1953). 5. Omran (1971). 6. McKeown and Brown (1955); McKeown and Record (1962); McKeown et al. (1975); McKeown (1976). 7.Wrigley and Schofield (1981). 8.Woods (1993); Huck (1994);Wrigley et al. (1997). 9. A conclusion substantially confirmed in the most rigorous re-analysis of the neneteenth-century cause of death evidence recently completed: Woods (2000), ch. 8, esp. pp. 357–58. 10. Szreter (2004). 11. Hennock (1973). 12. Berridge and Blume (2003). 13. Garrett et al. (2001), ch.4, esp. 162–63. 14. Putnam (2000), 21–23. 15. McKibbin (1998), 361–62. 16.T. Hunt (2004), 241–43. 17. Marsh (1994), 103. 18. For a brief, indicative attempt to do this, see Szreter (1999). 19. Lindert (2004).

PART I HISTORY AS CRITIQUE Debating the McKeown Thesis and the Postwar Policy Consensus

2 THE POPULATION HEALTH APPROACH IN HISTORICAL PERSPECTIVE*

There is no definitive history of the population health approach. In living memory, the important epidemiological research published during World War II by Jerry Morris and Richard Titmuss is invoked as a seminal model of population health analysis.1 Morris and Titmuss carefully demonstrated that the incidence of such “individual” afflictions as juvenile rheumatism, rheumatic heart disease, and peptic ulcer all varied according to changing social conditions, such as the rate of unemployment. Along with others, they sought to widen the scope of traditional public health beyond disease prevention toward social medicine, anticipating to some extent the philosophy of the Lalonde Report and the World Health Organization’s concept of positive health.2 However, social

* This chapter is slightly revised from the original publication in American Journal of Public Health 93, 3 (2003).

23

24

Health and Wealth

medicine never successfully institutionalized itself and instead an academic and clinical epidemiology tended, if anything, to diverge from practical public health work during the postwar decades.3 The recent resurgence of the population health approach has developed from dissatisfaction with some of the limitations of a strongly individual-oriented methodology, which has characterized recent clinical epidemiology. This is a paradigm that has scored notable successes in identifying risk factors such as smoking and hypertension but that, it is argued, has become too rigid and all-pervasive, partly because of its convenience for the administrative and accounting approach of the managerial regime politically imposed on the health service sector during the 1980s.4 However, from a longer-term perspective, the claims of each of these methodologies can perhaps be helpfully located within a much wider-ranging debate over the relationship between economic growth and human well-being, which provides the historical context for the emergence of a concept of population health. The modern origins of this debate lie in the late eighteenth century when the focus of discussion was over the significance of the so-called “diseases of civilization,” such as gout, respiratory diseases and tuberculosis, “hysteria,” and neuroses.5 The privileged classes were becoming aware that they increasingly enjoyed a degree of freedom from some of the epidemics that continued to ravage the impoverished masses (confirmed by demographic historians, who have shown that the life expectancy from birth of the upper classes first began to exceed the average for Britain after 1750).6 Yet this seemed to bring the rich an increased tendency to chronic and mental diseases of “luxury.” Furthermore, the poor remained as much mired in their misery as ever.What did this portend for the future health of civilization? Sovereigns had, of course, long had a military interest in the relative populousness of their domains; with the rise of mercantilist thought from the sixteenth century, they were also increasingly aware of population as an index of economic strength. Towns also developed an early interest in population health, taking various measures to contain epidemics.7 But in the eighteenth century of progressive Enlightenment thought, the dual revolutions of republican liberty and expanding commerce in Europe and the Americas introduced a new rationalist and democratic agenda. It was increasingly coming to be assumed that the

The Population Health Approach in Historical Perspective

25

desirable goal of protection from disease should apply, in principle, equally to all citizens of a nation state. In addition, the even more ambitious goal of positive health improvement for humans was becoming imaginable.8 Meanwhile, however, contemporaries were also faced with the contradictory evidence that the world’s first industrial revolution seemed to be having anything but obvious health benefits for the majority of the population. Enclosure and increasing farm sizes were creating rural unemployment while factory machinery rendered cottage industry redundant.9 The new industrial towns were overcrowded reception centers for destitute families seeking work. Previous efforts to devise scientific measures of health, pioneered by Graunt and Petty’s political arithmetic of London’s seventeenth-century bills of mortality, were now urgently redoubled, with medical men such as Dr John Heysham of Carlisle and Dr Thomas Percival of Warrington taking a lead, resulting in Joshua Milne’s first-ever accurate life table (the “Carlisle table”) in 1815.10 In the subsequent hands of William Farr, statistical superintendent in charge of Britain’s censuses and vital registration system from 1840 onwards, life table comparisons became the scientific gold standard of the Victorian public health movement in its attempts to publicize the nation’s urban health problems.11 We can talk of the emergence in early nineteenth-century France of a disciplinary school of public health and social epidemiology with its own journal (still published), Annales d’Hygiène publique et médécine légale, founded in 1829.12 The leading figures, such as Parent-Duchâtelet and Villermé, carefully documented the diverging incidence of mortality in different districts of Paris, relating them both to the wealth differentials of the inhabitants and to variation in sanitary facilities and services.They also demonstrated the poor health of such social groups as sex workers and of child workers in the textiles industry.Their research showed that for the privileged inhabitants of salubrious areas, the march of civilization was probably a net health gain; but, equally, without careful attention to the regulation of the market economy and to the living conditions and opportunities of the masses, economic growth could have quite opposite consequences for the life chances of the populace in general. Material progress—or economic growth—apparently had ambivalent health effects.

26

Health and Wealth

From its origins, therefore, on both sides of the Channel, the population health approach has always been stimulated by concerns over the human costs of the excesses of economic and associated urban growth. There can be little doubt that part of the reason for the resurgence of interest in this approach during the last two decades has been the epidemic-scale health problems once again unleashed by unrestrained global economic and urban growth. In England, no such academic school of public health medicine emerged (although Edinburgh University was a leading center throughout the period).This was partly because already by the 1830s several leading investigators, such as James Kay Shuttleworth,Thomas Southwood Smith, William Farr, and, above all, Edwin Chadwick, had direct access to government office.13 Edwin Chadwick, the éminence grise of the British central state in this period, aimed at an administrative and engineering solution to the problem of high urban death rates, the “Sanitary Idea.” Believing that miasma—the odors of organic decay—were the causes of epidemic disease, Chadwick created a national board of health to supervise the building of a sanitary infrastructure to ensure cleansing flows of water in and out of large cities.14 But in trying to force Britain’s towns to tax themselves for this purpose, Chadwick ran into a political firestorm of localist, libertarian opposition, which ended his career.15 Two decades later, the Royal Sanitary Commission of 1869 to 1871 found that no provincial cities in Britain had yet built the integrated sewers system that Chadwick’s landmark Public Health Act of 1848 had intended for them.16 Until the important franchise reforms of the period 1867 to 1884, Britain’s electorate was a “shopocracy” of small property holders, intent on low national and local property taxes (Fig. 2.1). Despite the public health movement’s best efforts to publicize the appalling extent of preventable mortality in Britain’s towns (Fig. 1.2), delay and prevarication was the order of the day.17 This state of affairs was not helped by the capacity of key commercial interests, notably private water companies, to use the law to dispute any efforts to force them to supply adequate clean water in an era before the germ theory and microscopic water analysis had established their scientific authority (Fig. 2.2).18 There seems to be something of a parallel here with the propensity today of wealthy tobacco companies and those dealing in other harmful products to dispute the evidence of the negative health effects of their products.19

The Population Health Approach in Historical Perspective

27

Fig. 2.1 A Punch cartoon from June 1848 of Lord Morpeth, the central government’s representative, promoting the bill for Chadwick’s Public Health Act.

The legislation is depicted as “sanatory” pearls being thrown in vain by the enlightened national statesman to the unappreciative “swine”: the lazy, ignorant, and venal councilors of the nation’s cities, content to wallow in their own filth. Reproduced in Szreter (1992), 143.

As today’s public health movement has also found, vested interests and property rights form a formidable hydra of political and legal obstacles to the implementation of the protective measures indicated by a population health perspective. Because so many of the innovative practices and products sanctioned by the criteria of profitability and shareholder value can never be fully assessed in advance for the totality of their health implications, the public health movement inevitably finds itself in conflict with often-powerful commercial interests. An

Fig. 2.2 Illustrations from The Lancet in 1851 of water impurity in London’s commercial supplies.

By 1851, the microscope enabled water analysts to make precise drawings such as these depicting the organic contents of the drinking water supplied by London’s increasingly notorious private companies (although in this case A. H. Hassall, the illustrator, had exaggerated the number of organisms in the space depicted). Some of these companies’ defective systems were clearly implicated by pioneering epidemiological research into the major cholera epidemics of the period. Reproduced in Hamlin (1990), 103.

The Population Health Approach in Historical Perspective

29

historical perspective shows that this situation derives from the intrinsically ambivalent effects that economic growth has on population health.

Economic Growth and Population Health: An Ambivalent Relationship It is still commonly assumed as a primary lesson of history that the process of economic growth automatically brings with it improvements in population health—at least in the long run.The evidence seems to be compelling. We all know that before the industrial revolution, life was “nasty, brutish and short,” to cite Thomas Hobbes’s celebrated dictum. In today’s advanced economies, we all live longer and healthier lives. QED: health has improved because of economic growth. But the human record in fact shows no necessary, direct relationship between economic advance and population health, but rather a more ambivalent and contingent relationship. During the millennia of prehistory, the skeletal record indicates that it is most probable that each of the periods of transitional shift—from hunter-gatherer to early settled agriculture, early to advanced agriculture, and then to ancient urban civilization—while representing economic advance and increased human population density, was also accompanied by greater susceptibility to disease and decreased average population health. It seems most probable that only with subsequent long-term adaptation did population health recover somewhat.20 Indeed, in the early modern period, it was the economically advanced towns that had the highest mortality rates.21 But when we come to the “modern” industrial revolution, and the development of scientific medicine, isn’t everything different? Well, no. The most that can be said in favor of modern economic growth is that the wealth that it accumulates creates the longer-term potential for population health improvements. But whether or not this potential is realized depends entirely on a set of quite distinct social and political negotiations and decisions on how exactly that wealth is to be used and distributed. The historical record clearly shows that the process whereby this wealth is created—economic growth itself—has no direct, necessary positive implications for population health. Indeed, in almost every historical

30

Health and Wealth

case, the first and most direct effect of rapid economic growth has been a negative impact on population health. Thus, the latest historical research increasingly confirms that those populations directly affected by the transatlantic transformation in economic relations driven by the British industrial revolution during the period 1780 to 1870 endured a significant negative health impact. The “demographic footprint” of this trauma remains clearly visible in the historical record of every one of the countries where it has been researched, in the form of a generation-long, negative discontinuity in the historical trends of life expectancy, infant mortality, or height attainments.22 In cases of later industrializers, such as Germany,23 Australia,24 or Japan,25 the negative health impacts also occurred, but a little later. Nor were the populations of successful industrializing economies the only ones to suffer in this process. Ireland, for instance, providing cheap labor to British and American cities and coal fields, was devastated by a famine while the London government refused to intervene in “the market”; the Indian economy, on the other hand, was carefully managed in the interests of British industry and capital, with little regard for the health or livelihood of the Indians.26 The notion that economic growth can automatically or necessarily deliver rising population health is a comforting myth, but it is also an elementary fallacy, resulting from imputing sufficient causation to an underspecified model containing just two variables. It is true that to achieve the high levels of population health enjoyed today in the West, particularly the very low rates of infant and neonatal mortality, substantial economic wealth has been a necessary precondition. But there have also been many, many other factors necessarily involved, of a social, political, ideological, and cultural nature, to convert the wealth generated by the processes of economic growth into increased population health for all. Economic growth is an intrinsically disruptive process. The history of almost all successful economies of the West shows that, in the absence of a sufficient political response at both national state and local government levels, this disruption will result in deprivations, disease, and death—the “four Ds.”27 While economic growth may be necessary, it is never a sufficient condition for improved population health. In Britain’s case, the discontinuity in population health was extensive, lasting half a century from the 1820s until the 1870s; it contained

The Population Health Approach in Historical Perspective

31

Fig. 2.3 Life expectancies at Birth in Major British Provincial Cities (above

100,000 inhabitants), 1801–1901, compared with the national aggregate trend. 47 46 45 44 43 Life expectation at birth (years)

42 41 40 39 38 37 36 35 34 33 32 31 Provincial Cities

30

England and Wales (national average)

29 28

1901

1891

1881

1871

1861

1851

1841

1831

1821

1811

1801

27

Date

Britain’s industrial cities were significantly less healthy than the national average at the beginning of the nineteenth century.Thereafter, they were plunged into an abyss of high mortality during the 1830s and 1840s, which prompted much social comment and a Royal Commission on the Health of Towns during the 1840s.There was some recovery in the 1850s, but no real improvements above the level of the 1820s until the 1870s and the era of “the civic gospel” and municipal “gas and water socialism.” Source: Derived from S. Szreter and G. Mooney, “Urbanisation, Mortality, and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities,” Economic History Review 51 (1998), figure 1 (reprinted in this volume in chapter 6 as Figure 6.1)

an epicenter of epidemiological disaster during the 1830s and 1840s in the central districts of the new industrial cities, where expectation of life at birth plummeted to levels not seen since the crisis years of the Black Death (Fig. 2.3).28

32

Health and Wealth

Significant health improvements only began to appear when the increasing political voice and self-organization of the growing urban masses finally made itself heard, increasingly gaining actual voting power from the late 1860s onwards (a process not completed until 1928).The civic gospel, originating in the nonconformist pulpits of Birmingham’s more well-heeled congregations, was a bold response from neopatrician networks of families within the new urban elites. It snowballed into a social movement promulgated throughout Britain’s proud provincial cities.29 Recognizing the need for an extensive program of investment in municipal health amenities and social services, this new generation of civic leaders devised new sources of funding from the massive revenues of local utility monopolies. Enjoying working-class support, this political program was a prime historical example of cross-class bridging and linking social capital (i.e., relationships of respect, trust, and cooperation).30 Several of those campaigning in hard-fought electoral battles on the hustings (Fig. 2.4), such as Joseph Chamberlain in Birmingham, were among the most successful managing directors of leading global businesses. They were assisted by the newly consolidating cadres of public service professionals, notably Medical Officers of Health.31 By the first decade of the twentieth century, major British cities like Birmingham, Liverpool, and Manchester were virtually welfare states in miniature. This is not just history.The recent transformation in salubrity of the large Indian city of Surat, hit by plague in September 1994, illustrates many of the same key factors regarding local political leadership and cross-class alliances.32 Similarly, current developments in the Brazilian city of Porto Alegre demonstrate how the political mobilization of the poor and of cross-class bridging and linking social capital can change a city’s environment and health;33 in this latter case, the change may be even more secure than in Surat because of more thoroughgoing mobilization and participation of the population.34 A not dissimilar pattern is visible in late nineteenth-century U.S. history, where the franchise was already a wide one and the more broadly based middle classes played a more central role in the sanitarian and urban reform movements, led by medical and other professionals (Fig. 2.5).35 The net result, in the United States, Britain, and Europe (where such reform tended to be more exclusively elite and

The Population Health Approach in Historical Perspective

33

Fig. 2.4 “The Battle of the Wards.” Joseph Chamberlain Fighting the 1878 Birmingham Municipal Election.

Joseph Chamberlain, wearing his trademark monocle and occupying the moral “high ground,” fighting the 1878 Birmingham municipal election. Three decades after the failed Public Health Act, Chamberlain led the Liberal caucus, a highly organized party machine, to a series of municipal electoral victories on an ambitious platform of civic spending and improvement.These programs were to be financed from long-term loans, revenue-raising municipal services such as gas and water, and rising tax rates on property. Reproduced in Hennock (1973), Plate 15.

state led),36 was that the urban middle classes agreed to greater taxes on their wealth and property, while the working classes often incurred increased indirect taxes (through their use of monopoly municipal services such as gas and tramways, for instance) to make the necessary hefty investments in enhancing and maintaining the overall urban environment.This included sanitary systems and public housing, paved and cleansed roads, and health promotion services, from food inspectors to universal education, maternity services to public baths.37

34

Health and Wealth

Fig. 2.5 American City 1919: the Defeat of Typhoid Fever by Municipalities.

Cartoon from the September 1919 issue of the journal American City depicting the defeat of typhoid fever by the large-scale municipal measures of water filtration and chlorination (American City 21 [1919]: 247). Reproduced in Melosi (2000), 137.

In an era when self-help, laissez-faire, and suspicion of central government was still the ideological order of the day in the Anglo-Saxon polities on both sides of the Atlantic, the central state’s role was primarily

The Population Health Approach in Historical Perspective

35

exhortatory, restricted to providing information about death rates and some financial carrots and inspectional sticks—and even this was more true of Britain than of the United States.38 In both countries, the role of municipal government was critical. Elsewhere, on the crowded continent of Europe and in Japan, national security fears and imperial rivalries had already been conducive to a more precocious interest on the part of the state in both the quality and the quantity of the nation’s supply of manpower—famously so in the case of Bismarck’s innovative, early German social insurance legislation of the 1880s, the efficiency of Japan’s military medicine,39 and the French state’s policies aimed at promoting high birth rates after its defeat in the Franco-Prussian war of 1870–71.40 Eventually, also motivated by military fears, the early twentieth-century British state under the “New Liberals” began to enact Bismarckian-style, centrally funded measures aimed at improving the health and physique of its urban industrial work-force.41 Even the U.S. federal government finally followed suit in the New Deal and post-World War II era. For the liberal, democratic industrialized nations, the twentieth century has exhibited a substantial embedding and institutionalization of a widening range of mainly state-organized and tax-funded preventive health, educational, and social services, which between them consume a substantial proportion of the growing national income. It has been these extensive “welfare states” that have primarily provided the crucial mechanism enabling these societies to continue to experience relatively rapid rates of economic growth throughout long periods of the twentieth century, while minimizing the disruptive impacts on people’s livelihoods that rapid economic change necessarily entails.Where welfare principles have been most thoroughly institutionalized and devolved (in terms of their management), as in corporate Japan or universalist Scandinavia, these societies have succeeded in routinely transforming such growth into enhanced bodily health and ever-increasing longevity for the majority of their citizens, resulting in the highest average life expectancies in the world. Indeed, the Swedish historical case is in a sense the exception that proves the rule. Industrialization came very late in the nineteenth century to Sweden, and it appears to have avoided the worst consequences of the “four Ds.” However, this was because Sweden had been carefully monitoring its population health since 1749, and was used to working

36

Health and Wealth

through devolved, local initiative, an administrative necessity in such a large country of scattered settlements. Sweden passed comprehensive public health legislation in 1874, at exactly the same time as Britain’s important second Public Health Act.42 But in Sweden’s case, this was in anticipation of, not following the ravages of, industrial urban growth. Thus, in Sweden, as in the twentieth century more generally, economic growth was carefully politically regulated and managed—in a devolved and not centralized fashion—to ensure that population health was improved, not compromised.

Forgetting History: The Washington Consensus The importance and difficulty of this extraordinary political and administrative achievement of creating effective welfare institutions, so as to consistently convert raw, intrinsically disruptive economic growth into enhanced population health for the majority of the citizenry, has been profoundly underestimated, if not completely ignored, in the policy priorities of the international development orthodoxy of the late twentieth century. Instead, there has emerged, under the auspices of the neoliberal “Washington consensus,” a relentless overemphasis on the promotion of free trade and rapid economic growth, first and foremost, and even at the expense of government investment in welfare and health services.To understand how such a misleading “commonsense” position could have become so dominant, we need to review briefly the main ideas that continue to inform that consensus, insofar as it relates to population health issues. From the outset of the postwar era, the overarching theory of demographic transition always strongly implied that economic growth alone was the ultimate source of benevolent demographic change. According to this theory, nations one after another have moved from the undesirable, premodern “high-pressure” equilibrium of high birth rates and high death rates to the more efficient and rational “low-pressure” regime of low vital rates, exemplified in the modernized West.43 Economic growth is posited as the beneficent motor force standing behind all this. It effected reductions in mortality by increasing per capita incomes and food supply and by placing ever-greater resources in the

The Population Health Approach in Historical Perspective

37

hands of an increasingly scientific and professional medicine, facilitating the release of mankind from the historic burden of infectious disease and poor nutrition; transition theory posited that fertility decline then followed in response to increased child survival. The postwar international public health, family planning, demographic, and development communities took it as their humanitarian mission to bring about this demographic transition in as many other countries as possible.44 From the end of the 1950s, they found themselves the beneficiaries of plentiful resources for these activities from Western governments and from U.S. philanthropic foundations, as the Cold War rivalry with the world’s communist states intensified.45 Demographic transition theory was, in fact, the projection onto earlier history of the seemingly miraculous experience of the generation in the West who came to maturity in the interwar decades of the twentieth century. They and their children were the first generations to truly benefit from the multiple life-preserving and therapeutic practical applications of the sequence of profound late nineteenth-century scientific breakthroughs upon which modern medical science is based: evolutionary theory, germ theory, microscopy, bacteriology, and nutritional physiology.46 But as a theory to account for mortality change in the two previous centuries, the demographic transition theory rested on slender historical evidence.47 The rigorous historical demographic research of the Cambridge Group for the History of Population and Social Structure (analyzing data from hundreds of English parish registers dating from the 1540s) has conclusively shown that for the key case of England, it was not, after all, declining mortality that was primarily responsible for the massive population growth during the period 1750 to 1850, but rising fertility brought about by falling age at marriage.48 In Britain, mortality did not fall significantly until 1870, two decades after the industrial revolution was completed. In fact, the demographic transition, as a general theory, has been refuted time and again—for instance, it has long been known that in the two substantial cases of France and the United States, fertility fell before mortality.49 In addition to transition theory, the separate historical epidemiological research of Thomas McKeown on Britain’s detailed civil registers of deaths for the period after 1850 has been very influential in giving

38

Health and Wealth

sustenance to the view that economic growth has a directly benevolent effect on population health. McKeown is rightly celebrated as a great iconoclast who accurately aimed an important blow at the status and power of clinical, scientific medicine, which he saw as abrogating far too much of the nation’s resources to its own professional agenda.50 McKeown conclusively demonstrated that medical science could not have accounted for more than a tiny fraction of any improvement in mortality that had occurred before the 1930s, when sulfonamides and antibacterial agents finally arrived. McKeown’s work, however, also had the effect of further reinforcing the simplistic economic determinism of demographic transition theory.This was because he explicitly demoted public health medicine— which he termed “municipal sanitation”—to a lowly second place, an also-ran in his account, while concluding that improved living standards, notably rising nutrition, had been primarily responsible for most mortality reduction before the 1930s.51 This left the impression of an even more direct link between economics and health than in classic transition theory, which had assumed that medical science also performed an essential role. McKeown’s message was highly convenient for the neoliberal ascendancy within the field of economics during the late 1970s and 1980s. Johansson has pointed out the significance of the fact that at this time McKeown’s interpretation received endorsement from an influential intermediary, Robert Fogel, the Chicago-based Nobel laureate in economics, in his initial historical anthropometric work (on trends in heights and weights).52 The strategy of the neoliberal Washington consensus was to maximize the scope for free market economic growth, reducing all government-provided, tax-funded public services, including free health and allied social services. McKeown had supposedly shown these to be of far less value than a booming economy where health improvements were concerned. Larger ideological and geopolitical forces were clearly at play here. The rising ascendancy of the New Right benefited politically from a widespread practical disengagement from policy issues during the 1980s by the intellectual left, which became preoccupied with more abstract issues of philosophical relativism—“postmodernism.” One of its most influential figures, Michel Foucault, focused his relativist assault on both

The Population Health Approach in Historical Perspective

39

the authority of medicine and the legitimacy of the nation-state and its “official” forms of knowledge through an examination of the nineteenthcentury history of its treatment of insanity and the procedures of the clinic.53 With its suspicion of “the state,” the capacity of the postmodernist position to provide a political challenge to the agenda of the New Right has been rather limited, especially as one of the legitimating rhetorics of the market is to extol its capacity to offer unlimited individual “choice.” The anti-authoritarian, relativist left and the radical libertarian right have thus concurred, for different reasons, on a vision of an anarchist utopia. McKeown’s interpretation was taken by the New Right as meaning that “It’s the economy, stupid.”To reduce global mortality, the number one priority was to produce as much economic growth as possible. Concerns over the distribution of material wealth were papered over by free market apologists’ talk of the “trickle-down” effect—a surprisingly casual notion, lacking theoretical elaboration or empirical confirmation. Sam Preston, the doyen of U.S. demography, launched a timely state-of-the-art, crossnational statistical demonstration to refute this aspect of McKeown’s case, arguing that medical technology, in the form of public health, had been of most importance in enhancing life expectancy, especially in the twentieth century. His analysis, however, was powerless to stem the ideological flood tide in the economics profession.54 Poverty reduction and welfare as priorities disappeared from the international development agenda for an entire decade, in favor of “structural adjustment programs” and “conditional” loans, which slashed public spending and services in the evangelical belief that free markets could best supply most goods and services. Only in the 1990s, thanks principally to the influence of Amartya Sen’s concepts of entitlements, capabilities, and functionings,55 did explicit ethical concerns about the health and welfare outcomes of economic growth re-emerge with the launching of the United Nations Development Program’s human development indicators. A further significant step has been the recognition in the World Bank’s World Development Report for 2000/2001, Part III, and in several associated World Bank publications entitled Voices of the Poor, that empowerment—the political voice of the world’s poor—and social capital— social networks and relations of mutual respect and support—are both

40

Health and Wealth

crucial. However, it should be noted that after the acrimonious dismissal of the World Bank’s controversial chief economist, Joe Stiglitz, who openly attacked the neoliberal Washington consensus polices of the previous decade,56 the Bank’s 2002 report appeared to display less enthusiasm for this emphasis. The tragedy of all this is that, during the last two decades of structural adjustment and conditionality, there has never been any strong historical evidence for believing in either the demographic transition theory or the McKeown-thesis view that maximizing economic growth can itself produce health benefits. A discriminating evaluation of the historical evidence indicates, quite to the contrary, that without a strongly interventionist role for local government, supported with the resources of the central state, economic growth will seriously compromise population health. Many who have accepted McKeown’s thesis still do not realize that he never presented any positive historical evidence about food and nutrition in British history. By contrast, all the historical work reviewed here has carefully shown, through primary source documentation, that a complex and continually expanding range of social and political interventions has been vital in securing widespread health benefits from the mere accumulation of material wealth. This includes watering, sewerage, the sealing and cleansing of roads, better housing, regulation of the urban food supply and environment, enhanced social security measures, the provision of widely accessible health services, and the fostering of a more democratic spread of knowledge about health and hygiene57 (for reviews, see Melosi [2000], Easterlin [1999] and Powles [2001]).

The Population Health Approach Today Epidemiologists and public health policymakers are engaged in a reappraisal of the models that they use to investigate health problems. They have argued that methodologies have often been too narrow: “medical care is but one of many socioeconomic ‘institutions’ (e.g., income maintenance, social security, education) that affect health.”58 There has, in fact, always been a significant stream of important work since Morris and Titmuss— such as that by Graham, Susser, Marmot, Syme, and Berkman—that has

The Population Health Approach in Historical Perspective

41

explored the wider social and cultural sources of epidemiological variation.59 A number of large compilations of new research have recently appeared that begin to suggest a return to this line of investigation.60 Furthermore, a number of important editorial and opinion-forming contributions are now calling for a disciplinary generalization of the new approaches and for much greater environmental, ideological, and global political awareness on the part of the public health discipline.61 At the beginning of the third millennium, massive disruption due to rapid and relatively unregulated economic growth is once again upon us.A wide-ranging vision will be needed to produce the compelling arguments from ethical first principles and the effective strategies and policies that can cope with the health challenges it poses. Such a new alternative synthesis, embracing ethics, politics, the importance of social capital, human security, the ecological and biological sciences, and new approaches to economic affairs and their measurement, appears to be emerging—one that acknowledges that market economic growth may not, in and of itself, be the prime mover of all that is of value, especially where health is concerned.62 The public health field and epidemiological science therefore need to be formulated as a population health approach, capable of engaging with these related global, ecological, and local problems. In these circumstances, the first, essential duty of public health epidemiologists is to measure and publicize the dimensions of damage being done to the health of populations. This activity is an essential informational prerequisite for mobilizing public opinion, and it tugs as sharply as possible on the consciences of the powerful elites, making clear to them the human costs of the wealth accumulation from which they believe they profit. It is precisely this role that a highly committed, small set of public health practitioners, in both central and local government, played in Britain during the mid-nineteenth-century era of laissez-faire.63 One of the most unfortunate consequences of the Washington consensus policies of structural adjustment imposed on less advanced economies has been a weakening of essential state capacity to collect reliable vital statistics covering the most marginal sections of the population—child workers, low-paid workers, black market workers, migrants, refugees, and remote rural communities. These are the very people who are paying the principal health price for the global market economy’s “successful” growth rates, achieved through shareholder capital’s ceaseless

42

Health and Wealth

search for the lowest labor, production, and fiscal costs.64 Thus, overzealous application of free market policies can even unintentionally commit “the perfect crime,” removing the epidemiological evidence of the health problems it creates. It is a primary duty of the international public health community to insist on the continuing right of all citizens to be registered and counted and the duty of all governments to collect and publicize correct, comprehensive vital statistics on all persons within their borders. The irony of the long-term history of economic growth, the march of science, and the expansion of markets is that, as we become ever more independent from the vagaries of untamed nature, so we have become ever more intimately interdependent on ourselves, on the consequences of our collective actions, and on the enormous, complex network of relationships that we call “the market.”65 That interdependence is now more evidently global in scope than ever. The series of spectacular national financial crises that characterized the 1990s and that show no sign of abating, as much as the events and still-reverberating sequelae of September 11th, 2001, have made this painfully obvious. However, far more insidious threats to our collective security and health are posed by the continuous and accumulating social inequality and environmental degradation produced by unregulated free market growth; these may, in the long run, be even more devastating to global population health.There is a stark contrast between the highly energetic response of the world’s power elite—in the form of the actions of the International Monetary Fund, the White House, and the Pentagon—to some of the more visible and acute political disruptions and these same institutions’ acquiescence to rising global social inequality and environmental damage, exemplified by the U.S. president’s unilateral abandonment of the Kyoto Protocols on climate change.66 The population health approach may have a particularly important role to play in demonstrating and sensitizing public opinion to the epidemiological early warning signs of important, though gradual, environmental and ecological changes that manifest themselves only at the population level. An epidemiological approach that prefers to focus only on individuals’ bodies, lifestyles, and personal risks is less likely to detect and correctly diagnose the causes of the early effects of these gradual changes in the world’s living conditions.There is, therefore, much research that needs to be done today from a population health perspective.

The Population Health Approach in Historical Perspective

43

Acknowledgments This essay was completed while the author was an Economic and Social Research Council (ESRC) fellow (award no. R000271041). It benefited from the many helpful comments of Theodore M. Brown, Elizabeth Fee, Daniel Fox, Daniel J. Friedman, John Lynch, Steve Kunitz, John Powles, George Davey Smith, Barbara Starfield, and the four anonymous journal referees.

Notes 1. Morris and Titmuss (1942); Morris and Titmuss (1944a); Morris and Titmuss (1944b); Oakley (1991); Oakley (1996). 2. Cochrane (1972); Lalonde (1974). 3. Porter (1997). 4. Rose (1985); Loomis and Wing (1990); Rose (1992). 5. Bynum (1983). 6. Woods and Williams (1995); Wrigley, Davies, Oeppen and Schofield (1997), 206. 7. Cipolla (1976). 8. Riley (1987). 9.Thompson (1968). 10. Glass (1973b). 11. Eyler (1979); see chapter 8, this volume. 12.Ackernecht (1948); Coleman (1982); La Berge (1984); La Berge (1992). 13. La Berge (1988); Flinn (1965); Cullen (1975). 14. Flinn (1965); Hamlin (1998). 15. Prest (1990). 16. Szreter (1988), 25–26. 17. Hamlin (1988). 18. Hamlin (1990). 19. Berlinguer (2002), chap.5. 20. Cohen (1989), chap.7. 21.Wrigley (1967). 22. Bourdelais and Demonet (1996); Pelletier, Legare and Bourbeau (1997), table 2; Weir (1997) (figs. 5.8, 5.10); Szreter and Mooney (1998); Horlings and Smit (1998); Haines (2001); Bengtsson and Dribe (2000). 23.Twarog (1997);Vogele (1998). 24.Whitwell, de Souza and Nicholas (1997). 25. Johansson and Mosk (1987).

44

Health and Wealth

26. Neal (1998);Watts (1997); Davis (2001). 27. Szreter (1997). 28. Szreter and Mooney (1998). 29. Hennock (1973). 30.Woolcock (2000); Szreter (2002). 31. Hennock (1973);Wohl (1983); Hardy (1988); Hardy (2001). 32. Shah (1997). 33. Abers (1998). 34. Chaplin (1999). 35. Szreter (2002); Wiebe (1967), chap 5; Rosenkrantz (1972); Leavitt (1982); Duffy (1990); Cain and Rotella (2001). 36. La Berge (1992);Vogele (1998); Evans (1987). 37. Leavitt (1982); Evans (1987); Preston and Van de Walle (1978); Condran, Williams and Cheney (1985); Hardy A. (1993); Szreter (1997); Melosi (2000); Sheard (2000). 38. Rosenkrantz (1972); Eyler (1979); Bellamy (1988); Szreter (1991b); Anderson (1991). 39. Johansson and Mosk (1987). 40.Teitelbaum and Winter (1985), 18–30. 41. Hennock (1987). 42. Nelson and Rogers (1994). 43.Thompson (1929); Notestein (1945). 44. Notestein (1953). 45. Hodgson (1983); Greenhalgh (1996); and see chapter 3, this volume. 46. Hardy (2001); Bynum (1994). 47. Szreter (1996), 9–21. 48. Wrigley, Davies, Oeppen and Schofield (1997); Wrigley and Schofield (1981). 49. Bourgeois-Pichat (1965); Degler (1980), chapter 9. 50. McKeown (1979). 51. McKeown (1975); McKeown (1976). 52. Johansson (1994). 53. Foucault (1971); Foucault (1973). 54. Preston (1975); Preston (1976). 55. Sen (1999). 56. Chang (2001); Stiglitz (2002). 57.Tomes (1998). 58. Evans, Barer and Marmor (1994), xiii. 59. Berkman and Kawachi (2000). 60. Marmot and Wilkinson (1999); Kawachi, Kennedy and Wilkinson (1999); Leon and Walt (2000); Eckersley and Dixon (2001).

The Population Health Approach in Historical Perspective

45

61. Farmer (1996); Beaglehole and Bonita (1997); Labonte (1998); Breslow (1999); Kunitz (2000); Krieger (2000); Coburn (2000); McMichael and Beaglehole (2000); Baum (2001). 62. Sen (1999); Evans and Stoddart (1990); Dasgupta (1993); Rice (1997); Woolcock (1998); Miringoff and Miringoff (1999); Keating and Hertzman (1999); Farmer (1999); Dasgupta and Sergageldin (2000); Putnam (2000); Wilkinson (2000); Baum (2000); Kickbusch (2000); Dasgupta (2001); Bettcher and Lee (2002); Galbraith (2002); King and Murray (2002). 63. Eyler (1979); Laxton (2000); Kearns (2000) and see chapter 8, this volume. 64. Klein (2000); Hertz (2001). 65. Kula (2001), 371–72. 66. Samet and Burke (2001).

3 THE IDEA OF DEMOGRAPHIC TRANSITION AND THE STUDY OF FERTILITY CHANGE A Critical Intellectual History*

This chapter’s main aim is to contribute to the study of fertility change through analyzing certain intellectual and institutional aspects of the field of study since World War II.The principal focus is the intellectual history of the idea of demographic transition: the idea that has provided students of changing fertility throughout the postwar era with the dominant collective definition of the phenomenon they are seeking to understand and explain. “Demographic transition” has been confusingly invoked at different times by different authors—or even by the same author at the same time—as theory (“the” demographic transition), historical model,

*

This chapter is slightly revised from its original publication in Population and Development Review 14, 4 (Dec. 1993).

46

The Idea of Demographic Transition and the Study of Fertility Change

47

predictive model, or mere descriptive term. All of these uses crop up at various points in the account below. I will make no attempt to adjudicate between them. My aim, rather, is to explain this ambivalence through investigating their joint provenance. If the postwar intellectual history of the study of changing fertility is intimately bound up with the idea of demographic transition, the institutional history has become deeply involved with the agencies and administration of population policy, the “family planning industry,” as Paul Demeny has christened it.1 During the 1950s an intellectual orthodoxy concerning the importance of the relationship between national economic development and population growth solidified among social scientists, economic planners, and political leaders in the West and in those nations that looked predominantly to the liberal democracies of the West.Within this orthodoxy, the dominant line of thought has tended to emphasize the extent to which relatively rapid population growth can obstruct the potential for economic growth in less-developed countries. While there have certainly been lively proponents of the opposite— heterodox or “revisionist”—position, this remains a minority viewpoint.2 The design and implementation of effective family planning policies have therefore come to be seen as important in the pursuit of the great goal of national economic growth. Over the last decade a number of scholars have begun to examine the relationship between these institutional aspects of the field’s recent history and the cognitive content of the dominant approach to the study of fertility change.This is a matter of interest and legitimate study in its own right. But it reflects also a sense of frustration among students of fertility behavior that there has been remarkably little progress in understanding the dramatic changes in fertility that have occurred in so many societies during the last two centuries or so. The most rigorous assessment of the intellectual history of the modern field of population studies has come from Dennis Hodgson, in three carefully documented articles in this journal.3 Hodgson argues that during the 1950s leading demographic social scientists became much more influenced than ever before by policy considerations. He identifies a consequent change they adopted in their approach to the study of fertility while nevertheless retaining the extant theory or model of demographic transition. Hodgson contends that the

48

Health and Wealth

resultant “orthodoxy” has had long lasting negative consequences for the scientific study of fertility change. The present contribution is much in debt to this meticulous, pioneering research. As will become clear, however, I wish to present a rather different interpretation. In order to make further progress with the study of fertility change, demographic historians and social scientists need to consider a more radical reappraisal of the recent intellectual history of the field and of the possible forms of “scientific” study available to them. In particular, I will argue that the demographic study of fertility was already, before the 1950s, thoroughly influenced by policy considerations. The idea of demographic transition was itself the product of a particular conception of social science as a guide for policy, a science employing a positivistic methodology that was simultaneously investigative and predictive. Although substantially retained as the working practice of the policy sciences, such a conception does not today correspond to the only accepted notion of “science”: there is a range of important alternatives, especially where social and historical problems are concerned. To progress further, demographic historians and social scientists also need to endorse and engage with this wider range of available “scientific” approaches. However, the continuing currency of the idea of demographic transition, albeit as merely a descriptive term in the eyes of most of its users, is hampering such a development. The critical reappraisal of the recent intellectual history of the field offered here is an attempt to examine the nature of these methodological constraints and the reasons for the continuing deference to the idea of demographic transition.

The Theory Of Demographic Transition,Vintage 1944–45 It is a remarkable paradox that although there has been an accumulation of modern and early modern historical evidence that would seem to have comprehensively discredited the accuracy and validity of demographic transition both as a theory and as a general historical description, this model of demographic change remains a central preoccupation in contemporary population studies. As early as the 1950s demographers became aware of modern European historical evidence seriously at variance with the transition model of change.4 Since then the detailed

The Idea of Demographic Transition and the Study of Fertility Change

49

research of demographic historians on early modern Europe has conclusively refuted the empirical accuracy and the analytical value of the model’s representation of preindustrial societies as generally characterized by a “high pressure” demographic equilibrium.5 Yet demographic transition continues to find employment both as an instrument for forecasting by the United Nations and the World Bank and in the academic study of past and present fertility behavior. Although Etienne van de Walle has recently charted a decline since 1984 in professional usage of the term “demographic transition theory,” he finds no similar decline for the terms “demographic transition” and “fertility transition.”6 It appears as if the modern international field of study that addresses large-scale change in fertility behavior is permanently wedded to the conceptual scheme with which it started its new life after World War II. In addition to its ability to survive a continuous stream of contradictory findings that would long ago have killed off more mortal entities, the life-history of demographic transition theory reveals another remarkable characteristic: it was born twice. The theory has had a much-publicized career at the center of demographers’ attention ever since its development during the early 1940s at Princeton University’s Office of Population Research. However, the theory of demographic transition had already been publicly presented in 1929 by America’s then-leading demographer, Warren S.Thompson.At that time it seems to have suffered a stillbirth; yet sixteen years later the theory was suddenly reborn as a favorite child. How, then, do we explain these paradoxes? Demographic transition theory is generally considered to have been given its classic formulation in two separate publications, by Frank W. Notestein and by Kingsley Davis, both composed in 1944 and published in 1945.7 At that time Notestein was director of the prestigious Office of Population Research, established at Princeton in 1936, and Davis was a senior colleague on the staff there.8 From 1945 onward there was a sustained period of active application and modification of the theory, led predominantly by members or former members of the highly influential Princeton school. Demographic transition in its classic presentation was a general theory which stipulated that strong population growth initially occurred during industrialization because fertility remained uncontrolled and high while mortality declined, due to the improved food supplies and personal

50

Health and Wealth

living standards generated by the combination of technical innovations summarized under the rubric “industrial revolution”: improvements in agriculture, transport, and manufacturing, and, finally, sanitary and medical advances. In short, the whole process of modernization in Europe and Europe overseas brought rising levels of living, new controls over disease, and reduced mortality. Meanwhile, fertility was much less responsive to the processes of modernization. Any society having to face the heavy mortality characteristic of the pre-modern era must have high fertility to survive. . . . [In such societies] religious doctrines, moral codes, laws, education, community customs, marriage habits, and family organizations are all focused toward maintaining high fertility. These change only gradually and in response to the strongest stimulation.9

The theory held that fertility would only fall as a result of the cumulative mutually reinforcing spectrum of effects consequent on fullscale industrialization and modernization: enhanced survival; a growing culture of individualism; rising consumer aspirations; emergence of huge and socially mobile urban populations; loss of various functions of the family to the factory and the school; and decline of fatalistic in favor of conative habits of thought. In short, under the impact of urban life, the social aim of perpetuating the family gave way progressively to that of promoting the health, education, and material welfare of the individual child; family limitation became widespread; and the end of the period of population growth came in sight.10

On the strength of this formulation of a general process, three broad types of national population could be distinguished. First were those populations of European descent that had passed through all three of these stages to a state of “low pressure” equilibrium. From the point of view of population growth they were considered to be now in “incipient decline.” Second, there were “populations in an earlier stage of demographic evolution” where fast “transitional growth” of population was now occurring. This was because mortality had declined but traditional high fertility persisted, as “the forces of modernization” had not

The Idea of Demographic Transition and the Study of Fertility Change

51

yet exerted their full effect. A third category of countries had scarcely begun to enter the trajectory of transition. Although their current population growth rates were feeble because high mortality was offsetting their high fertility, they represented “high growth potential” that would be triggered once economic development and modernization began to reach them.11 Transition theory in its classic form therefore entailed an unabashedly evolutionary and recapitulationist general theory of the process whereby any country successfully moved from a pre- to a postindustrial state of demographic equilibrium.12 Although there was nothing historically inevitable in the process, in order to industrialize and modernize a country must pass through the stages of demographic transition, with the appearance of fertility-controlling behavior marking the advent of the final stage, and the general spread of such behavior confirming successful sociocultural adjustment to the conditions of a modernized, economically developed nation. Whether a country succeeded or not in negotiating the transition was a historically contingent matter. It is highly relevant that Notestein’s seminal formulation was in fact presented not to demographers, but to a conference dealing with the impending problems of organizing postwar food supplies and trade: a meeting of planners held at the University of Chicago in September 1944, in anticipation of establishing the proposed United Nations Food and Agriculture Organization.13 Notestein’s appearance at this forum was a response to the preexisting demand from the new and growing constituency of economic and policy scientists. They urgently required reliable estimates of future population growth in different parts of the globe. In his general introduction to the conference, Theodore Schultz advertised the value of Notestein’s address to the participants and their interests.Transition theory enabled them to classify all nations into a policy-relevant threefold typology: “These types are much-needed building blocks for social analysis.”14 For the demographers who formulated transition theory, its original attraction had no doubt appeared to be the sense that it made of interwar preoccupations with very low fertility in many developed countries. It explained and located this phenomenon as a process within a global historical pattern. For the conference called in anticipation of the creation of FAO, however, the primary interest was what the theory had to say about the populations of undeveloped and

52

Health and Wealth

developing countries in the future. As I argue in the next section, it was specifically this policy application of transition theory that gave it the wider attention it received after 1944 and provided the impetus for its further elaboration over the next few years.

The Contrasting Reception of Demographic Transition Theory in The United States, 1929 and 1945 When Warren S.Thompson published in 1929 a general historical theory of the relationship between population and economic growth similar in all essentials to the subsequent theory of demographic transition, it had attracted little wider interest and comment.15 In fact, there were several prewar precursors of demographic transition theory in a number of countries, although Thompson’s statement is certainly the most comprehensive formulation published in the United States.16 Yet so thoroughly forgotten was this early statement that not until recently has Thompson’s claim to priority been widely recognized. This contrast in reception in 1929 and in 1945 cannot be simply explained away as the result of differences between Thompson and Notestein in their institutionalized capacity to influence the field of population studies. In many ways the two men are as near to perfect parallels as can be possible at two points in time. In 1929 Thompson was the same age as Notestein was in 1945, and they were in analogous positions of preeminence, each at the head of the premier American demographic research institution of his time.17 However, the principal interest for American demographers until well into the 1930s continued to be the eugenics-inspired project of tracing domestic fertility differentials between classes and races.18 Despite his prominent status in the discipline throughout the 1930s, as author of the principal English-language general textbook, Population Problems (three editions 1930–42), Thompson’s earlier formulation of transition theory found no significant wider audience of social scientists or funding agencies eager to seize upon it. (This is also true of the various other early progenitors of transition theory in other countries.19) There simply was no strong social science or policy interest in demographic transition theory and its implications in the 1930s. By 1944 all this had changed. Notestein found

The Idea of Demographic Transition and the Study of Fertility Change

53

himself at the head of a burgeoning international demand for the theory from many sides.20 This contrast indicates how much had changed since 1929 in the social science and economic policy context in which these two students of population operated. How, then, do we account for this change? Three major factors can be identified: a changed institutional context; important new intellectual developments; and the impact of contingent political events. First, as to institutional change, by the end of World War II there was in the United States a heightened level of acceptability for economic and social planning in government. Of course, economic planning and “social engineering” had long ago won a well-established de facto place in American business practice. Major interwar philanthropic initiatives from the business community had led to the founding of the Brookings Institution and the Social Science Research Council, for instance.21 Moreover, the credibility and efficacy of the behavioral and administrative social sciences had been established in the eyes of leading American businessmen from their own experiences in building and managing successful business empires. Large corporations, such as the Ford Motor Company or Rockefeller’s Standard Oil, were among the earliest employers of experts in industrial psychology and industrial relations, as well as of corporate planners and investment strategists.22 Nevertheless, in the libertarian New World, the de jure legitimacy of social science and economic planning as official practice for the federal government acquired public acceptability only after a prolonged period of empirical vindication in New Deal and wartime programs.23 Hence, Hodgson has convincingly argued that the New Deal projects of the 1930s played the role of midwife in the emergence of an independent, professionalized discipline of demography in the United States.24 Planners’ needs for various projections of population movements focused demographers’ attentions on the more technical aspects of their subject relating to observation, measurement, and validation of statistics. Hodgson argues that this began a process of relative emancipation of institutionalized demography from the overtly racist and elitist interwar agenda of eugenics and immigration restriction.25 (This was, of course, also part of a wider shift in the late 1930s in the social sciences away from a biologistic perspective, reinforced by the common revulsion from German racist policies under the Nazis.)

54

Health and Wealth

Second, economic planning was not only stimulated by new administrative practices of the federal government but was also legitimated and expounded in theory through the intellectual developments sweeping the discipline of liberal economics. A new synthesis of Keynesian and neoclassical economics was worked out on both sides of the Atlantic during the early and mid-1940s. As a result of Keynesian emphasis on the factors influencing the level and characteristics of effective demand, there had appeared, even before the outbreak of World War II, significant interest in the economic implications of demographic change from prominent Keynesians, British and American.26 The most influential early convert in the United States was Alvin Hansen.27 It was principally through his seminar in fiscal policy at Harvard that Keynesianism was infused into U.S. economic theory and policy during the early 1940s: participants included Evsey Domar, John Kenneth Galbraith, Paul A. Samuelson, and James Tobin. Many of these quickly became involved in practical “Keynesian” policy, assisting with the Roosevelt administration’s conduct of the economy during the war. This decade, therefore, witnessed the reemergence of an economics discipline that once more claimed a practical and administrative relevance for its science and that was prepared to offer a committed and self-confident derivative set of policies to politicians, policymakers, and other planners.Thus, an important part of the explanation of the stark contrast in the reception of theorizing about demographic transition lies in the intellectual and institutional changes that had swept through the relevant social and policy sciences in the intervening years. National and international economic planners and strategists were a breed that had hardly existed as an identifiable group in the United States of 1929. By 1945 their claims, influence, and numbers had all grown enormously in cumulative response to the demands of the Great Depression, World War II, and the imminent demands of managing the return to peace in a war-torn world. In order to explain more precisely how and why the theory achieved success when it did, the third factor mentioned above—the impact of contingent political events—must also be invoked.This is also the point at which considerations relevant to the wider issues raised at the outset can be addressed: transition theory’s peculiar capacity for survival, its conceptual ambivalence, and its intellectual status.

The Idea of Demographic Transition and the Study of Fertility Change

55

Based on a traditional distrustful isolationist position (which saw almost as little intrinsic merit in European monarchies, and their apparently inevitable association with colonialist empires, as in socialism or communism) there had emerged during World War II two broad strands of American strategy for managing the transition to a safe and prosperous peace.The first was the foundation of powerful transnational institutions for the rational management and coordination of world political and economic affairs. It was hoped these would carry the authority of universal assent to their constitutional and jurisdictional status.The principal initiatives here were the International Monetary Fund, the World Bank (formerly the International Bank for Reconstruction and Development), and, of course, the United Nations and its fourteen specialist organizations, notably FAO, UNESCO, WHO, and UNICEF. The second strand was encouragement of moves toward decolonization, democratization, and economic and social development for the former imperial possessions of the shattered Old World powers, in the firm belief that the establishment of independence, democracy, and free markets around the world provided the essential basis to remedy the economic and political ills of these impoverished countries.28 It was specifically in application to this second branch of U.S. reconstructionist strategy that transition theory found an enthusiastic market for its wares. Faced with a confusing array of problems involved in feeding the populations and in alleviating grave economic and political stresses in a disparate collection of colonial countries, the theory of demographic transition appeared to be something of a philosopher’s stone. For those wishing to formulate and execute coherent policy with a global scale of application, the theory provided an appropriately scaled general historical model. Within the eminently manageable confines of its simple conceptual framework, transition theory appeared to show that all current colonial and non-European societies could be placed into a rank-ordered typology in terms of their observable economic and demographic characteristics. Furthermore, this evolutionary taxonomy related the current situation of each of these countries to that of the successfully industrialized nations and also broadly indicated a prognosis for their future development. As Dudley Kirk, another of the Princeton demographers closely involved with the wartime elaboration of transition theory, had put it in December 1943, “In regard to demographic

56

Health and Wealth

matters the different countries of the world may be considered as on a single continuum of development.”29 Notestein’s seminal presentation in 1944 was carefully attuned to this anti-imperial, decolonizing diagnosis and its liberalizing and democratizing prognosis. Indeed, it was a substantial contribution to this viewpoint in its own right. It has seldom been remarked upon by subsequent demographic analysts that the presentation of the classic version of transition theory (described above) occupies only the first half of Notestein’s published text of 1945. The second half comprises a pocket political manifesto against the demographic dangers and shortcomings of the colonial past.30 Notestein’s argument revolved around a comparison of the modern demographic record of dependent, colonial India with that of Japan—an independent sovereign state that had become a representative democracy in the early decades of the twentieth century. The historical record of interwar Japan appeared to show that demographic transition had begun there already before World War II, demonstrating that transition was perfectly possible in a non-European country. Birth rates already commenced falling there during the first half of the century, a consequence of the successful indigenous industrialization occurring there. There were no such signs in India, however, and this Notestein attributed to the logic of predatory colonial exploitation. Unlike the healthy endogenous development of independent Japan, colonialism had merely imposed from the outside the minimum necessary infrastructural changes for India to function as a source of raw materials and as a market for British manufactured goods.31 Minimalist colonial development policy of this sort might reduce mortality to some degree as an incidental spin-off, but such superficial influences could not work upon the deeply entrenched social and cultural traditions that maintained high fertility. Only the granting of political autonomy and the establishment of a market economy and a democratic society could induce a downward shift in fertility. Notestein then graphically offered two stark alternatives for the future of India and all such colonial countries: either the misery of recurrent cycles of temporary population growth followed by Malthusian famine crises, if left in their colonial purgatory; or else “thorough and balanced modernization[,] . . . urbanization, industrialization, rising levels of living, popular education, and popular participation in political life” so

The Idea of Demographic Transition and the Study of Fertility Change

57

that “the same forces that eventually induced a declining fertility in the West would probably come into play.”32 The model of independent and (relatively) democratic Japan showed that this latter path was possible in the East, too. This was a formula with great appeal to the New World’s postwar generation of global reconstructionist planners. It simultaneously condemned the extortionate ways of the Old World’s imperial powers and confirmed the wisdom of exporting American liberal democratic political and economic practices to these benighted colonial countries. According to transition theory, the institution of liberal and democratic ground rules in the economic as in the political realm was, in these societies, the necessary precondition for entering the evolutionary path of transition toward emancipation from colonial bondage.

Notestein’s Transition in Demographic Theory The prognosis of the classic version of demographic transition theory was far from a program for rapid results. It did not envisage any simple, cheap, or easy solutions to the problems of economic backwardness. With regard to high fertility, Notestein emphasized the tenacity of traditional cultural prescriptions evolved over generations and the need for these to change before individuals’ motives and intentions could begin to encompass fertility-controlling behavior.This required an ambitious and patient long-term perspective and strategy, encompassing “the whole process of modernization.” Only thorough and widespread economic development, bringing in its train the social and cultural changes associated with modern democratic polities, could in due course ensure the prosperity necessary for future demographic stability. Hodgson, Demeny, and John and Pat Caldwell are all in agreement that this aspect of Notestein’s approach at this time was fundamental and distinctive.33 Notestein saw fertility behavior as culturally embedded and stressed the need to approach its modification through attention to the complexities of demand (changing the setting in which intentions and motivations formed), rather than the simpler issue of mere supply (the provision of contraceptive information and devices).As Notestein put it in another early discussion of demographic transition theory (a contribution

58

Health and Wealth

to a “Round Table” at the Milbank Memorial Fund in 1944, which he chaired, on “Demographic studies of selected areas of rapid growth”): 1. Populations whose social institutions and personal aspirations are those developed in high mortality cultures are little interested in contraception and will not make effective use of the methods normally at their disposal. Of course, in nearly all cultures some individuals practice contraception and resort to a variety of other controls of fertility. However, they do not do so in sufficient numbers and with sufficient effectiveness to bring about any very substantial reduction of the fertility of the group. 2. Conversely, populations whose institutions and personal aspirations are those of modern individualistic cultures will control their fertility in substantial degree with or without the assistance of modern contraceptive techniques. Nearly all peoples have at their disposal the knowledge of contraceptive practices that are in fact used with great effectiveness in some populations. 3. The dissemination of contraceptive knowledge as the sole solution to the problems of population pressure is of little importance. In an appropriate social-economic setting, birth control propaganda, contraceptive and other [sic], and birth control clinics undoubtedly can and do serve important educational purposes and can be very useful in hastening the reduction of fertility. Contraception is an important means, among others, by which people can control their fertility. Whether they control it depends on the social setting; hence new patterns of behavior are to be established principally by the alteration of that setting.34 (author’s emphasis)

All this was based on a compelling inference drawn from Notestein’s reading of the most authoritative comparative and historical inquiries available to him.35 Such research appeared to show that the range of contraceptive practices known to humankind was bewildering in its variety; virtually all cultures at all times seemed to have had access to at least some contraceptive techniques. Notestein concluded therefore that the absence of systematic use of such techniques was not the result of ignorance as to means but rather was due to a lack of motivation. Furthermore, this was empirically confirmed in his own contemporary research on contraceptive use among women in the United States.36

The Idea of Demographic Transition and the Study of Fertility Change

59

Just five years later, in 1950, as Hodgson has carefully shown, Notestein and Kingsley Davis can both he found advocating governmentsponsored policies of family planning as an urgent priority for pretransitional countries.37 As a policy for population control, this was something that the main thrust of demographic transition theory in its original form would have ruled out as an ephemeral and misconceived diversion of energies. Transition theory emphasized the importance of logically prior, long-term projects to promote the all-around economic growth necessary to engender the new social and cultural institutions that alone could transform traditional ways of thought. To alter the allimportant setting in which individuals’ motives and intentions were formed required massive change: building an educational system serving both sexes, constructing the social and communications infrastructure entailed in urban growth, and developing efficient internal commodity markets, to name the most obvious. According to the original version of transition theory, superficial projects for a “quick fix” to the problem of overpopulation, sidestepping the need for prior “modernization” of the economy and culture generally, were doomed to failure and smacked of old-style predatory colonialism. How, then, did this highly significant shift of ground occur in the writings of these two men? Hodgson argued that it was related to an increasing preoccupation by Notestein and Davis with rendering feasible and practical policy advice. This produced two obvious and correlated changes in their writings.The first was a transposition in the basic terms of reference, whereby discussion shifted from the properties of societies and cultures to those of abstracted “individuals” or “peasant families.”The second was the summary endowment of these “uneducated” individuals and “peasants” with the rationality of “homo economicus.”38 Hodgson pinpointed how both men seem eventually to have hit upon the same rhetorical flourish to justify what in fact amounted to a startling and dramatic conceptual volte-face, overturning their earlier priorities of 1944. In each case, the beguilingly simple assertion was made that throughout the world one could find that the typical wily peasant, or “most people,” were not “stupid.”39 This observation apparently entailed the self-explanatory implication that, if not “stupid,” then individuals everywhere could be relied upon to be economically rational in their fertility behavior. The main policy priority, therefore, was to focus on the supply of appropriate

60

Health and Wealth

birth control technology.40 The need for complex economic and cultural changes, formerly considered vital for generating demand and motivation for systematic family planning, was thereby removed at a stroke. But what, then, caused the emergence of this galvanizing overriding commitment to birth control activism among the leading demographers in the United States? Careful delineation of chronology provides the essential clues to understanding the motives behind this remarkable transition in demographic theory. Hodgson treats the entire period, 1945–55, as a unity. But, as I pointed out above, it is clear from his own analysis that the strong commitment to proactive family planning programs was already manifest in each of the two men’s publications at least as early as 1950.While further elaborations in the same direction can then be traced in their works over the next four years, this was really no more than an intellectual dotting of i’s to rationalize the new position and to bring it into consistency with a modified version of transition theory. In order to identify the reasons for and the timing of this transposition, I have examined the relevant writings of Notestein during the period 1944–50. I have concentrated on the work of Notestein alone so as to be as precise as possible in identifying and dating the changes in thinking. My focus on Notestein’s work is not intended to imply that he was the sole cognitive innovator in postwar American demography. It is clear that there were many mutual influences among those involved with the Princeton Office: Kingsley Davis, Irene B. Taeuber, Wilbert E. Moore, John Durand, Dudley Kirk, and Ansley J. Coale, to name a few. However, because of Notestein’s professional and institutional seniority, combined with his powerful personal connections with their international reach, the evolution of his thinking was the most influential in determining the relationship between the idea of demographic transition and the study of fertility change during this period. Insofar as the study of fertility change is concerned, the key conceptual change to the theory of demographic transition was the modification whereby fertility was no longer viewed as the ultimate dependent variable—the final outcome due to other necessarily prior manifestations of economic, social, and cultural modernization. Instead it came to be viewed as something that historically had, on occasion, changed more or less independently of these other forces and as something that could and should be changed by interventionist policies designed to work in

The Idea of Demographic Transition and the Study of Fertility Change

61

advance of other measures aimed at effecting wider social, economic, and cultural change. Notestein’s published writings seem to indicate that this transformation of the theory occurred in several stages between 1944 and 1950. The first stage is already apparent in embryonic form in the paper from early 1944, cited above, given a few months before his presentation of the classic version of transition theory in Chicago.41 In a discussion of certain colonial agrarian countries currently experiencing fast population growth because of high fertility persisting alongside falling morality, Notestein argued that, “paradoxically,” according to demographic transition theory, “a reduction of the growth potentialities can be achieved only on terms of increased population growth in the near future.”42 This followed, of course, because transition theory showed that lower fertility could only be reached after the long-term process of modernization. In the meantime populations typically multiplied several-fold because of their earlier mortality declines. The only alternative was for such countries to remain in a state of relative underdevelopment, in which traditional high fertility continued alongside lower mortality rates, leading to periodic Malthusian crises of famine, disease, or war. Notestein argued that to allow the latter situation to develop was not only inhumane but also economically senseless and politically dangerous, as it courted continual outbreaks of international conflict.This meant that The crux of the problem is the greatest possible reduction of the lag between the downward trends of mortality and fertility. If relief from population pressure is the goal, it is dangerous to continue frittering away the productive power of modern techniques in a social setting calculated to maintain high fertility. There is urgent need to apply in synchronized fashion every device for the creation of a social setting favorable to reduced fertility. This in fact would require a complete and integrated program of modernization.43

As one can see, Notestein’s attention was here primarily focused on the policy applications of demographic transition theory—to inform and devise a strategy to control the predicted imminent rapid increase in population pressure. He was already countenancing, indeed advocating, ways in which the process of demographic transition might be modified

62

Health and Wealth

and accelerated. Because he viewed the theory not merely as a historical generalization but also as a predictive instrument for control of future events and for policy formulation, the ground was set for further changes in the theory’s specification, in the light of current affairs and policy considerations. At this point in 1944, however, Notestein could only envisage fertility reduction occurring after full-scale rehearsal of the process of modernization. This stance began to change in his next major published statement on this subject, written for another Milbank Memorial Fund “Round Table” held in November 1947 on “International approaches to problems of undeveloped countries.” Notestein provided the introductory summary of the demographic background. He was now keenly aware that mortality in some less-developed countries was falling with “remarkable speed.”44 He reiterated, optimistically, his interventionist argument that “there is nothing inevitable about the exact amount of time . . . involved in the demographic transition. Careful planning, particularly in the early stages, might speed the process. . . .”45 In pursuit of this policy aim, he concluded that First of all, we need to know how to reduce birth rates in an agrarian society. The problem is too urgent to permit us to await the results of gradual processes of urbanization, such as took place in the Western world.We need to know more about the causes of the decline of the birth rate in rural France in the early nineteenth century, and in Eastern Europe between the wars. We need concrete experiments in the processes of social change in peasant populations with high fertility.46

However, he feared that The problem of the voluntary control of fertility when the individual incentives for such control are not strong may prove insoluble with available methods.47

Therefore: We also need increased knowledge of the physiology of reproduction. . . . It is quite possible that an expansion of fundamental knowledge of the physiology of human reproduction would result in much simpler

The Idea of Demographic Transition and the Study of Fertility Change

63

and more effective methods of contraception which would find more general acceptance.48

Thus, it is clear that an important shift had occurred in Notestein’s thinking by the end of 1947: he was now countenancing the desirability of lowering fertility in agrarian societies in advance of “modernization.” But this was not yet conceived of as a realistic possibility. Notestein was not yet advocating birth control programs as practical policy, principally because he could not see how this could be done in the present state of knowledge. In the same article he also wrote, “It must he emphasized, however, that the decline in fertility requires more profound changes than the mere availability of the convenient contraceptive.”49 He was therefore calling for further research, which he hoped would either result in the development of some kind of contraceptive “magic bullet” or reveal how agrarian societies might be induced to change their fertility behavior even in the absence of such a technological breakthrough. In the current state of ignorance regarding peasant societies’ limited capacities for fertility control, and in the absence of more effective, simple methods of contraception, Notestein did not feel this was yet a policy to be recommended. But he had already become less enamored of his earlier emphasis on full-scale modernization as a convincing policy proposal and was concerned that the problems of lessdeveloped countries were too urgent to await the functioning of these gradual processes. After his November 1947 article, the next relevant contribution by Notestein was his coauthorship of a report on a 1948 trip to the Far East with two Rockefeller Foundation officers, Marshall C. Balfour and Roger F. Evans, and the Princeton demographer Irene B. Taeuber, on behalf of the Rockefeller Foundation.50 The report, completed by October 1949,51 discusses the findings of an intensive, three-month, whistle-stop survey tour to six countries of East and Southeast Asia. The aim was to advise the Rockefeller Foundation how best to deploy its funds in promoting the scientific study of public health and economic development problems of relevance to countries on the Asian side of the Pacific rim. The report was the joint product of all four authors, but Notestein would have been primarily responsible for passages that elaborated the implications of findings in terms of transition theory.

64

Health and Wealth

In this document evidence of the final shift in Notestein’s thinking can be found: the critical change of priorities, whereby he began to advocate the implementation of birth control policies as something that could usefully be promulgated with immediate effect and in advance of more ambitious economic and social projects. The document in effect charts the contours of the intellectual pathway whereby Notestein had been able to move from his 1944 position to that found in the publications of the early 1950s, as a form of natural progression. He travelled that road without radically contradicting himself at any point along the way. The principal novelty in Notestein’s approach recorded in this report was his positive endorsement of the immediate institution of government-sponsored, proactive birth control policies, even though no contraceptive magic bullet had arrived since November 1947. Positive birth control policies were not presented as a complete alternative to efforts aimed at more comprehensive development, but Notestein now considered that they might perform a vital and integral part of such a development strategy from the very start. Compatibility with the main thrust of the original version of transition theory was maintained through an ingenious conceptual maneuver. The report offered a distinction between, on the one hand, the “firstorder,” deeply embedded forces that maintained large-scale inter-national differences in overall fertility levels between different cultures and, on the other hand, a finer set of “second-order,” intra-national factors that might produce observable and manipulable variation in fertility behavior within a single cultural regime: The level of fertility . . . is a product of the total culture, including its most deeply laid and intimate aspects which are slow to change. . . .However, the limits within which variation of fertility is restricted by the culture and economy probably are rather broad.52 [I]t should be possible to modify reproductive behavior to some extent without fundamental changes in other components of the culture. No social system, however coercive, maintains absolute homogeneity of behavior. All systems have their dissident extremes open to innovative suggestion; all have those who conform only because of the absence of alternatives.53

The Idea of Demographic Transition and the Study of Fertility Change

65

The key term “social system” will no doubt alert many readers to the similarity between this conceptualization of the process of social change and the dynamic role of “deviance” in Parsonian-derived “modernization” theory.54 This influence is hardly surprising: Kingsley Davis had himself studied under Parsons at Harvard, while two other sociologists among Notestein’s Princeton colleagues, Wilbert E. Moore and Marion Levy, were to be the leading progenitors (along with Everett E. Hagen, Bert F. Hoselitz, and Joseph J. Spengler) of the derivative “Modernization School.”55 Notestein here appears to be following the recent lead of Levy, invoking Parsonian functionalism to provide the means to envisage a process of social change intrinsic to Chinese peasant society.56 By placing his faith in the Parsonian conceptualization of social change, Notestein satisfied himself that he had an account (in fact a prediction) of how the spread of birth control would practically occur despite the absence of fundamental change to the social setting. He could therefore proceed to advocate it as a policy priority. Among his various experiences on this trip, Notestein was particularly impressed by his visit to a peasant village in China where he found himself confronted by a community apparently quite enthusiastic about family limitation but at a loss for an effective means to achieve it. According to the quotation above, in 1944 he would have seen these villagers as no more than a few mavericks insufficient in numbers or effectiveness to bring about any wider change in fertility.57 But Notestein now viewed them in an altogether different light, as direct evidence that there were, indeed, potential innovators in an agrarian society of a trend toward second-order, intra-cultural fertility decline, analogous to those urban professionals who were considered the pioneers of family limitation in Europe and North America in the previous century. The crucial change of heart regarding development policy priorities—concentrating simply on the supply of family planning services as against the promotion of long-term economic development and infrastructure projects to engender demand for birth control—was then broached as a possibility in the 1949 report in the following passage, as yet in a tentative and qualified form: We should like to make quite clear our position on this problem of the reduction of fertility within a given social situation. Even successful

66

Health and Wealth efforts in this direction will not serve as a substitute for a balanced program of development. . . . Fertility control is not a substitute for other ameliorative effort; instead, it is a means that will assist in making ameliorative effort successful—indeed it may turn out to be a necessary condition for such success.The East, unlike the West, cannot afford to await the automatic processes of social change, incident to urbanization and industrialization, in order to complete its transition to an efficient system of population replacement.58 (my emphasis)

Already in 1947 Notestein had concluded that, with its fast-falling mortality, the East could not afford to await the eventual effects of sweeping cultural change consequent on economic growth to trigger its own fertility decline. He was now arguing that if some measure of population control did not accompany the earliest stages of economic growth, then increases in national income would be literally swallowed up in the consumption needs of additional mouths to feed, instead of leading to the accumulation of productive capital and infrastructure.59 It therefore followed that maximum possible assistance should be given wherever indigenous inclinations toward incipient birth control existed. The report composed in 1949 was still some distance short of the more forthright public claims that Notestein and Davis were prepared to make over the following two years: that the typical peasant was highly amenable to the self-evident advantages of family planning. Nevertheless it clearly dates the important final step of transition in Notestein’s thinking. Having already renounced the gradualist implications of his earlier prognostications, he had now positively endorsed family planning activism as an early priority in development policy. Over the ensuing few years the virtues of family planning activism and the need for fertility research, conceived primarily as an adjunct to the implementation of development programs, were commitments that came increasingly to the fore in the publications and activities of Notestein and the Princeton-based network of American demographers. Once the key conceptual change in transition theory has been dated to the period between November 1947 and October 1949 (and most probably the first nine months of 1949, after returning from China), it becomes possible to advance beyond Hodgson’s skillful, pioneering analysis.The cognitive developments can now be more exactly placed in their

The Idea of Demographic Transition and the Study of Fertility Change

67

wider historical context and related both to the Princeton Office’s institutional role and to the impact upon it and its personnel of the momentous political events of those times. In particular, as will be shown below, there is every reason to believe that the unexpected developments in international relations in the Pacific over the five years following the end of World War II, coming to a head in 1948 and 1949, must have had a considerable impact upon American liberal intellectuals in general, and upon the perceptions of the transition demographers of Princeton in particular.

The Princeton Office, Demography, and International Relations:The Impact of the Fall of China, 1948–49 The unexpected defeat of Chiang Kai-shek’s nationalist regime in China by the communist forces of Mao Tse-tung was a major upset in longstanding U.S. strategic assumptions regarding the nature of the broad global balance of power that would emerge in the postwar world. America’s foreign relations strategy had entertained high hopes, both diplomatically and economically, for the republican China that had initially emerged after the nationalist revolution by Sun Yatsen’s Kuomintang in 1911. Historically, China had successfully resisted European colonization and merited praise for that; its newfound republicanism, albeit in effect a military dictatorship under siege, was at least a constitutional alternative of the right sort to that of the European monarchies and their overseas empires. Nationalist China also represented a hefty counterweight on the Asian continent to the world’s only Marxist-Leninist state, Soviet Russia. Given the long-standing U.S. preoccupation with the security of its Pacific aspect, all the more sensitive since Pearl Harbor, China was most propitiously located for the role of international policeman and guarantor of peace and order on the troublesome western littoral of the Pacific.Thus, when the United States had invited just three other nations to participate in the Dumbarton Oaks meeting of 1944 to finalize plans for the future United Nations, the third country invited, along with the Soviet Union and Britain, had been Chiang Kai-shek’s China. By the beginning of December 1948, the Chinese communists had won the decisive engagement in the battle of Huai-Hai with the fall of

68

Health and Wealth

Suchow, as their further advances the following spring proved. There finally followed the proclamation of a Chinese People’s Republic in Peking on 1 October 1949.This was virtually a trigger for the outbreak in the United Stales of the bizarre cultural epidemic known to history as McCarthyism, certainly a manifestation of a political nation undergoing severe anxieties over its security and future. If any further impetus to collective paranoia was required, this had already been provided by the scientists of Soviet Russia, who had exploded their first atomic bomb in the summer of 1949, to the great surprise and consternation of Western experts as well as the public in general. Most menacing of all to the foreign relations strategists was the ominous thought that whereas one Marxist-inspired revolution might be dismissed as an accident of history brought on by a careless Czar, two began to look distinctly like an ugly habit on the part of nations composed of impoverished and disaffected peasantries. Glancing around the globe, outside Europe there seemed an almost endless number of such nations: the subcontinent of India, precariously divided between Hindus and Muslims, came most forcibly to mind as the next possible location for a serious outbreak of communism. In the course of late 1948 and 1949 those in the United States still dreaming of a globe emerging from colonial servitude into a regime of liberal democratic free trade were awaking to a nightmare, experiencing a strong sense of loss of control in a dangerous and alien world. Why is this well-known slice of modern international relations history of particular relevance here? First, it emphasizes that 1948–49 was a critical year in America’s relations with its neighbors in the Pacific, during which a radical top-level reappraisal suddenly became necessary at short notice.60 Second, it serves as a reminder that no intellectuals in the United States at this time could rest immune from the impact of these dramatic developments: McCarthyism attests to the pervasiveness of the unease felt and to its palpable effects on American intellectual life. But in the case of the Princeton Office and its staff of demographers there are much more direct reasons why we should expect immediate consequences of this transformation in foreign affairs to be reflected in their intellectual output. This is quite simply because the demographic work of the Office had always been strongly focused on matters relating to international relations and, during the war, it had in fact become intimately associated with the State Department itself.

The Idea of Demographic Transition and the Study of Fertility Change

69

According to Norman B. Ryder, the Princeton Office’s initial financial patron, A. G. Milbank, was persuaded to fund it as a new part of Princeton’s Woodrow Wilson School of Public and International Affairs, which Milbank’s father had helped found, on the grounds that the School lacked expertise in the demographic dimension of the foreign relations problems that it addressed.61 The effect of the introduction of this international perspective on Notestein’s own work can be clearly demonstrated. The list of his publications compiled for his obituary by Ryder shows that all of Notestein’s publications prior to 1937 (fifteen items) dealt with domestic U.S. population problems.62 After his appointment to head the Princeton Office in 1936, two of his five publications over the next two years were devoted to international demographic issues (both on China). Thereafter, between 1943 and 1951 inclusive, only three out of twenty-six publications concerned domestic demography, while the rest were focused on the international scene. From its inception the Princeton Office attracted the support of major financial and political patrons. The Milbank Memorial Fund, the Carnegie Corporation, and the Rockefeller Foundation were together mainly responsible for funding the Office’s growing activities. Its main clients during the 1940s were the exiled League of Nations (whose Economic, Financial and Transit Section had been offered wartime accommodation at Princeton), the subsequent United Nations Population Commission, and the United States State Department.Wellconnected power-brokers brought resources and contracts to the Office, such as the millionaire former eugenicist, Frederick Osborn, who had persuaded A. G. Milbank to finance the Office in the first place, and Harold Dodds, the president of Princeton, who apparently arranged both its work for the League of Nations and the finance to support the work from the three foundations mentioned above.63 By far the most financially powerful and politically involved of these super-patrons after World War II was the combination of the Rockefeller Foundation and John D. Rockefeller 3rd. Like Osborn and Milbank, Rockefeller had already been involved during the interwar period in funding eugenicsinspired domestic projects in demography and “social hygiene.”64 After the war the scope and aim of his activities were becoming more international.While Rockefeller the Foundation and Rockefeller the individual were formally independent entities, they in fact came to perform

70

Health and Wealth

strongly imbricated roles in connection with the Far East, on behalf of a U.S. foreign policy in turmoil. Thus, Raymond B. Fosdick, president of the Rockefeller Foundation and a veteran in the field of foreign relations, was selected by Secretary of State Dean Acheson to tour East Asia in the summer of 1949 along with Philip Jessup of the State Department and Everett Case of the Institute for Pacific Relations.65 When, on returning, this top-level team met to discuss the policy implications of their findings with a group of China experts selected by the State Department, John D. Rockefeller 3rd was a natural choice as a participant.66 It is clear, then, that Rockefeller, Fosdick, and the Rockefeller Foundation were during 1948–49 deeply embroiled in the issue of China and the administration’s response to the impending communist victory there; and so, too, was Notestein. On the eve of the battle of Huai-Hai itself, fought from November 1948 to January 1949, Notestein,Taeuber, and their two colleagues from the Rockefeller Foundation were still in China nearing the end of their three-month trip. While their presence there further emphasizes the startling nature of the subsequent turn of events in that country even for the most well-informed American observers, it also underlines the extent to which these individuals at the Princeton Office were directly and personally aware of the significance of developments in international relations in East Asia, particularly those in China.While Cold War developments in Europe had undoubtedly been the main preoccupation for the wider American public opinion during the Berlin blockade of 1948–49, the Princeton Office was already by then much more closely involved with Asia and the Pacific, which quickly became the most sensitive area of American public concern during 1949 and 1950 (with the outbreak of the Korean War in the latter year). Thus, throughout the 1940s the Princeton Office was immersed in the concerns and issues raised by America’s international relations and strategic interests. From the outbreak of war in the Pacific, much of the Princeton Office’s most important work had been by direct commission from the U.S. State Department.67 After the war this relationship was transmuted into the role of supplying the administration with demographic information relevant to “the problems of the peace,” to use Notestein’s phrase.68 The continuing predominant influence of the interests of this client are shown by the subsequent publications of some of the

The Idea of Demographic Transition and the Study of Fertility Change

71

Office’s principal staff, which were devoted to the most strategically important countries of Asia. Notestein himself worked on Palestine; Davis worked and published on India and Pakistan from 1944 to 1954; and Taueber worked and published on Japan and on the Pacific area from 1945 to 1958. T. E. Smith published on Malaya in 1952 (in the Malayan Emergency of 1948 the British colonial authorities came under attack from communist guerrillas, and a five-year jungle war ensued); and George Barclay’s study of Chiang Kai-shek’s island refuge of Taiwan appeared in 1954.69 There is further testimony to the importance of this international relations perspective in Notestein’s publications. In particular, his chairman’s paper to the 1944 “Round Table” at the Milbank Memorial Fund, cited above, was notable for the frankness and fullness with which he dwelled on “Considerations for American policy,” as his concluding section was entitled, outlining likely demographic outcomes in less-developed countries in relation to possible U.S. policy initiatives in terms of “the humanitarian ideals, economic interests, and the peaceful security of the United States.”70 The problems of international relations had, thus, supplied Princeton demographers both with most of their funding and with the broad frame of many of the intellectual problems with which they grappled. As Notestein himself observed, “Demography is essentially an applied discipline . . . the basic problems . . . we bring to the field.”71 At the end of the 1940s the essential nature and urgency of the most pressing problems being brought to American demographers changed dramatically. In 1944 the principal problem had been to create intellectual order out of the chaos of scores of partially industrialized countries with their semiliterate populations spread across the globe. This order was needed to inform the efforts of U.S. economic planners, food and agriculture experts, and foreign relations strategists in their attempts to plan food requirements and to organize the postwar reconstruction of world trade and political relationships from the point of view of U.S. interests in liberal-democratic and free-trading polities. Notestein, Davis, and the Princeton Office had supplied the much-appreciated original formulation of demographic transition theory in response to this demand. However, the developing implacability of Soviet Russia and the sudden victory of Marxist-Leninist ideology in China transformed the nature of

72

Health and Wealth

the most urgent problems being brought to demographers by the end of the 1940s. Since relative lack of economic advance in peasant societies seemed to produce conditions favoring communist takeovers, even against all military odds as in China, the question posed now by the strategic policy planners and philanthropic foundations was whether there was anything that liberal social science and the economic resources of Western capitalism could do to avoid such regrettable occurrences. On the presumption that the achievement of greater and more democratically spread economic advances in these poor countries was the best hope of protection against further communist takeovers, this question, when posed to demographers, resolved itself into that of whether their science could supply Keynesian economic planners and political scientists with practical assistance toward this goal? Within the framework of their previous analysis (transition theory vintage 1944–45), which had envisaged demographic change primarily as a dependent variable consequent on prior economic development, the question whether this was necessarily always the case was not posed. Now that demographers were being asked whether demographic factors could not also be brought in to help with generating economic growth, they found it worth their while to reexamine their former assumptions. In appreciation of the desire to offer constructive advice rather than simply sit by and watch as the map of Asia turned red, the first small step, which Davis and Notestein independently took in published work appearing in 1950, was to advocate the only thing that could be done in the short term: the initiation of family planning policies in countries such as India.The following year Davis published his monograph on the population of India and Pakistan in which he pessimistically predicted the emergence of totalitarian governments and a totally planned economy there. He presented family planning programs as an essential component of any liberal or social democratic alternative path toward development, but thought these highly unlikely to be taken up.72 Notestein’s well-known address in 1952 to an international conference of agricultural economists ushered in a new phase of pro-family planning activism among transition theorists.73 For those facing the task of planning for economic growth in less-developed societies, he elaborated upon the apparently optimistic policy implications of the newly formulated possibility of reverse causation in demographic transition. Notestein

The Idea of Demographic Transition and the Study of Fertility Change

73

persuasively amplified his argument that the historical model of gradual, endogenous economic growth with subsequent demographic adjustments could not be expected to repeat itself in colonial and former colonial areas in the altered global context of the mid-twentieth century. The demographic and trading context of currently less-developed countries, he argued, was fundamentally different from that of the now-developed nations in the nineteenth century.The early industrializers had been able to sell their products freely worldwide in return for relatively cheap foodstuffs and raw materials; furthermore, they had not constituted such large fractions of the global population as the oversized poor countries now did. While the food bills of today’s poor countries were proportionately higher, the world market for the products of their nascent industry was much more competitive. Notestein therefore looked forward to devising strongly proactive planning policies for economic growth that might embrace a deliberate attempt to foster a fall in birth rates in advance of economic growth, in order to avoid the enormous food bills that would otherwise consume all potential capital growth. Notestein then ensured that the intellectual project of providing a rigorous framework to demonstrate the implications for economic development of different demographic regimes, with and without effective programs for fertility restraint, went forward at Princeton over the next five years.74 Essentially this was a model projecting the likely trajectory of incremental capital/output ratios with varying dependency ratios associated with the different age structures characteristic of the three stages of transition.The longer the time lag before fertility fell, the heavier was the burden of current consumption and therefore the slower the flow of investment into capital formation, which was considered to be the key variable governing the rate of economic growth. Early attempts to formulate such a model for economic development with a fully integrated demographic component were devised at Princeton by Harvey Leibenstein. But the most influential was the later Princeton version, which appeared in 1958, resulting from the collaboration of Ansley J. Coale (Notestein’s successor the following year as director of the Princeton Office) with the economist Edgar M. Hoover.75 The CoaleHoover model exerted considerable impact on policymakers including, ultimately, playing a part in the important decision to commit U.S. foreign aid funds to family planning activities.76

74

Health and Wealth

Thus, the Princeton-dominated U.S. school of transition— demographers had reached a point in the early 1950s where the leading theorists such as Notestein and Davis had concluded that history, sociology, international relations, and humanity all indicated an important and perhaps even crucial role for a birth control policy to be adopted by the governments of those poorer parts of the world attempting to foster economic growth while maintaining a liberal polity and economy. The government of India was openly receptive to such proposals. With the outbreak of the Korean War in 1950, the intensifying mutual competition between the superpowers for client states meant that the U.S. Congress was prepared to vote increasingly large sums in loans and aid, especially to the numerous countries in Asia bordering the Soviet Union and China.77 But these funds were as yet not for birth control programs. Demographers were to find themselves helpless bystanders, apparently bound to watch opportunities to fund family planning programs pass them by. This was because throughout the 1950s in the United States an insidious, diffuse, and incontestable atmosphere of public opprobrium surrounded the issue of birth control. This, along with the implacable personal hostility of some influential public figures, for example John Foster Dulles, prevented demographers from obtaining serious financial support for their preferred policies.78 Clearly, for population experts, who saw themselves as rationalist and humanist scientists, this was a galling predicament: Notestein’s memoirs exhibit some of his impatience and exasperation when reflecting on this decade.79 Unable to assist India substantially to finance or organize its would-be population program, and unable to put into practice anywhere else their convictions regarding the likely benefits of family planning policies for developing economies, Princeton demographers spent most of the decade from the early 1950s until the early 1960s gradually digging themselves deeper and deeper into a position of intellectual justification for governmentorganized family planning programs, then still largely a planner’s dream. This decade of obstructed activism—insofar as direct access to federal policy formulation and funds was concerned—was in fact important in producing the spectacular momentum of the following decades. Energies both at Princeton and elsewhere were temporarily channeled into several preparatory activities: the Coale-Hoover project, basic

The Idea of Demographic Transition and the Study of Fertility Change

75

research to devise effective contraceptive technology, training an international nucleus of future demographers and policymakers, and campaigning and building international institutional bases.This proselytizing activity was addressed primarily to international audiences: apart from the Coale-Hoover project, there was also the launching, in 1952, of the Population Council. The 1954 United Nations World Population Conference in Rome and the 1955 Bandung Seminar were important platforms, which resulted in the foundation of three further regional centers for demographic training to join the first, which had already been established in Delhi: Bombay (1956), Santiago (1957), and Cairo (1963). Again, this was partly the result of Indian initiative, and the centers were sponsored by a combination of UN and Population Council (involving the Ford Foundation) funds.80 In all this, the influence of Notestein and his two powerful patrons, John D. Rockefeller 3rd and Frederick Osborn, was ubiquitous.81 Furthermore, former students at the Princeton Office were now filling some of the key institutional positions, such as John Durand, who succeeded Notestein (and P. K.Whelpton) as the third director of the United Nations Population Division (created in 1946), and Dudley Kirk, who became the first director of the Population Council’s Demographic Division in 1953.82 All this enforced preparatory work effectively built up a powerful submerged program waiting to burst into action. The patient work of education and training was already producing a yearly crop of some thirty trained demographic specialists from the various UN centers by the end of the 1950s. By the time family planning programs finally became politically and financially feasible, the hopes pinned upon them were enormous, as were the programs that were fielded during the late 1960s and after, complete with numerous surveys such as the so-called KAP series (begun in the 1950s as part of the preceding campaign to demonstrate unmet need for family planning) and later the World Fertility Survey. Large-scale funds eventually became available in 1967 with the congressional earmarking of USAID funds for population activities.83 As Peter J. Donaldson has documented, under the rule of R. T. Ravenholt as director of the Office of Population at AID, there was a virtually exclusive preoccupation with supplying contraceptive services, with little interest in investigating or furthering the social and economic developments that might create the conditions for greater receptivity to

76

Health and Wealth

birth control.84 To attribute this strategy exclusively to Ravenholt, however, is to overlook the influence of the wider ideological and political climate of the times. The communist and socialist strategies of centrally planned economic development, in association with confiscatory or at best redistributive measures for land and property, appeared to be having considerable successes and were attracting clients among the postcolonial nations. Policymakers and conservative public opinion in the West, anxious to preserve and promote liberal values, were extremely wary of any involvement with wider-ranging social and economic policies seeking structural changes possibly with redistributive implications. Provision of family planning for voluntary acceptance therefore appealed as a safe liberal policy for development. Thus, the international “family planning industry” mushroomed into existence from the mid-1960s on such a scale and with such a determination to implement its program that isolated warnings from some, to the effect that the analysis and policy underlying this supply-centered activism might be in any way flawed or inadequate, went largely unheeded.85 The intellectual legacy of a decade of thwarted intentions, encouraged by the implications of international ideological competition in the 1960s and 1970s, resulted in an overly dogmatic and rigid commitment to family planning activism, apparently licensed by the idea of demographic transition.

The Persistence of the Idea of Demographic Transition In attempting to make sense of the paradoxes surrounding the origins and persistence of the idea of demographic transition, I have argued that the wider institutional and political context has played an important role throughout.The characteristics and chronology of the “career” of demographic transition theory—its interwar obscurity and its wartime efflorescence and subsequent mutation in Notestein’s own hands—would seem to have had as much to do with these wider influences as with purely cognitive and intellectual considerations. Given the inescapable logic of Realpolitik competition for client states between the opposed Marxist-Leninist and liberal ideological camps in the Cold War era, a powerful policy demand arose for the

The Idea of Demographic Transition and the Study of Fertility Change

77

creation of a liberal, democratic model of planned economic development to export to much-wanted political allies around the globe. Keynesian liberal economists experienced no great difficulty in devising such a model.86 The only question for demographers was whether there would be a contributory input from their science, too, or whether they would hold to the prognostications from the original version of demographic transition theory. Although this had been their first great success in the postwar era of policy science and economic planning, its prognosis was decidedly pessimistic as to the utility of launching proactive birth control programs to promote economic development. Nevertheless, as I have shown above, American demographers led by Notestein found that they were able to respond positively to this call, and apparently without abandoning the theory of demographic transition. In fact it did not prove to be a particularly difficult feat of theoretical manipulation to accommodate an activist policy stance without seeming to change the outline of demographic transition. Hodgson has identified the sleight-of-hand, whereby the simple abstraction of the economically rational individual was substituted for the awkwardly nonrational institutions and mores of actual societies and cultures as the central object of attention. A further important modification was the new postulate of causal reversibility as between economic, cultural, and demographic factors—the central relationships of the transition model of historical change. This alteration seemed to be compelled for the best possible reasons: to maintain the model’s correspondence with a more variable historical record than was at first suspected (as I noted above, Notestein pointed out as early as his November 1947 article that birth rates had declined in nineteenth-century rural France and parts of interwar Eastern Europe in advance of economic development), and to maintain its relevance in the changed circumstances of the postwar global economy. Nevertheless, a serious methodological problem arose directly from this particular theoretical modification, with important implications not clearly perceived at the time or since. In abandoning the more rigorous, unidirectional specification of causal relationships posited in the classic version of demographic transition theory, the model’s conceptual structure was allowed to become so general and the theoretical relations so flexible that, as a causal explanation of change, it became an empirically irrefutable theory. Changing demographic variables had now

78

Health and Wealth

come to be envisaged as either dependent or independent, relative to any observable economic or cultural factor. As a result, unambiguous propositions regarding the specific causes of change could no longer be constructed for empirical testing because all forms of causal relationship were allowed by the theory as potentially possible. For a number of reasons the undesirable implications of this modification of transition theory were not properly appreciated at the time or since. Examining these reasons will help to explain the model’s persistence. First, there was the contemporaneous rise to prominence in the 1950s of a wider, general theory of historical change: “modernization theory,” derived from the dominant Parsonian structural-functionalist paradigm in American liberal sociology. As remarked above, this provided Notestein with important conceptual assistance when he altered transition theory in 1949. Indeed, as ten years later Norman Ryder correctly observed, if the modified version of “demographic transition theory” was to be considered a theory in any sense, then it was only by virtue of its entailing the more general propositions of modernization theory.87 The rhetorical switch to the notion of rational actors was consistent with the endorsement of modernization as a general theory of historical change. Both of these developments reflected the appeal of antihistoricist, universalist approaches characteristic of the liberal social sciences at the time.88 As Robert Nisbet has persuasively argued, the evolutionary functionalism of Talcott Parsons is an unsuitable and misleading methodological framework for detailed empirical inquiry into the causation involved in specific cases of social and historical change.89 Parsons’s framework for analyzing social change “is in essence nineteenth-century social evolutionism” dependent on the discredited “Comparative Method,” whereby different types of people or society were classified in relation to each other along an arbitrarily defined linear scale purporting to represent a temporal sequence.90 Nisbet points out that this procedure may have communicative value to its users as a grand metaphor, an idea which describes at a high level of abstraction the whole history of humankind with respect to certain selected features of that history.91 But such a metaphor, however beguiling as a sweeping comparative description, does not provide a fruitful heuristic for the empirical study of actual, historical change in any specific instance because it deals only with abstracted, reified types or stages. “In short what is implied by Parsons to

The Idea of Demographic Transition and the Study of Fertility Change

79

be change is not change at all, but variation of classificatory type.”92 It would have been inappropriate and misleading to infer from the comparative method in the nineteenth century that the “modern” inhabitants of Western Europe had in any sense literally developed from the “primitive” inhabitants of Australasia and then to make this the basis for an empirical research project looking at precisely how this had happened. Similarly, it is unhelpful and merely arbitrary to assume as the basis for empirical demographic research that any specific examples of a “modern” demographic or social system have historically developed from something essentially similar to a current example of a “traditional” system. Indeed research into the early modern social and demographic history of European peoples has confirmed that this is not so.93 Nevertheless, “modernization” and its conceptual parent, structural functionalism, became firmly entrenched in the United States as the dominant orthodoxies of mainstream social science from the 1950s until the 1970s. This meant that the inadequacy of the modified version of transition theory, as a framework for studying the causes of fertility change, remained largely unquestioned throughout, protected under the capacious umbrella of this consensus.94 A second important reason for the failure of demographers to perceive the explanatory amorphousness at the core of the revised transition theory arose as a by-product of the eager endorsement of a statistical technology for empirical research in the social sciences. Demography was always the most intrinsically quantitative of all the social sciences, and empirical research on population attributes had always been a computationally demanding activity (not surprisingly, the U.S. Bureau of the Census had played a crucial role in the development of both mechanized and electronic computers).95 The accessibility and affordability of electronic computing resources began to improve dramatically for American demographers during the 1960s, radically transforming the scale and complexity of statistical analysis that they could realistically contemplate. In historical demography, the methodologically highly influential Princeton European Fertility Project, directed by Ansley Coale, represented an early appreciation of this opportunity. The greater availability of automated resources for analyzing machine-readable data carried with it a rapidly increasing facility for deploying the established techniques of statistical analysis on large databases, from simple forms of cross-tabulation to

80

Health and Wealth

multivariate applications of correlation and regression. In the study of fertility change such statistical analysis became not just widespread and routine but, by the 1970s, de rigueur for all those who wished their empirical research to be treated as properly “scientific” and worthy of wider notice and comment. However, the statistical methodology of ecological association is not and never has been a methodology for the rigorous study of causation in a historical and deterministic sense. Hence J. C. Maxwell, whose kinetic theory of thermo-dynamics had been the pioneering application of this statistical method for inferring probable causes, had carefully distinguished it from what he significantly chose to term the “strict historical method” (which equated, for Maxwell, to the method and logic of experimental testing in the natural sciences) of establishing determinant causes.96 According to its probabilistic and inductivist foundations, statistical analysis of this sort can do no more than indicate a degree of likelihood for the existence of determinate causal relations. This indication is attained only through the indirect process of inference from the patterns of post hoc outcomes.The investigation of causation in a deterministic sense simply is not addressed by this statistical methodology (and this limitation applies whether or not the variables are time-lagged in relation to each other).The attempt to specify and establish the nature of such deterministic causation more rigorously requires a quite different approach.Yet, despite ritual disclaimers to the contrary, measures of statistical association between indexes of changing fertility and other empirical variables have come to be treated by students of fertility change as if they were evidence for or against historical causation in a deterministic sense. Thus the postwar study of fertility change acquired—through endorsement of modernization theory by Notestein and his colleagues— a conceptual framework intrinsically incapable of generating empirically refutable hypotheses concerning the sources of change.To aggravate this problem, this defect has itself been rendered difficult to perceive and diagnose because of the concealment effected by the subsequent adoption of the powers of the investigative and analytical technology of computerized statistics.The latter’s probabilistic and ecological premises legitimized a disciplinary norm of empirical indeterminacy in the presentation of research results in terms of probabilistic measures of statistical association of varying strength.This practice effectively disguised the

The Idea of Demographic Transition and the Study of Fertility Change

81

fundamental methodological problem: that the “modernized” version of transition theory was itself conceptually indeterminate and could not generate unambiguous testable hypotheses regarding the specific causes of fertility change. Empirical research within this doubly inconclusive intellectual framework therefore became a limitless maze. Debate among demographers over the causation involved in fertility decline became trapped for decades in a recurring dispute over the primacy of “economic” versus “cultural” factors, with each side presenting necessarily inconclusive evidence and counterevidence of measurements of ecological, statistical association to support their respective cases.97 Third, just as the intellectual protection afforded by the “modernization” consensus was wearing thin in the late 1960s, a different source of succor was rising to prominence in the study of fertility change, something that has continued to sustain the idea of demographic transition at least as a descriptive term and a predictive tool down to the present.This was the emergence of a powerful and well-funded source of international demand for the transition model deriving from the practical policy-implementation requirements of the family planning industry.This reason for the continuing charmed life of demographic transition theory, long after the demise of the modernization consensus, has been clearly identified by, among others, Demeny, Hodgson, and Donaldson.98 The idea of demographic transition has continued to provide both a ready-made rationale for policy activism and a convenient projection tool for forecasting demographic futures under varying assumptions as to policy effectiveness (i.e., precisely the two uses that Notestein himself pioneered in his 1952 address, as noted above). While it has certainly been by no means the only conceptual tool put to this use (the measurement technology developed to assess “unmet need” for contraception being another prominent example), it is this utility for the family planning industry that helps to explain the survival and persistence of the idea of demographic transition.

Social Science and Policy in the Study of Fertility Change Hodgson and Demeny have both detected an intellectually unhealthy trend in demographic social science over the last three to four decades,

82

Health and Wealth

with influence over the commissioning and evaluation of research increasingly determined by the relatively short-term and narrowly defined goals of policy advice and implementation. As did Charles Hirschman, they have emphasized the significance of the tension within demography—as in any social science—between, on the one hand, the policy-related aims of seeking to advise upon and influence the course of imminent future events and, on the other hand, the necessarily patient “scientific” pursuit of a knowledge and understanding of some problem simply for the sake of its comprehension.99 According to Demeny, social science research directed to the developing countries in the field of population has now become almost exclusively harnessed to serve the narrowly conceived short-term interests of programs that embody the existing orthodoxy in international population policy. . . .Equally, it disdains work that may be critical of existing programs, or research that seeks to explore alternatives to received policy approaches. It seeks, and with the power of the purse enforces, predictability, control, and subservience. Pushed to its extreme, this stance generates research that finds what the sponsor already knows to be revealed truth. Research so characterized is an oxymoron.100

Hodgson concluded in his 1983 article: During the 1950s the assumptions and theories employed by demographers in the United States . . . were affected by the shift from social scientific to policy perspective.This shift had a profound impact on U.S. demography.101

Here, then, is a view of a latter-day “fall from grace,” which asserts that population studies was a less policy-contaminated and so rather more scientific and intellectually healthy field before the 1950s. Certainly, the major recent reassessment of demographic transition theory by JeanClaude Chesnais, now translated into English, would also seem to agree substantially with this view, finding much to admire in Notestein’s 1945 classic formula.102 Hodgson distinguishes the 1944–45 form of transition theory from the ensuing body of “theory” after the mid-1950s by pejoratively labeling the latter “orthodoxy.” Demeny largely concurs, viewing “orthodoxy” as the intellectually debased creature of “the population industry.” But the foregoing account has argued that the commitment to

The Idea of Demographic Transition and the Study of Fertility Change

83

applied policy-relevant social science was firmly established in U.S. demographic social science long before the rise of the population industry. Indeed, to a considerable extent it was demographers’ own determined organizational and pedagogic efforts that engendered this vigorous creature. A reading of Notestein’s early work confirms that he always saw the rational, social scientific analysis of population problems as an activity that would simultaneously lead to greater understanding of the phenomena in question and also directly provide guidance for practical intervention. Hence, Notestein, in a study of China published in 1937, was already musing in a Malthusian vein on the potential problems that would be created for China if mortality were rapidly checked without a correspondingly fast fall in the country’s high fertility.103 Although he did not yet anticipate such a fast decline in mortality as a possibility in the near future, by the mid-1940s it was precisely the dawning realization that such a fall was in progress in many agrarian countries that provided much of the focus of his attention when discussing the immediate policy implications of demographic transition theory: the need to reduce the time lag between declines in mortality and fertility. Furthermore, from this 1937 publication one can see that Notestein’s interest in the demography of countries such as Japan and China was from the start explicitly of a quasievolutionary, comparative nature, assessing their demographic characteristics on a scale of reference that measured their divergence from “present day Western standards.”104 He already used the term “transitional” when describing the intermediary characteristics of the Japanese population by comparison with India and China on the one hand, and “Western standards” on the other.105 Even Notestein’s earliest work on differential fertility within the United States was not simply an effort to understand the phenomenon. Notestein was interested in why poor and rural women had high fertility in order to change their behavior. He designed a careful research project which showed that they used less contraception and used it less efficiently.106 As a result, he argued in 1939 that these findings showed that influential political pressure groups such as the American Eugenics Society (though carefully distancing himself from any commitment to hereditarian views) should support the birth control movement in America, as this would help to change these women’s contraceptive

84

Health and Wealth

practice.107 His, then, was an ameliorative and instrumental conception of empirical social science and demographic research as a methodology simultaneously capable of providing rigorous, scientific insights and relevant policy prognostications. In another paper, presented to the American Philosophical Society in November 1938, Notestein explained that research on “differences in fertility” was necessary “if we are to predict and control population growth.”108 In his 1991 article Hodgson presented an analysis of population studies in the United States during the interwar era consistent with his interpretation of a subsequent move away from scientific toward policy considerations. He distinguished genuine “population scientists” in the interwar years from three other “ideological groups” more involved in policy: immigration restrictionists, eugenicists, and birth controllers. But when discussing the individuals who made up the group of genuine population scientists—such as Franklin H. Giddings, Walter F. Willcox, Frank Lorimer,Warren S.Thompson, Louis Dublin,William Rossiter, and Joseph Hill—Hodgson himself provided full documentation of their preoccupations with most of the central interests of his three “ideological groups,” extending even to formal affiliation, in many instances, with the Eugenics Society of the United States.109 Thus, as the example of Notestein illustrates, the notion that American population scientists were relatively free from policy considerations before the 1950s seems unsubstantiated. As a result of this interpretive framework, which sees policy considerations as something new, invading scientific territory in the 1950s, Hodgson attributed the conceptual changes that occurred in demographic transition theory primarily to that development.110 The alternative interpretation, offered here, argues that the work of demographic social scientists in the United States had a long-standing, close association with policy interests. Alterations to transition theory represented a response to changes in the content and nature of those policy considerations (changes in “the basic problems” being brought to demographers, as Notestein put it), which were in turn contingent on political events. Demographic transition theory was itself a product of a particular conception of social science as at one and the same time an engine for investigation, prediction, and guidance of social change. As a linear, evolutionary classification scheme, it was an archetypical construct for simultaneously specifying and justifying the direction that active policy

The Idea of Demographic Transition and the Study of Fertility Change

85

should follow. Although there was only one evolutionary path to take— from the “inefficiency” of high birth and death rates through the transitional stage to the hallowed goal of a “low pressure” equilibrium—there was nothing historically inevitable about this path. A population might remain trapped forever in the Malthusian misery of the first or even second stage of transition. Herein lay the social scientist’s moral predicament and the responsibility to act, once in possession of the vital, scientifically produced knowledge of demographic transition theory. For Notestein, transition theory in the 1940s and 1950s not only showed what had happened in the West and what could happen elsewhere but also what ought to happen.As much as one can tell from his writings, the ultimate justification for this was partly a balanced estimate of America’s long-term economic and geopolitical interests and partly purely humanitarian considerations.111 In respect of the latter motivation, Notestein’s background in the Milbank Memorial Fund and close contacts with John D. Rockefeller 3rd and the Rockefeller Foundation are significant.These philanthropic institutions had long-standing domestic and international commitments to the relief of unnecessary suffering by promoting the benefits of medical science through preventive and public health programs. Notestein may well have seen demographic transition theory as analogous to an efficacious, preventive medical theory, derived from careful observation using the experimental method and providing the predictive basis for successful prevention or “treatment.” These considerations raise the crucial question of what possible meanings are intended by “scientific” where social and demographic problems are the object of study. While it is difficult to be certain, because Hodgson does not explicitly address this issue, his account seems to employ a highly restricted definition of scientific activity that more or less equates to the contemporary positivist understanding held by most demographers during the decades of the mid-century. This corresponds to the practices of the hypothetico-deductivist (or “covering laws”) philosophy of explanation, as definitively reformulated in the late 1940s by the logical positivist émigré, then teaching at Yale, Carl G. Hempel.112 As a version of the experimental method of empirical observation, this formulation elaborates essentially the same long-prestigious deductivist method that was famously deployed by Newton for the analysis of the mechanics of the heavenly bodies and was first clearly codified by

86

Health and Wealth

John Stuart Mill in his System of Logic of 1843.This method assumes that all relevant initial conditions circumscribing the subject of study can be specified in advance and it can therefore be conceived as a closed system. The methodology is then capable of yielding calibrated information on the mutual cause and effect relationships between the entities in the system. It recognizes no distinction in principle between the scientific study of social and of natural phenomena. It asserts that explanation and prediction are essentially two sides of the same coin, and therefore to explain gives the power to control. Notestein has been cited, above, explicitly articulating this notion from the 1930s onward. While the covering-laws school continues to have its practitioners in the social sciences, this is only one conception of scientific practice as currently recognized. Hodgson is entitled to restrict himself only to this notion of science when discussing the views of demographic social scientists between the 1930s and 1950s because this was then the (largely implicit) understanding of “science” that demographers aspired to practice. But when we step back from the purely historical exegesis to offer an interpretation of the field and a diagnosis of its current state of health, it is essential to take into account the spectrum of alternative philosophies of explanation and associated methodologies of research that, today, are acknowledged to exist in the social and historical sciences. It may be helpful to distinguish at least three broad schools of thought that currently coexist in these sciences.113 They are the deductivist; the contextualist, interpretative, or hermeneutic; and various forms of the realist. Salient characteristics of the deductivist or covering-laws position have been briefly described just above. Contextualists deny the possibility of applying the premises upon which the deductivist methodology depends, especially in the study of social phenomena. First, they argue that there can be no assumption of fixed identities and closed systems with initial conditions specified. Second, the relationship between observer and the object to be studied is itself highly influential and radically variable, as it is socially and culturally constructed.Third, matters of purpose, motive, meaning, and symbol are all essential subject matters in the humanities. An interpretative methodology is therefore required which discerns from the inside the meaning of the concepts that govern actors’ lives in a community.This is quite different from the hypotheticodeductivist approach but is no less rational or verifiable for all that.114

The Idea of Demographic Transition and the Study of Fertility Change

87

Realists see an essential reciprocity of causation between individuals or actors and the potentially constraining aspects of the world into which they are born and socialized.115 There is a contingent or dialectical relationship between individual agents and their encompassing society or culture. They reproduce and at the same time transform and change the extant institutional structures, which are both their constraints and their resources for change. For causal understanding it is not enough to know from the inside the conceptual world of participants in a community, since unacknowledged and unarticulated aspects of their physical and cultural environment or impacts upon it may be important causal influences. Realists hold, correspondingly, that to exclude an understanding of the internal play of beliefs, ideas, and intentions from the analysis, as prescribed by the covering-laws approach, is equally misguided. Contextualists and realists both reject the covering-laws notion that explanation and prediction can be treated as conceptual or methodological equivalents.The essence of social problems is that they occur in open, radically indeterminate, and variable contexts and this must be studied and elucidated, not assumed out of the analysis. Social phenomena occur as an irreversible flow or complex sequence of events. All that is available for study is their scientific, historical reconstruction, from which can come an understanding of how that irreversible history happened. According to both contextualists and realists, the aim of scientific explanation and its methods is therefore understanding only, and not prediction or control. Indeed, it has been noted with some irony that, with the development of the science of thermodynamics and the concept of entropy, physics itself has long been a field that no longer subscribes to the notions of reversible, deterministic causation exemplified by classical Newtonian mechanics, and yet many social scientists have throughout this century continued to strive to emulate this model.116 When discussing the recent intellectual history of, and current practices in the “scientific” study of fertility change, it is particularly relevant to take into account the varying relationship of these different conceptions of social and historical science to the two distinct aims of understanding and of intervention or control. The strong influence that has been exerted by policy considerations has favored the deductivist model because it broadly corresponds in its specification to the preferred best-practice methods used by policymakers and by economic and social planners to assess the

88

Health and Wealth

relative utility of proposed policy interventions.There are perfectly understandable reasons why policy formulators and administrators should favor this approach for their own practical, interventionist purposes. The methodology’s apparent capacity to yield quantifiable predictive information renders it particularly attractive and suitable for their action-oriented requirements, especially in liberal democracies where they are subject to some degree of popular accountability for their decisions. In themselves subscribing to this particular, predictive methodology for the social sciences Notestein, Davis, and their colleagues in the immediately postwar generation were already talking exactly the same epistemological and methodological language as were policy scientists and administrators. Empirical social science and science for policy applications were not methodologically or philosophically distinct for this generation. Only their priorities varied somewhat. Hence, it was easy for Notestein or Davis to move between the two sets of priorities, without this forcing them to address more fundamental issues regarding their theories or models of explanation. The problem for the field of population studies is the intellectual and methodological conservatism that results from the influence of this understandable continuing adherence by policymaking institutions and their officials to a narrow definition of “science” as the covering-laws methodology only. By virtue of their considerable influence over the field as users and paymasters, this has had the unintended consequence of perpetuating a methodology that over several decades has exhibited severe limitations in yielding an understanding of historical fertility change.This is the case precisely because changes in those radically indeterminate phenomena and relationships that are beyond the methodology’s proper scope to analyze—purposes, values, meanings, social roles, motives, and intentions—in all likelihood hold the key to a satisfactory historical understanding of the processes and causes of fertility change in any particular community. However, an important consequence of the need and desire to communicate research results to a policymaking audience has been the retention of the covering-laws methodology and its rhetoric of predictive explanation.117 This invisible hand of institutional bias has therefore been responsible for maintaining the privileged position in the field of one particular—and rather dated—form of social science and, with it, the idea of demographic transition.This was an idea

The Idea of Demographic Transition and the Study of Fertility Change

89

originally born out of a covering-laws conception of social science, and it continues to be an idea well suited to the predictive requirements of policy. Thus, the principal virtue and function of the idea of demographic transition has always been in providing a graphic metaphor that summarily describes—and predicts—a long-term overall emergent pattern of change. As such it has enormous justificatory, motivational, and communicative value for agencies and institutions wishing to effect such change. But, as Robert Nisbet has argued, a summary description of this metaphorical sort offers no necessary assistance or insight into the causal explanation of how such change occurred or occurs in any particular case. Unless an explicit teleology is subscribed to, it is simply an act of faith to base empirical and historical research on its premises. As a heuristic to guide detailed research aimed at understanding how fertility changes in specific historical circumstances, the idea of demographic transition is not only unnecessary but also inappropriate. The study of fertility change needs emancipation from the dominance of the abstract idea of “demographic” or “fertility” transition and the associated, too-exclusive deference to the covering-laws methodology. This field could profit from paying much more attention to the wider range of scientific approaches that are currently pursued in the social and historical sciences.There is need for an accumulation of patient, carefully contextualized, investigative projects on fertility change in specific communities, where the form that fertility change takes is not judged in advance, as is the case with those subscribing to the notion of “fertility transition.”118 Only such studies as these can do justice to the variety of changing fertility behaviors in any community and can examine the ways in which economic and political forces of change are mediated by local, cultural, and institutional forms such as changes in language, values, and roles (historical changes in the meanings of motherhood, parenthood, childhood, and adolescence, for instance).To understand changing fertility requires the historical reconstruction in specific contexts of the varying ways in which modifications have occurred in the perceived relative costs of childrearing.119 This is the central, complex variable involved in fertility change.120 I contend that the most promising approach for future progress in the study of the causes of fertility change is historical and empirical research employing a range of broadly realist methodologies

90

Health and Wealth

to explore and understand all the dimensions involved in changes in the perceived relative costs of childrearing.

Acknowledgments Earlier versions of this essay were given to research seminars at the Institut national d’études démographiques, in the Economic History departments of Glasgow and Edinburgh Universities, and at the Wellcome Unit in Oxford. I am grateful to participants at each of those occasions for their responses. Additionally I thank Hilary Cooper, Libby Schweber, Tony Wrigley, and Richard Smith for advice on earlier drafts. Finally, I acknowledge the importance of comments on the penultimate draft from Stephen Kunitz.

Notes 1. Demeny (1988), 466. 2. On “revisionism,” see Hodgson (1988); on the failure of these heterodox positions to achieve a sustained impact, see Wilmoth and Ball (1992), 656–58. 3. In addition to Hodgson (1988), see Hodgson (1983) and (1991). 4. In 1952 Notestein, author of the classic version of demographic transition theory, publicized the existence of historical evidence for France and Bulgaria that directly refuted the theory’s model of change (Notestein 1953).The long-running Princeton project investigating the European fertility decline, directed by A.J. Coale from 1963, was a specific attempt to “test” rigorously but not unsympathetically the subsequent demographic transition-modernization model of fertility change in a variety of nineteenth- and twentieth-century historical cases. None of the individual country studies nor the summary volume was able to offer any conclusive support for this version of demographic transition theory. Coale and Watkins (1986). 5.The important publications in this field over the last twenty-five years have been legion.The pioneering methodological work was performed by French demographic historians in the preceding decade: Henry (1956); Gautier and Henry (1958); Goubert (1960). Probably the most intellectually influential single contribution was Hajnal (1965). Laslett’s best-seller (1965) was published in the same year and succeeded in rapidly attracting wider Anglophone attention to the new field. The most rigorously researched and ambitious single study of early modern demographic history has been Wrigley and Schofield (1981).

The Idea of Demographic Transition and the Study of Fertility Change

91

6.Van de Walle (1992), 486–88. 7. Notestein in Schultz (1945), 36–57; Davis (1945). Davis edited this entire issue, which was devoted to demographic transition theory. On the conceptual similarities between “demographic transition” and “fertility transition” see note 118 below. 8. Ryder (1984), 12. 9. Notestein (1945), 39–40. 10. Ibid., 41. 11. Ibid., 41–42. 12. On the earlier history of recapitulationism in biology and embryology, see Gould (1977). Anthropology has been the classic locus of academic debate over the shortcomings of evolutionary frameworks in the human sciences.A critique was started in earnest from within that discipline by the American cultural anthropologist Franz Boas (1858–1942). On Boas, see Stocking Jr. (1968). For a stimulating contribution to this subject, see Fabian (1983). 13. Caldwell and Caldwell (1986), 15. 14. Schultz in Schultz (1945), vi. 15.Thompson (1929). 16. Hodgson provides the most extensive account of the numerous American precursors to the 1945 statements of transition theory, in “Demography as social science and policy science,” cited in note 3. He finds key elements of the theory adumbrated among American demographers such as Ross as early as 1909. But it was Thompson’s 1929 statement that was a full prototype of the 1945 version. Although there can be no disputing that “demographic transition” has been very much the product and instrument of the community of demographers based at Princeton, at least five distinct European antecedents, not mentioned by Hodgson, should also be noted by those interested in the prehistory of the theory: Landry (1909), (1934); Brentano (1910); Carr-Saunders (1922); Stevenson (1925); and Rabinowicz (1929). On the last-named, see Subrtova (1984). I am grateful to Jean Bourgeois-Pichat for drawing my attention to this article. 17. Thompson and Notestein were the leading American demographers of their respective generations.Thompson, born in 1887, was most active c. 1915–50; Notestein, born in 1902, was most active c. 1930–75. Each was the recipient of the most generous and ambitious form of patronage available to a demographer of his generation. Thompson received his own department for population studies from the Scripps Foundation at the age of thirty-five; Notestein was placed in charge of the newly created Princeton Office at age thirty-three. 18. See Szreter (1993), 298–304. 19. See note 16. 20. In France, for instance, Sauvy at the newly founded INED was quick to arrange a French translation (by Vincent) of the essentials of Notestein’s exposition: Notestein (1946), 615–22. 21. These were founded through the financial assistance and organizational skills of Raymond Fosdick and Beardsley Ruml, respectively, each of whom was a

92

Health and Wealth

leading figure within the Rockefeller complex of philanthropic foundations. See Collier and Horowitz (1976), 142–43. 22. For a general treatment of this see Alchon (1985). 23. Of course, detailed planning of a comprehensive kind was already incorporated in socialist economic theory and had already become the normal practice within Soviet Russia. Less well known are the early colonial experiments in integrated economic planning operated at the peripheries of the free enterprise empires. An important British example is Governor Guggisberg’s ten-year plan of 1919 for development of the Gold Coast. For this and others, some even earlier, see Robertson (1984), 15–16; 52–53. For further early American examples, see Brown and Reagan (1989). 24. Hodgson (1991). 25. Ibid., 21. 26. Reddaway (1939); Hansen (1939); and for a brief but significant statement by Keynes himself, see Keynes (1937). 27. Young (1987), 115. Hansen (1887–1975) was Professor of Political Economy at Harvard 1937–57. 28. A third element in U.S. strategic thinking, the Marshall Aid plan for European recovery, emerged only during 1947 when the political implications of the massive extent of European destruction were brought home to the State Department, with the threatened withdrawal of financial aid to the anti-Soviet regimes in Greece and Turkey by a near-bankrupt British government. General Marshall first announced the proposed European Recovery Program in June 1947, and the Organization for European Economic Cooperation (which became the OECD in September 1961) was finally set up in April 1948, to dispense $17 billion to eighteen west European countries over the following four years (75 percent of this went to Britain, France, Italy, Germany, and Holland). Scammell (1983), 12–13. 29. Kirk (1944), 29. 30. The Caldwells have pointed out that the “exploitative colonialism” argument was a central feature of the classic version of demographic transition theory, appearing in all the early statements. Caldwell and Caldwell (1986), 13–15. 31.The critique of such trading practices had, of course, found its most rigorous and penetrating academic statement in America at this time in the work aimed at analyzing Schacht’s Nazi policies, by the young German refugee, Hirschman (1945). 32. Notestein (1945), 52. 33. Hodgson (1988), 542–43; Demeny (1988), 458–59; Caldwell and Caldwell (1986), 6–7, 9. Notestein’s views were distinctive, in that during the interwar years it was more common to emphasize the simple provision and availability of efficient contraception. This included influential neo-Malthusians, such as Marie Stopes in Britain and Margaret Sanger in the United States.Theirs is part of the early history of the family planning movement, which Notestein, having initially rejected it on

The Idea of Demographic Transition and the Study of Fertility Change

93

intellectual and scientific grounds, eventually came to endorse, as the rest of this article shows. On the early birth controllers, see Soloway (1982); Reed (1978). 34. Notestein (1944), 437. The proceedings appear in Milbank Memorial Fund Quarterly 22 (July, October 1944: 222–317; 383–444).The Caldwells see this event as the point at which the Princeton group collectively endorsed the notion of demographic transition as a universal phenomenon. Caldwell and Caldwell (1986), 13–15. 35. Notably, from Carr-Saunders (1922), an exhaustive synthesis of anthropological and ethnographic monographs; and from Himes (1970), originally published 1936. 36. Stix and Notestein (1940). 37. Notestein (1950); Davis (1950). 38. Hodgson (1983), 11–20. 39. Ibid., 13, 18, 23. 40. Ibid., 19. 41. Notestein (1944), 434. 42. Ibid., 438. 43. Ibid., 438–39. 44. Notestein (1948), 250. 45. Ibid., 251. 46. Ibid., 253–54. 47. Ibid., 254. 48. Ibid. 49. Ibid., 250. 50. Balfour, Evans, Rockefeller, Notestein, and Taueber (1950). This 132page report, complete with maps and photographs, was published in a mimeographed limited edition, so as to make it available “to the scholars and scientists interested in this subject.” The published version contained “minor revisions to excise the specific recommendations concerning administrative and other problems of The Rockefeller Foundation.” 51. Ibid., 13. 52. Ibid., 113. 53. Ibid., 117. 54. For a fully elaborated version of this, see, for instance, Hagen (1964). 55. The house journal of the modernization school was founded in 1952, as Economic Development and Cultural Change. For further discussion, see below and notes 87–92. 56. Levy (1949). 57. See quotation above, note 34. 58. Balfour et al. (1950), 118. 59. Ibid., 6–7. 60. Hence, according to Macmahon, “The imminent triumph of the Chinese Communists led Truman administration planners to reassess American policy objectives in Asia in mid-1949.” Macmahon (1988), 819.

94

Health and Wealth

61. Ryder (1984), 8–9. 62. Ibid., 16–20. 63. Ibid., 8–10. 64. Collier and Horowitz (1976), 285. His father, John D. Rockefeller Jr, had also sponsored eugenics and social hygiene work: ibid., 105–6; and Kevles (1985), 55, 60. 65. Collier and Horowitz (1976), 280. Earlier in the century Fosdick had been a protégé of Woodrow Wilson’s, both as a student at Princeton and then in connection with the organization of the League of Nations: ibid., 106. 66. He was by then widely known for an active knowledge and interest in the Far East, dating from his first visit to Japan (after graduation) in 1929, when he deputized for his father at a conference of the Institute for Pacific Relations. This organization had itself been principally funded at its outset in 1925 by Rockefeller Jr., and had since become the main basis of U.S. intelligence expertise for the region during World War II. Collier and Horowitz (1976), 194–95; 280–81. 67. Once war was declared, the first two major commissions from the State Department were for studies of Japan and India, funded by the Milbank Memorial Fund and the Rockefeller Foundation: Caldwell and Caldwell (1986), 13. 68. Notestein (1982), 665, 683. 69. Ibid., 665; Notestein (1971), 74–75. 70. Notestein (1944), 434 et seq. 71. Notestein (1982), 683. 72. Hodgson (1983), 18. 73. Notestein (1953). 74. Hodgson (1983), 25. 75. Leibenstein (1954); Leibenstein (1957); Coale and Hoover (1958). Another important contemporary contribution from outside the Princeton Office was Nelson (1956). 76. Donaldson (1990a). 77. US$9.1 billion went to these countries in loans and aid between 1952 and 1957 under the Mutual Security Program: Scammell (1983), 76. 78. Ryder (1984), 13. See also Donaldson (1988), on resistance by American Cardinals until the 1960s. 79. Notestein (1982), 675–79. 80. Caldwell and Caldwell (1986), 28–29, 32, 45–47. 81. Ryder (1984), 13. 82. Ibid., 11, 13. 83. Donaldson (1990a), 395. 84. Donaldson (1990b), 87. 85. For instance, the admonitions in Hauser (1967); and Davis (1967). Although Notestein’s and Davis’s thinking developed along similar lines during the 1940s and early 1950s, as Hodgson (1983) has shown, thereafter they diverged significantly. Davis (1963) was an important and distinctive theoretical contribution.

The Idea of Demographic Transition and the Study of Fertility Change

95

86. Lewis had in 1949 publicized the distinction between centralized state planning by direction as in the Soviet Union, and the possibility of planning by inducement, as something appropriate for liberal market-based democracies with much more decentralized powers and decision making: Lewis (1949), 16–20. 87. Ryder (1959). 88. There is no space here to discuss in detail why this generation of liberal empirical social scientists should have become so wedded to this particular conception of social science.Two powerful influences suggest themselves as being significant.The first was the long-standing tradition, in the United States as in Britain, of empirical social science conceived as a form of intellectually advanced, rational philanthropy, whose primary rationale was to ameliorate social problems. On the formative influence of this context on the social sciences in the United States from the 1880s to the 1940s, see, for instance, Furner (1975); Bulmer (1984); Bannister (1987);Turner and Turner (1990). The second, and perhaps more important influence was the international “reconstructionist” impulse that had already seized the imagination of many Western intellectuals and social scientists in the 1930s following the chaos of the Great Crash and its aftermath.This received an enormous fillip with the conclusion of hostilities in 1945. Michael Pollak has argued that the general rise to prominence of this antihistoricist, universalist behavioral social science in the United States in the late 1940s and 1950s was partly a reaction by émigrés against the divisive historicist and separatist traditions of social science in the continental European nations they had left behind. It was a conscious attempt to build and use a methodology of investigation and social reconstruction that was universalist, secular, and humanitarian in its premises, reaching beyond the national differences that they saw as the source of so much confusion and suffering. Many of the most influential figures were themselves refugees from the violence and chaos of continental Europe, such as Hempel and Lazarsfeld in the United States and Mannheim and Popper in Britain. Pollak (1979); Pollak (1988). 89. Nisbet (1969), especially Part III. 90. Ibid., 263. 91. Ibid., chaps. 1 and 3. 92. Ibid., 265. 93. See the publications cited in note 5. 94.The vanguard critique of modernization theory from within the discipline of sociology was in fact published as early as 1959:Wright Mills (1959). Mills’s premature death in 1962 may partly account for the slow permeation of his message into sociological thought over the ensuing decade and a half.There was no influential sequel in American sociology until the publication of Gouldner (1970).The critique was then consolidated by Gouldner’s founding in 1974 of the journal, Theory and Society, as a forum explicitly for the development of alternatives to the Parsonian paradigm. 95. See Anderson (1988) on the Census Bureau’s role in the development both of Herman Hollerith’s punch card tabulating machines in the 1880s and of Univac in the 1940s.

96

Health and Wealth

96. Porter (1986), 110–11. 97. For a particularly clear review of this debate and an argument for the “cultural” viewpoint, see Cleland and Wilson (1987). 98. Demeny (1988); Hodgson (1983); Donaldson (1990b). 99. Hirschman (1981). 100. Demeny (1988), 470–71. 101. Hodgson (1983), 2. 102. Chesnais (1986), 5–14.Translated by Kreager and Kreager (1992). 103. Notestein and Chiao (1937), 393–95. It is explained in the Preface that Notestein’s patron, Edgar Sydenstricker, had originally arranged for the involvement of the Milbank Memorial Fund in the demographic side of Prof. J.L.Buck’s project (which originated at a conference of the Institute of Pacific Relations in Honolulu in 1927, as the brainchild of O.E. Baker, an agricultural economist in the U.S. Department of Agriculture). Sydenstricker was the brother of Pearl Buck, author of the classic novel depicting Chinese peasant life, The Good Earth, and wife of John Lossing Buck (Professor of Agricultural Economics at the University of Nanking). Notestein had tabulated the data for Sydenstricker in New York and therefore took over the writing of the chapter upon Sydenstricker’s unexpected death. 104. Ibid., 377. 105. Ibid. 106. Stix and Notestein (1940). 107. Though he did not claim that clinics and propaganda, alone, would change their behavior. Notestein (1939a). 108. Notestein (1939b), 511. 109. Hodgson (1991), 18–19. 110. Hodgson (1983), 27–28. 111. See, for instance, the quotation from 1944 cited above, note 70. Note, however, that this was a consciously selective form of humanitarianism on Notestein’s part. The benefits to be derived from living in a low-pressure demographic regime of low mortality and low fertility far outweighed for Notestein any possible moral counterarguments for respecting the integrity of those different cultures that were associated with “inefficient” demographic regimes. Thus, in this same article in 1944, Notestein saw the “considerable protection of native customs, religion and social organization” under what he acknowledged as “the more enlightened colonial regimes” to be misguided policies, because they “foster the maintenance of high fertility.” All quotations from Notestein (1944), 431. 112. For a discussion see Ryan (1970), chap. 3. 113. These distinctions follow Bhaskar’s contributions to W.F. Bynum, E.J. Browne, and R. Porter, eds. (1981), especially the articles on Aristotle’s theory of cause; explanation; naturalism; positivism; realism. 114.The classic formulation of hermeneutic social science methodology can be found in Winch (1958) and (1990). 115. On realism, see Bhaskar (1978); (1979).

The Idea of Demographic Transition and the Study of Fertility Change

97

116. Aberle (1987). 117. For a stimulating sociological analysis of this, see Turner’s work on the patron-client relationship in the social sciences, especially the phenomenon of “metonymy.” This is the intellectually conservative tendency whereby a “patron” audience judges the value of proposed or completed new research primarily in terms of those partial aspects that are most easily assimilated into its preexisting terms of reference and its nonspecialist understanding of the field, rather than taking the trouble and the risk to grapple with and incorporate something novel. Turner (1990). 118. van de Walle (1992), has shown rising popularity for the term “fertility transition” since 1973, following Coale’s much-cited formulation of preconditions for the appearance of fertility-controlling behavior: Coale (1973), 53–72. Fertility transition is supposedly a more precise, more measurable, and more easily studied (through the covering-laws methodology) subset of the demographic transition, referring only to the change in fertility behavior “from natural fertility to family limitation.” But the idea and its approach are subject to the same methodological limitations as those of “demographic transition.” The process of change is again reduced merely to variation between classificatory types: the arbitrarily defined beginning and end states of natural and controlled fertility. Just as empirical research has shown that there is no single “traditional” demographic regime (or society), so, too, it has found that no single form of “natural fertility” can be unequivocally distinguished from controlled fertility. See Blake (1985); Wilson, Oeppen, and Pardoe (1988). 119. Early, relatively isolated examples of such work include Stycos (1955), (1968); also the historical work of Banks (1954), (1964). Among the more important of the increasing number of recent studies are: Schneider and Schneider (1976) and (1984); McCormack (1982); Caldwell, Hill, and Hull (1988); Knodel (1988); Kertzer and Hogan (1989); Bean, Mineau, and Anderton (1990); and many of the contributions to Gillis,Tilly, and Levine (1992). 120. For an extended presentation of this framework, see Szreter (1996), chap. 9. Note that, regardless of first impressions, the heuristic framework of “perceived relative costs of childrearing” does not in fact refer primarily to economic considerations. The “costs” of children are to be explored in their widest sense, involving social, cultural, emotional, and political considerations. Furthermore, since these costs are “perceived,” this entails the identification of the perceiving agents and their changing interrelationships with children. Obviously this means parents, but also other kin and guardians, siblings, neighbors, others in the community, and, ultimately, all interested political institutions and actors. There is, therefore, much in common between this approach and the one recently proposed by Johansson (1991).

4 THE IMPORTANCE OF SOCIAL INTERVENTION IN BRITAIN’S MORTALITY DECLINE c.1850–1914* A Reinterpretation of the Role of Public Health1

Introduction Dr John Tatham of the General Register Office (GRO), looking back in 1905 over more than half a century’s achievements by the public health movement since the passing of the first Public Health Act of 1848, found it necessary deprecatingly to remind his readers that “it will be well to utter a caution at this stage against the prevalent tendency to attribute to

* This chapter is slightly revised from its original publication in Social History of Medicine 1, 1 (April 1988).

98

The Importance of Social Intervention in Britain’s Mortality Decline

99

the results of sanitary administration alone the whole of the life-saving which has taken place. . . .”2 As most undergraduates today in medicine or modern history will know, it is now widely considered that this confidently expressed belief, that directed human agency informed by medical and sanitary science was the principal source of improvement in the nation’s health, has apparently been deflated and debunked conclusively by the historical epidemiological research project of Professor Thomas McKeown and associates. The strong currency that McKeown’s new orthodoxy continues to enjoy was illustrated recently by a leading article in the British Medical Journal, which concluded that improving nutrition—the essence of the “McKeown thesis”—is still the best explanation we have for the historical fall in mortality in Britain.3 The main purpose of this chapter will be to argue that McKeown’s analysis of the empirical data has been misleading and to show that closer attention to the crucial elements of his own quantitative evidence in fact confirms the essential spirit of Tatham’s contemporary assessment. It will be urged that the public health movement working through local government, rather than nutritional improvements through rising living standards, should be seen as the true moving force behind the decline of mortality in this period. Professor Thomas McKeown’s The Modern Rise of Population was published in 1976 as an accessible summary of over two decades of painstaking empirical work, applying the insights of current medical and epidemiological knowledge to a historical analysis of Britain’s detailed national series of death records.4 This work achieved something of a conceptual revolution in the disciplines of history and medicine, overturning a long-standing general orthodoxy regarding the importance of medical science and the medical profession in bringing about the decline in mortality that accompanied industrialization in Britain.5 It effectively demonstrated that those advances in the science of medicine forming the basis of today’s conventional clinical and hospital teaching and practice, in particular the immuno- and chemo-therapies, played only a very minor role in accounting for the historic decline in mortality levels. McKeown simply and conclusively showed that many of the most important diseases involved had already all but disappeared in England and Wales before the earliest date at which the relevant scientific medical innovations occurred.

100

Health and Wealth

It should be stressed at the outset that this achievement of McKeown’s work, in deflating the historical claims of one particular section of the medical profession and its “high tech” invasive and biochemical medicine, remains unaffected by the arguments set out below. McKeown’s unanswerable point is precisely that this modern kind of applied medical science virtually did not exist during the period addressed here. However, in addition to this negative finding that the forward march of modern “scientific medicine” cannot be given the credit for the historical fall in mortality, McKeown also propounded a positive explanatory thesis. He claimed that his analysis of the epidemiological evidence showed that the major factor responsible was “a rising standard of living, of which the most significant feature was improved diet.”6 It is this distinct positive thesis, regarding the overwhelming importance of nutritional improvements derived from a rising standard of living in driving mortality decline, that is the subject of criticism in what follows. As a result of this strong nutritional thesis, combined with the impact of McKeown’s devastating case against the pretensions of the “technocratic” section of the postwar medical profession, the notion seems to have spread like a contagion that all medicine, the medical profession and, in fact, organized human agency in general had remarkably little to do with the historical decline of mortality in Britain until the interwar period at the earliest. Although “municipal sanitation” and “hygiene improvements”—in other words, the public health movement addressed by this article—were identified by McKeown as positive influences, their impact and effects were deemed to be very much of a secondary and merely reinforcing kind. McKeown believed that his empirical work on the nineteenth-century evidence had conclusively established this in two ways. First, that part of the mortality decline supposedly attributable exclusively to increased nutrition was claimed to have occurred earliest, whereas public health measures came along relatively late in the day, when the momentum of declining mortality was already established. Second, on etiological grounds, according to the available epidemiological records tracking changes in the incidence of different causes of death, sanitary measures could only have had at the maximum the potential to eliminate roughly a quarter of all deaths, whereas rising nutritional standards had probably been responsible for about twice that proportion.7 Thus, nutritional improvements were

The Importance of Social Intervention in Britain’s Mortality Decline

101

unequivocally presented as the prime moving and primary sustaining forces in accounting for the Victorian mortality decline. However, it is shown below that neither of these arguments can be sustained on a careful reexamination of the historical evidence. Britain’s history in this respect has been seen as something of an exception by development economists and demographers, since the wider, cross-national comparative work of Samuel Preston has demonstrated that for almost all other countries it has been upward shifts in the level of medical technology and services available and the successful introduction of public health measures that have been markedly more significant than rising per capita incomes (a gross proxy for rises in the general standard of living) in accounting for their falling levels of mortality.8 But social and economic historians have never found it conceptually difficult to treat the experience of the first industrial nation as a special case. In this respect, the supposedly predominant importance of the airborne disease, respiratory tuberculosis (TB, “consumption,” and phthisis are its common synonyms) has always been emphasized by McKeown as the key to Britain’s unique mortality decline. Thus, although the most recent collection of essays to be published on the British mortality decline contained a welcome examination of several public health aspects, its editors still found it necessary to concede that Britain in particular “differs from the norm because of the high incidence of respiratory tuberculosis,” and that rising living standards may therefore have been important here “without the relationship being both a necessary and a universal one.”9 McKeown’s authority is generally endorsed, even by those engaged in research on various aspects of public health in Britain. It is agreed that, “In terms . . . of aggregate and cause-specific mortality and the environmental determinants of the reduction in deaths from infectious diseases during the nineteenth century, the work of Thomas McKeown is central.”10 It is broadly assumed, after McKeown, that, whatever their research might indicate regarding occasional local or episodal advances, the public health movement in the aggregate was not particularly instrumentally effective in achieving its aims, whatever the fond delusions of those, such as John Tatham, who devoted their lives to this work. But is the British case, indeed, the exception? How strong is either the evidence that respiratory TB was the dominant component leading

102

Health and Wealth

national mortality trends, or the argument that this component was driven primarily by changing nutritional inputs? Are there alternative interpretations consistent with the data analysed and presented by McKeown? What might the existence of such an alternative imply for our social and medical history of modern Britain? These are the questions that I intend to address here. This chapter has, therefore, three sequential aims: first, to identify and delineate the essential argument and evidence presented by McKeown in favor of nutrition; second, to subject them to critical scrutiny; and third, to offer the outline of an alternative revisionist interpretation of the onset of Britain’s modern mortality decline. This will suggest that human agency, in the form of a gradually negotiated expansion of preventive public health provisions and services at the local level, rather than the impersonal “invisible hand” of inexorably rising nutritional and living standards, should be reinstated at the center of our attempts to explain the modern mortality decline in Britain. There is, therefore, much more scope in this field of modern British history than has perhaps been previously appreciated for fruitful exchange between, on the one hand, social historians of medicine, public health, and local government and, on the other hand, demographic and economic historians of large-scale social change.

The “McKeown Thesis” In its fully developed form, McKeown originally presented a grandiose allencompassing thesis accounting for Britain’s demographic growth since the early eighteenth century and for the subsequent rise in world population as a whole. The cause was mainly decreases in mortality rather than any significant increase in fertility, and this, in turn, was primarily due to an increasing per capita nutritional intake.11 However, this ambitious general explanation was based on a number of purely speculative premises regarding the characteristics of the preindustrial demographic regime. These assumptions have since been radically undermined as a result of the revolutionary empirical findings that have emerged from the recent work of demographic historians, utilizing the quantitative information contained in Britain’s parish registers, dating back to the mid-sixteenth century.12

The Importance of Social Intervention in Britain’s Mortality Decline

103

It has been shown, for instance, first, that the rapid population growth associated with initial industrialization in Britain was principally due to rising fertility (mainly as a result of earlier marriage), rather than to falling mortality.13 Second, although there was indeed a fall in mortality in the course of the eighteenth century, it was of a scale quite within the bounds of previous preindustrial fluctuations in the sixteenth and seventeenth centuries. The relatively low level of mortality attained in the 1820s after a century of improvement was the same as that previously experienced in the late sixteenth century. Thereafter, overall mortality ceased to fall for almost half a century throughout the central decades of the mid-nineteenth century.14 Thus, the notion that underpinned McKeown’s grand thesis, that there had been a single movement of continuous and uninterrupted mortality decline across the last three centuries, can no longer be considered valid. Nevertheless, despite the obsolescence of this grand version of the McKeown thesis, the substantial empirical work of analysis that he and his team performed on the national death registration data for the subsequent period from 1837 onwards seems to have ensured that McKeown’s nutritional thesis has continued to enjoy an authoritative status, at least with respect to that part of the improvement in the nation’s health known to have occurred during the Victorian and Edwardian periods.Therefore, I will confine my attention here to a detailed reassessment of this remaining aspect of the “McKeown thesis”: his interpretation of the civil registration data. The analysis of death rates in nineteenth- and twentieth-century Britain presented by McKeown et al. is based on a uniquely detailed historical source material. These are the returns of deaths classified by age and certified cause of death, which are available for the entire population of Britain, excluding Scotland, from July 1837 onwards.15 Details about the numbers dying from each disease by age and sex was combined with comparable information regarding the total population alive at each of the national censuses taken every ten years to produce a series of agespecific, cause-specific death-rates, published decennially by the Registrar-General in a special supplement.16 The summary results of McKeown’s analysis of this data were presented in a series of tables in chapter 3 of Modern Rise. The accompanying table (Table 4.1, below) is directly derived from this information, based on age-standardized death-rates for the most important individual diseases

104

Health and Wealth

Table 4.1: England and Wales. Standardized Death Rates per million, 1848/54–1901, and 1901–1971 Rate per million for all causes 1848/54: 21, 856 Rate per million for all causes 1901: 16,958 Of total reduction 1848/54–1971: % occurring 1848/54–1901 Airborne micro-organisms: Respiratory tuberculosis Scarlet fever; diphtheria* Smallpox Other Bronchitis, pneumonia, influenza Water/Food-borne micro-organisms: Cholera; diarrhea Typhoid; typhus** Other Other micro-organisms: (principally “convulsions” before 1901) Other conditions: (not micro-organisms) Total (all causes)

1971: 5,384 % occurring 1901–1971

9.0 4.0 1.5 1.0 ⫹3.0

8.5 2.0 5.5 10.0

3.5 5.0 1.0

7.5 1.0 3.5

4.5

8.0

2.5

23.0

30.0

70.0

Source: adapted from McKeown (1976), chap. 3. All figures rounded to nearest 0.5 per cent and, therefore, do not sum exactly to 100 per cent. * These two diseases were not separately distinguished until 1855. Most of the reduction before 1901 was due to declining incidence of scarlet fever, as diphtheria did not begin to fall until the turn of the century, when antitoxin treatment began: McKeown (1976), 56 and 98. ** Typhus should be in the “Other micro-organisms” category, but was not distinguished from typhoid before 1869. However, much the greatest part of the reduction before 1901 is attributable to typhoid alone, occurring from the 1870s onwards. See R-G (1884–5), xiii.

The Importance of Social Intervention in Britain’s Mortality Decline

105

that can be identified. It shows how much the changing incidence of each disease has contributed to the overall fall in recorded mortality that has occurred between approximately 1851 and 1971, dividing up that overall amount of change into the percentage occurring before and after 1901. McKeown grouped the individual diseases into four broad etiological categories, according to what modern medical science understands to be the main pathways of transmission involved in the spread of each particular disease.Three of McKeown’s four categories relate to diseases that are due to the invasion of the human host by a micro-organism, meaning usually bacteria or a virus. First, there is the airborne category of diseases where the microbes in question can simply float about in suspension in the air, usually associated with tiny droplets of water vapor or saliva spray from the exhalations of infected victims or carriers. Second, there are the diseases caused by water- and food-borne microbes.Third, there is a small residual category of other diseases also attributable to micro-organisms, where the vector of transmission is neither air- nor food- nor waterborne.These include strictly contagious diseases, that is, those passed by direct contact between animals and humans (e.g. plague, typhus) or just between humans (e.g. sexually transmitted diseases). Finally, there is the category of afflictions that are not microbially caused, such as congenital defects and the degenerative diseases associated with the normal processes of aging (subject, of course, to modification by lifestyle, diet, and overall environment). These include cancers and coronary heart diseases as the most significant examples. As can be seen from Table 4.1, the first two categories are by far the most important in the earlier stages of the mortality decline with which we are here concerned. With this simple but very useful classification system established, McKeown went on to argue that any observed fall in the incidence of a disease must be due to one of the following five causes: 1. an autonomous decline in the virulence of the micro-organism itself; 2. an improvement in the overall environment so as to reduce the chances of initial exposure to potentially harmful organisms. This could result from either: (a) scientific advances in immunization techniques;

106

Health and Wealth

or (b) a public health policy designed to sanitize the urban environment—McKeown calls this “municipal sanitation” or “hygiene improvements”; 3. an improvement in the human victims’ defensive resources after initial exposure to hostile organisms.This could occur through either: (a) the development of effective scientific methods of treating symptoms; or (b) via an increase in the level and quality of the exposed population’s average nutritional intake—that is, better and more abundant food, thereby improving the individual’s own natural defences. McKeown’s strategy in presenting his argument was to assess each of these five candidate “causes” of mortality decline in turn, regarding their possible proportionate contributions to the overall observed fall in mortality levels. First, he dealt with (1) the possibility that there might have been a spontaneous change in the virulence of some of the infective microorganisms (chapter 4 of Modern Rise). In fact the discussion of this issue was far from conclusive for the simple reason that in some very important cases there is no current scientific consensus, while in others the historical evidence is inadequate for a clear assessment to be made.17 When in 1962 McKeown and Record had originally presented their analysis of the data for 1851–1901, they had cautiously concluded that this aspect “may have been responsible for not less than one-fifth of the total improvement and—as a very rough estimate—for not more than onethird.”18 In his 1976 text McKeown was willing to allow that two of the airborne diseases, scarlet fever and influenza, probably declined spontaneously in this manner.19 However, in his 1976 conclusion the impression was given, by taking a wider sweeping perspective including the eighteenth and twentieth centuries as well, that this factor was relatively insignificant and could be more or less ruled out as a significant component of the mortality decline.20 Next, McKeown in chapter 5 dealt with what was called the medical contribution, by which was meant, first, scientific advances in protective

The Importance of Social Intervention in Britain’s Mortality Decline

107

immunization and second, scientific advances in chemotherapy and hospitalized treatment of sufferers, that is, in the list above, 2(a) and 3(a), respectively. Hospitals were dismissed outright, referring back to an article published in 1955, which had concluded that at least until the hospital reforms in the last third of the nineteenth century prompted by Florence Nightingale’s highly critical revelations in her Notes on Hospitals,“on balance the effects of hospital work in this period were probably harmful.”21 The chapter then proceeded to demonstrate for each of the major diseases in turn that, with the exception of smallpox and diphtheria, the dates at which either effective immunization procedures or scientific medical treatments first became available were often far too late in time to be able to account for all but the last few percentage points of the overall decline of the disease. This was certainly true of respiratory tuberculosis, measles, and scarlet fever; and broadly true for whooping cough and the bronchitis, pneumonia, and influenza group. All had been declining very considerably in incidence long before effective chemotherapy or other scientific techniques had become available (mostly in the mid-twentieth century). Having eliminated in this fashion both aspects of advances in medical science, McKeown was now left with just two possible causal factors out of the original five, to account between them for the lion’s share of the decline in mortality. In his attempt to adjudicate between them, grouping individual diseases into etiological categories now played a crucial role in the apparent demonstration that nutritional improvement was much more significant than sanitary and hygienic measures. The argument presented was as follows.22 It can only have been the water- and food-borne diseases that could have been controlled by municipal sanitation and similar preventive public health measures in the nineteenth and early twentieth centuries. Airborne diseases by contrast could not be prevented in this way from spreading or from occurring. It was admitted that isolation of individuals with symptoms might have some net effect, but then the efficacy of the hospitals had already been roundly dismissed, while it was pointed out that many airborne diseases could be carried and spread by persons not even manifesting symptoms. McKeown argued, therefore, that any real decline in the incidence of mortality from the airborne category of diseases could only be the result of improvements in the potential victim’s resistance to the disease by virtue of an improved nutritional and dietary status, since the chances of initial

108

Health and Wealth

exposure to the disease could not be affected by public health preventive measures, while all other possibilities had now been excluded.Therefore, it followed that if the historical evidence showed a greater decline in the airborne diseases category, then this indicated a greater role for nutritional improvement, while the larger the fall in the water- and foodborne category of diseases the more significant the role of public health and hygiene measures. Using this a priori argument, McKeown’s data apparently showed that the airborne category of diseases was responsible for about twice the percentage share of the total reduction in death-rates in both periods, before and after 1901. Accordingly, this constituted irrefutable evidence that, above all else, improvement in nutritional intake brought about by rising living standards, rather than any other factor—including public health measures—has been the most important cause of the decline in mortality in Britain. And, of course, McKeown felt it legitimate to extrapolate this finding backwards into the eighteenth century, on the assumption that the mortality decline was a unitary process across all three centuries.

Critique of McKeown’s Interpretation First, as has been pointed out by many others, the weight of presumption in favor of improvements in nutrition as the primary causal factor in the registered mortality decline emerged merely by default, as a result of the skeptical devaluation of other factors, including medical intervention, rather than because of any convincing positive evidence in its favor. Indeed, whenever such positive evidence has been examined either for the eighteenth or nineteenth centuries, it has failed to provide any convincing support for McKeown’s hypothesis.23 The presumption was in fact achieved by a rhetorical sleight of hand using the logic of the argument by exclusion—the (in)famous analogy with the eliminatory detective method of Sherlock Holmes.24 Of the five “suspect” causal factors that McKeown cross-examined, the “culprit”—nutritional improvement through a rising standard of living—was left to last. As a result, the evidence for or against it was never subjected to the same highly critical appraisal that each of the other four candidate factors received. It therefore

The Importance of Social Intervention in Britain’s Mortality Decline

109

benefited accordingly in the estimation of its relative importance, since what the others lost through skeptical downgrading, it inevitably gained by the zero-sum rules of the argument by exclusion.25 Second, and related to this, the argument by exclusion is only legitimate if all the suspects have been correctly identified and are separately examined. But here “the standard of living” acts very much as a conceptual, residual catch-all, simply subsuming by fiat a variety of other possible factors, which are, therefore, not explicitly addressed in the analysis. Thus, Caldwell has recently complained that McKeown identified potential change in health inputs with medical discoveries and attempted to show that these were of little consequence. . . . He implicitly included everything else . . . under material progress. Similarly, he did not consider the expansion of the health infrastructure, although admittedly there was probably little in the way of additional medical technology to import and no political thought of creating a universal free health service.26

Although a simplification, Caldwell’s main thrust is sound: the form and economistic terminology of McKeown’s argument by exclusion has resulted in the suppression of any explicit consideration of the independent role of those sociopolitical developments that were responsible for such hard-won improvements as those in working conditions, housing, education, and various health services. One might have expected in a study coming out so strongly in favor of nutrition as the major factor that there would at the very least have been some detailed consideration given to the history of food adulteration and the battle for its regulation and control. But all this is blandly subsumed under the economistic term, “standard of living.” McKeown’s interpretation of the epidemiological evidence has, therefore, been crucially misleading in suggesting that these social, cultural, and political dimensions can quite properly be conceived merely as the automatic corollary of changes in a country’s per capita real income. However, as will be demonstrated below, even without altering McKeown’s own analytical categories, reappraisal of the same detailed epidemiological evidence in fact leads to quite the opposite conclusions. In his interpretation of the data, McKeown was particularly impressed with the importance of the overall long-run decline of the single airborne disease, respiratory tuberculosis (TB). In 1848–54 the

110

Health and Wealth

disease had been the most lethal single cause of death, accounting for 13.3 percent of all deaths occurring at that time. Furthermore, McKeown claimed that TB was in fact already in a process of decline at the date when the Registrar-General’s (R-G) data series began.27 When taken in combination with the fact that all the other airborne diseases contributed importantly to the overall reduction in mortality, taking the period 1848 to 1971 as a whole, and also with the apparent demonstration that neither clinical medicine nor municipal sanitation could account for the decline in such airborne diseases, these observations led McKeown to stress strongly the part played by nutritional improvement in the overall modern mortality decline, as we have seen. However, if we look closer at just the nineteenth century, McKeown’s own evidence provides far from unequivocal support either for the contention that a fall in airborne disease is the leading epidemiological feature of the period, or for the derivative conclusion that this could only be primarily the reflection of general improvement in dietary standards and nutritional levels. According to McKeown’s analysis the annual standardized deathrate per million living in England and Wales fell from about 22,000 in the mid-nineteenth century to about 5,400 by 1971, with 30 percent of this overall reduction occurring before 1901. Referring to Table 4.1, above, and the notes at the foot, we can see that the initial stages of the fall, before 1901, were mainly the result of the reduced incidence of five individual causes of death. First, respiratory tuberculosis appears to have been responsible for about two-sevenths of the nineteenth-century decline. Second, typhoid (sometimes referred to as “enteric fever”) accounted for a further one-seventh of the fall as a result of dramatic decline from the 1870s. Third, scarlet fever virtually vanished and so accounted for an almost similar fraction of the decline. Fourth, the elimination of cholera alongside a considerable fall in diarrheal diseases also accounted for almost a one-seventh part of the reduction. Finally, a somewhat problematic cause of death, “convulsions,” contributed again about one-seventh part. It is likely that much of the apparent fall in this last category represented more accurate classification of infant deaths to other causes, notably diarrhea, to which category, therefore, some part of this reduction should be reallocated.28 Apart from respiratory TB, therefore, there were two other airborne diseases that declined very significantly in the nineteenth century,

The Importance of Social Intervention in Britain’s Mortality Decline

111

scarlet fever and smallpox. However, neither of these can be used to support the nutrition hypothesis. It has long been recognized that human intervention, in the form of inoculation starting in the eighteenth century and then vaccination, quarantining, and isolation procedures in the nineteenth century, must be granted the major role in the case of smallpox.29 As for scarlet fever, McKeown is prepared to acknowledge that the epidemiological evidence strongly suggests that this was in all probability a disease that burned itself out spontaneously.30 But most disconcerting of all for McKeown’s general interpretation is the behavior of the composite airborne category, “bronchitis, pneumonia and influenza,” which has so far been omitted from the discussion. This was the second most important cause of death in 1848–54, accounting for 10.25 percent of all deaths. It actually registered a very considerable absolute increase in mortality of well over 20 percent down to 1901. By the turn of the century this category was clearly the most important single killer, contributing over 16 percent of all deaths, a greater proportion of the total than respiratory TB had represented in the mid-nineteenth century. Thus, McKeown would have us treat the airborne diseases as a single unitary group, which between them accounted for about half of the decline in mortality before 1901, and would have us believe that nutritional improvements, made possible by a rising standard of living, can alone be considered responsible for the large-scale reduction of the group as a whole.Yet, on closer examination, we find that this completely ignores the important contrary trend exhibited by one of the two most lethal disease categories in the group. Furthermore, we find that the nutrition argument applies almost exclusively to only one of the several diseases within the group, respiratory TB. But how strong is McKeown’s case that even this one disease’s reduction was due to rising living standards and food consumption alone? First, contrary to McKeown’s sweeping assertion, it should be pointed out that overall exposure of the population to airborne diseases would have been affected by the general level of crowding and ventilation in domestic or working environments. Droplet-transmitted airborne diseases will spread most effectively where humans are in close and unventilated proximity with the exhalations of victims or carriers. It is most probable that overcrowded conditions of living, sleeping, and working became more prevalent as industrialization and urbanization intensified.

112

Health and Wealth

The reversal of this trend was not simply the by-product of rising real wages but more the result of a complicated history of struggle and pressure for relevant clauses in Factories and Workshops Acts, Housing, and Crowding Acts, and the enforcement of building regulations and by-laws (see below). Thus, incidence of airborne diseases probably was influenced by certain public health and preventive measures. In addition, the aetiology of respiratory TB is a highly complex one, which is far from completely understood.31 Although it is probable that absence of malnutrition in a population is a necessary condition for the elimination of tuberculosis mortality altogether, it is equally probable that danger is decreased if other risk factors are reduced: particularly, frequency of incidence of other infectious diseases, but also overcrowding, lack of sunlight, air ventilation, and various occupational hazards.32 Thus, G. Cronjé has found adult male rates of TB mortality consistently above female rates in urban registration counties 1871–1900, yet the reverse situation in rural counties, where rates were generally a little lower.33 Such anomalous sex differentials seem to suggest that general nutritional factors were less important than certain sex-specific activities in determining the relative incidence of TB.34 Cronjé notes that urban men were on average much more exposed to the uncontrolled atmospheres of overcrowded factories and workshops than either their womenfolk or the rural men, while rural women were on average more subjected to childbearing than their urban counterparts during this period of urban fertility decline.35 It would certainly seem presumptuous, therefore, to attribute a long-term reduction in TB mortality to one single factor, such as improving nutritional standards. What, then, were McKeown’s grounds for this bold assertion? The critical factor was the apparent empirical finding that respiratory TB was already declining from the late 1830s and 1840s, before any other major disease had begun to fall (apart from smallpox, which had probably been on the wane since the latter part of the eighteenth century).This chronological priority in TB’s decline was vitally important for McKeown’s interpretation. It effectively ruled out the possible influence of urban environmental improvements, since these cannot be seriously claimed for the 1830s and 1840s. However, it was of even greater importance in establishing the plausibility of a strong “nutritional determinism” thesis for the following reason.Tuberculosis often takes a lethal hold where an

The Importance of Social Intervention in Britain’s Mortality Decline

113

individual has already been weakened by attack from a previous infection by another category of disease, notoriously so with whooping cough. Thus, any general decrease in the incidence of other diseases would probably have a secondary “knock-on” effect in reducing the number of temporarily weakened individuals available to fall victim to TB. It is also generally true, vice versa, that the presence of TB impedes an individual’s capacity to resist attack from other diseases, so that a prior decline in TB could also be claimed to exert a secondary influence, facilitating the decline of other diseases. Therefore, the apparent discovery that TB led chronologically in the general decline of disease incidence means that in addition to the primary influence of a rising standard of living in reducing this airborne disease through enhanced nutritional defences, it can be claimed that in all probability there was an additional knock-on effect of reducing fatalities from other diseases. As so often in matters of causation, precise chronology, therefore, becomes extremely important. How robust is this all-important empirical finding regarding TB’s chronological priority? McKeown’s 1976 text merely offers it as an assertion that “The number of deaths from tuberculosis fell rapidly from 1838, and this disease was associated with nearly half of the total decrease of the death rate during the second half of the nineteenth century.”36 The evidence and primary research upon which this view was based is contained in the earlier article of 1962.An examination of the evidence originally adduced there by McKeown and Record to demonstrate the early decline of TB is, in fact, far from convincing. Their detailed analysis of this “treacherous evidence” (their own words),37 provided by the cause-specific vital registration data of deaths for the individual years 1838–50, cautioned that reliable and robust conclusions regarding TB trends could only be made on the basis of a joint consideration of the movements in both the phthisis (respiratory TB) and bronchitis figures aggregated together. The aggregation was necessary specifically because contemporary certifying authorities had made inadequate distinction between the two causes of death.38 Particularly damaging to the validity of any inference in favor of a trend decline in TB was the possibility of “changes in certification (especially from tuberculosis to bronchitis).”39 From such a consideration the authors concluded that although the direction of change during the period 1838–46 was entirely uncertain, it could confidently be asserted that there was a definite fall in

114

Health and Wealth

TB mortality in the years 1847–50 because both diseases were falling together during this brief period.40 However, on the basis of this microscopic examination it was then unjustifiably asserted that the fall across these four years was the commencement of a general and sustained drop in TB mortality continuing for the rest of the century.The authors failed to mention at this point in the analysis that their own graph, entitled “Secular trend in mortality from consumption or phthisis” and printed five pages earlier, showed a strong resurgence of mortality from respiratory TB over the ensuing five years after 1850 and thereafter no clear trend decline until after 1866–67.41 In other words, 1847–50 was merely a short-term fluctuation and not a major turning-point in the trends. So, there is, in fact, no good evidence for TB’s chronological priority in the mortality decline. And in any case, there had always been the claim of the much earlier, medically induced decline in smallpox, the quantitative importance of which McKeown failed to acknowledge. Although smallpox did not appear to be a predominant factor in the civil registration returns that McKeown analyzed, this was precisely because it had already been beaten back considerably by the 1830s. All the evidence of medical testimony in the eighteenth and early nineteenth centuries suggest that it had been a major scourge, especially of childhood.42 Finally, there still remains to be taken into account the strong counter-trend, already remarked upon, which the increasingly lethal bronchitis group of airborne respiratory diseases exhibited throughout the rest of the nineteenth century.This constitutes the most awkward and serious general caveat on the validity of McKeown’s airborne/“nutritional determinism” interpretation, however it is explained. Either this anomalous 20–25 percent increase in the incidence of the bronchitis group fatalities has to be simply accepted as genuine, in which case it constitutes a direct contradiction of the view that a general fall in airborne diseases is the principal epidemiological feature of the nineteenth century and so the whole case collapses. Or else it could perhaps be argued, in view of McKeown’s own warnings regarding imprecision of certification and the likelihood of transfers between the two categories, that this rise was not real and should be offset against the apparent decrease in reported TB death-rates.43 However, even this expedient would be no less damning for the “McKeown thesis.” According to Table 4.1, the remaining drop in

The Importance of Social Intervention in Britain’s Mortality Decline

115

pulmonary (respiratory) TB, after subtraction of the increase in bronchitis fatalities, would only be 6 percent of the total fall, or one-fifth of the 30 percent reduction that occurred before 1901.This would then be only of the same order of absolute magnitude as either the typhoid/typhus reduction (5 percent) or the cholera/diarrhea reduction, if the latter’s figure of 3.5 percent were to be inflated by, say, one-third part of the fall attributed to “convulsions.”44 Thus, with the anomalous rise in bronchitis group fatalities properly acknowledged, the classic sanitation diseases come to the fore in quantitative terms.These two water/food-borne categories (typhoid/typhus and cholera/diarrhea) would between them be responsible for at least 8.5 percent and perhaps 10 percent of the overall mortality decline before 1901. That is one-third part of the nineteenth-century reduction, or over half as much again as that attributable to the airborne combination of TB and the bronchitis group. Furthermore, the much later date suggested here for onset of phthisis decline (after 1866–67 at the earliest, or perhaps even later once the effect of adding back in the bronchitis group has been properly taken into account), implies that the fall in respiratory TB itself may have been a secondary and derivative effect of earlier, or at least concomitant, falls in the sanitation diseases, rather than vice versa. Improvement in respiratory TB would, then, no longer appear to have been either the chronologically prior or the quantitatively predominant feature of the nineteenth-century mortality decline in England and Wales. According to the logic of McKeown’s own arguments, the foregoing would indicate a primary role for sanitary reform and public health measures, rather than rising nutritional levels or living standards. The changing incidence of mortality from respiratory TB in Victorian Britain, rather than being cast in the role of a leading and determining influence, can be seen as a dependent function of the general intensity and frequency of other debilitating diseases. Many of these were themselves killers but only of a certain proportion of their infected victims, leaving the remainder weakened and prey to late breakdown disease from a previous primary TB infection.45 This conceptualization of mortality from TB, as essentially a secondary effect of the aggregate incidence of other infectious and sanitation diseases, is strongly suggested by William Farr’s early analyses of the rural-urban differentials in cause-specific mortality patterns. Although respiratory TB was the largest single cause of death at

116

Health and Wealth

that time, Farr observed that wherever the overall death-rate was relatively high, as in most urban and industrial registration districts, this was not primarily because of enhanced risks of respiratory TB, which was only about 20–25 percent more lethal in the towns as against the countryside.46 By contrast, certain other major killers were about 200 percent more lethal, and it was these that reflected the primary risks of city life.They included notably “convulsions” (“a frequent intercurrent symptom in diarrhea” noted Farr),47 hydrocephalus, teething, gastroenteritis, diarrhea, “typhus” (that is, both typhus and typhoid), smallpox, measles, and the bronchitis group of respiratory diseases.48 Farr specifically pointed out that the latter’s high incidence was a result of the common sequelae of frequent measles and influenza epidemics in the cities.49 According to this analysis, therefore, the peculiarly pernicious disease pattern of the urban districts in the late 1830s was not so much due to differentially excessive respiratory TB, but to problems caused by absence of sanitation and hygiene, taking a particularly high toll at birth and in early infancy, and compounded by certain frequently epidemic infectious diseases.

An Alternative Interpretation: Urban Congestion Remedied by Social Intervention Thus, according to the reinterpretation of McKeown’s epidemiological evidence proposed above, it is no longer the decline of airborne diseases as a unitary category that appears to be the predominant and leading characteristic of changing mortality patterns in nineteenth-century England and Wales, but rather the behavior of the classic sanitation and hygiene diseases.There can be little doubt that the first two-thirds of the nineteenth century witnessed an increasing incidence of such diseases, which was directly attributable to the unplanned proliferation of overcrowded cities and towns lacking even the most basic sanitary facilities such as proper water supply and waste-disposal systems.50 Conversely, the ensuing disappearance of water-borne diseases in the last third of the century was due to the eventual provision of adequate sanitary facilities, long delayed but finally implemented. McKeown himself noted of the nineteenth century that

The Importance of Social Intervention in Britain’s Mortality Decline

117

the appearance of cholera, possibly for the first time, leaves little doubt that . . . hygienic conditions deteriorated. The rapid movement of population from country to towns must have led to deterioration of hygiene and increased exposure to diseases spread by water and food.

And so: Mortality from these infections . . . did not begin to decline until there were improvements in water supplies and sewage disposal, in England and Wales from the seventh decade [of the nineteenth century].51

Between 1801 and 1871 the rate of urban growth in Britain was quite unprecedented, both in the provinces and the metropolis. At the commencement of the nineteenth century no provincial town contained as many as one hundred thousand inhabitants. By 1871 there were seventeen cities over this size on mainland Britain, apart from London. Glasgow and Liverpool each numbered around half a million, while the capital had tripled to over three million. National aggregate mortality patterns only indirectly reflect the full impact of this period of intensive but chaotic and disorganized urban expansion on the nation’s health. According to the best single summary measure currently available,Wrigley and Schofield’s series for the expectation of life at birth (eo), an upward secular trend dating from either the 1680s or 1730s (depending on how one chooses to interpret the behavior of the index across that period), whereby average life expectancy at birth rose from around 30 years to about 40 years, then slowed to a halt at the end of the first quarter of the nineteenth century. For about half a century, from the 1820s until the 1870s, there was virtually no perceptible further improvement.Thereafter, there was a gradual rise to about 47–48 years by the end of the century, followed by a somewhat faster rise, to just over 60 years by 1931.52 Paradoxically—for McKeown’s thesis—it had been almost exactly at this same point in time, when the long eighteenth-century rise in life expectancy had stalled to a halt, that a concomitant eighteenth-century fall (or at best stagnation) in national aggregate real wages was reversed and there had begun a trend of continual, although not continuous, improvements in average real wages throughout the rest of the nineteenth century.53

118

Health and Wealth

McKeown entirely discounted the possibility of any chronological discontinuity of this sort, assuming instead a reasonably direct long-term correlation between uninterrupted upward trends in economic growth, food supply, rising living standards, and improving mortality levels (his own mortality data did not extend back beyond 1838 and the course of demographic movements over the previous couple of centuries was largely a matter of conjecture in the “pre Wrigley-and-Schofield” era).54 The explanation of the inverse relationship is not, however, difficult if it is simply accepted that the relative state of insalubrity in the expanding urban environments, rather than improvements in average real wages or the food supply, must have been the more predominant factor influencing national mortality trends in the nineteenth century.The historical process of industrialization was able to generate massive productivity gains as a result of innovations in the technology of production, most of which entailed a geographically more intensive demand for labor than had hitherto existed. It is no paradox, therefore, but simply two sides of the same coin that this process could simultaneously engender higher wage-rates for the industrial workers and their families congregating at the places where these new enterprises were emerging, yet also exert a negative influence on their average life expectancy because of the crowded and chaotic living conditions prevalent in the mushrooming towns and cities created by the rapidly expanding employment opportunities. The stationary national figure for expectation of life at birth across the second and third quarters of the nineteenth century merely summarizes the nation’s average mortality experience, urban and rural populations aggregated together. This quite certainly belies wide geographical divergences in experience.Those remaining in the countryside were very probably continuing to experience the trajectory of slow but steady improvement that had characterized the second half of the eighteenth century. By contrast those who migrated to the expanding towns and cities to bring up their families—a rapidly growing proportion of the national aggregate throughout this period—must have experienced a real fall in life expectancy on so doing.55 Such a divergence in rural and urban experiences during the first half of the nineteenth century was clearly indicated in the results of William Farr’s famous pioneering construction of comparative life-tables for Liverpool, London, and rural Surrey. Average expectations of life at birth in c.1841 were found to be

The Importance of Social Intervention in Britain’s Mortality Decline

119

a respectable 45.1 in Surrey, a worrying 36.7 in London, and an appalling 25.7 in Liverpool, a city that had already more than tripled in size since the first census of 1801.56 While increasingly huge populations continued to concentrate ever more intensively in townships growing into cities but lacking the appropriate social overhead capital to preserve—let alone promote—health, morbidity and mortality risks inevitably proliferated. Also inevitably, these multiplying and compounding health hazards could only be alleviated through the appropriate social and political responses: the technical development of, and proper deployment of, precisely that infrastructure that was previously largely unnecessary. For instance, despite its rapid growth and the unhealthy overcrowded conditions this implied, a mains sewer system for London as a whole, which dumped the waste securely downstream of its population, was not completed until 1865—the first such large-scale integrated system in the country. This followed a long period of extremely harmful, highly localized initiatives by the propertyowning classes. They were the first to install their own water-flushing closets in large numbers from the 1770s onwards; but in the absence of a mains sewage system, these were simply allowed to empty into the nearest culvert or river, from which much of the town’s population in turn took their drinking water.57 Unfortunately, this development was to be repeated in other cities and towns around the country in the course of the nineteenth century.58 The lethal lesson was only slowly learned that selective sanitation for the upper classes alone was not a sufficient panacea in the prevention of water-borne disease. Sewering alone, without commensurate attention to the purity of the water supply, could prove a downright liability, as was tragically demonstrated by London’s final cholera epidemic of 1866–67, immediately following the completion of London’s sewers system. This was the last such epidemic and it was the famous occasion on which William Farr, using a method pioneered at the previous outbreak of 1853–54, was able to trace precisely the culprit. By dividing London into districts according to the different companies supplying water, Farr narrowed down the problem to the East London Waterworks Co., who were illegally supplying water from the Old Ford reservoir in Bethnal Green, which was contaminated by the recently completed West Ham sewage system.59 This is a perfect example of the kind of medical science in the public health

120

Health and Wealth

field, which was vital in stimulating what McKeown loosely calls “municipal sanitation” or “ hygiene.”The narrow definition of medical intervention, as either scientific discovery or the effects of clinical and hospital practice only, misleadingly understates the importance of medical men, and human agency in general, in bringing about the nineteenth-century decline in mortality. Sanitarians contributed by convincing public opinion of the need for strategic measures to improve the urban environment (the particular contribution of the General Register Office, or GRO), by demonstrating the practical worth and feasibility of such schemes, and then by administering their operation. The period from the late 1830s to 1875 has come to be seen as encompassing a “heroic age” of pioneering advances in public health activism and legislation. The era began with probing investigations by medical men such as William Farr at the GRO, Dr. Arnott, Dr. Kay, and Dr. Southwood Smith, stimulating the formulation by Edwin Chadwick of his ambitious program, “The Sanitary Idea,” which eventually issued in the first Public Health Act of 1848. Despite the notorious reaction that this provoked among those jealous to protect their local influence and power against the apparent encroaching intentions of a Chadwickian centralizing state and despite Chadwick’s fall from office, energetic central direction of public health affairs by Sir John Simon still continued.60 Royston Lambert long ago showed that the check to central government activism supposedly represented by the 1858 Local Government Act was only relative and not absolute, more in spirit than fact.61 It has generally been considered that this dynamic phase petered out with the creation of the Local Government Board in 1871, resulting in the subordination within that institution of expansionary and interventionist public health interests to the reactionary, conservative instincts of an upper administrative staff drawn mainly from the Poor Law Board. After four years of increasing frustration at the restrictions being imposed on his medical staff, John Simon resigned in 1875, marking the formal end of this “heroic” period.62 Although important scientific developments in preventive medicine and epidemiology of course continued, the period from 1875 to the end of the century has tended to be seen as a contrasting and less dynamic period, during which Gladstonian budgetary control and Treasury retrenchment stifled the initiatives of those medical men and their sympathizers in government who

The Importance of Social Intervention in Britain’s Mortality Decline

121

were the progressive advocates of the public health movement.63 Thus, on the assumption that it was the three middle decades of the nineteenth century when most progress was occurring in the field of public health, the lack of any obvious chronological fit between public health advances and the general fall in mortality from infectious and sanitary diseases, which did not occur until the last third of the century, has perhaps discouraged historians from assigning any particular significance to the expansion of preventive public health measures as the major influence on mortality patterns. However, an entirely different chronology emerges if we shift the focus of attention away from the central government departments and the nationally famous figures who led the public health crusade, and instead look to the provinces and the municipalities. Although a comprehensive coverage of the history of municipal sanitation in every growing town and city throughout Britain is quite beyond us as yet, there are clear signs that this will prove a very profitable line of enquiry.Anthony Wohl’s Endangered Lives (1983) has certainly presented enough evidence in an accessible form to show that despite the slowing down in central government activity and the relative quiescence of sanitarians in and around Westminster and Whitehall, it was in fact the last thirty years of the nineteenth century when most of the significant improvements and works of construction and concrete applications of preventive health measures went forward and were actually occurring on the ground throughout the provincial cities and towns of Britain. With the rise in the 1860s of a genuine ethos of local civic pride in their muncipalities, the long-standing strategy of the GRO had added effect. This was the deliberate fostering of an atmosphere of rivalry and competition between local authorities by publishing comparative information on local death-rates as regularly as possible and with graphic comparisons in terms of numbers of lives needlessly lost in the “Black Spots,” relative to the more salubrious “Healthy Districts.” The optimal health conditions were thereby insidiously established by this clever propaganda manoeuvre as an objective to which all responsible local authorities aspired. Commerce and business was believed to be attracted to those cities with the lowest death-rates (a macabre inversion of today’s logic of commercial location that seeks out those authorities with the lowest local fiscal-rates).64

122

Health and Wealth

The broad-based 1850s backlash against Chadwick’s centralizing Poor Law and Health Boards had clearly demonstrated to all in government and administration that formal adherence to the principle of local autonomy was a nonnegotiable political necessity. Sanitary progress within these political rules was, nevertheless, perfectly possible once proponents of public health had adjusted their program appropriately so as to work through and with local authorities, rather than attempting to override them, as Chadwick initially had. However, while this adjustment in thinking was occurring, Victorian public health remained hamstrung at the local level by the twin problems of a multiplicity of overlapping authorities and the noncompulsory, merely permissive nature of most of their statutory duties. Steps to improve the urban environment often clashed with the pecuniary interests of factory and workshop owners, landlords, and shopkeepers.65 In these circumstances the ambiguity, or positive obstructionism of economizing ratepayers could all too easily prevail over public health arguments for expensive local facilities and services. By the mid-1860s, however, sanitarians were focusing their attentions forcefully on precisely these local political and administrative obstacles blocking their path. Having reluctantly accepted localism in public health, the solution was to compel local government to be effective, as the reforming barrister Edward Jenkins perceived, writing in 1866: “To a sanitary reformer there is no greater bugbear than a permissive enactment.A system which involves expense to persons interested in that expense is sure, in nine cases out of ten, to be unheeded.”66 The basis for a program of increasingly effective pursuit of the nation’s health within the framework of local government and administration was provided by the three Acts in the 1870s that followed the recommendations of the report of the famous Royal Sanitary Commission of 1869–71. The Commission was itself the government’s response to a public health debate, instigated by those sanitarians, such as Jenkins among many others, who were galvanized by the tantalizing failure of the path-breaking 1866 Sanitary Act: its defective drafting had confounded the novel system of compulsory local sanitary duties subject to central inspectorial supervision it was intended to establish. The 1871 Local Government Act finally produced a unified department of state to deal with most aspects of local government with a minister responsible for implementation, the president of the newly created Local Government

The Importance of Social Intervention in Britain’s Mortality Decline

123

Board. The 1872 Public Health Act established the corresponding national network of literally hundreds of local sanitary authorities, each with a now-obligatory Medical Officer of Health. And the great consolidating Public Health Act of 1875 clearly laid down most of the public health functions and statutory duties of these local authorities and their staff, remaining in force until the subsequent Act of 1936. Thus, while it is true that a centralized system of “state medicine” of the sort that had been ambitiously envisaged by H.W. Rumsey was not adopted,67 historians of the central departments and national figures have perhaps dwelled too much and somewhat Whiggishly on this aspect of the “sanitary revival” of these years: the non-emergence of a prototype centralist Ministry of Health. In so doing there has been a failure to give due credit to the political realism of what was actually achieved through the relatively successful harnessing of local and provincial energies and administrative structures to the subsequent promotion of the nation’s public health. With the essential machinery of unambiguous local accountability in place, effective take-up of public health measures began to gather pace. Alongside this was a continual process of modification and diversification in local authorities’ powers and duties, as the practical experiences of their officials in attempting to fulfill statutory duties revealed new administrative, technical, and financial obstacles and requirements. For instance, the 1872 Public Health Act obliged local authorities, as one of their statutory duties, to ensure a pure water supply. In turn, this led to pressure for the 1878 Public Health (Water) Act whereby municipal purchase of private waterworks was made truly financially feasible. Whereas in 1879 only 415 urban local authorities were in charge of their water supplies, by 1905 over two-thirds of the 1,138 urban sanitary authorities then in existence were running the local waterworks, so that the health of the populace was decreasingly left in the hands of the likes of the East London Waterworks Co.68 Another example is that of the increasingly close regulation of the quality of the urban food supply, which duly resulted from the attention that Medical Officers in the 1860s had begun to pay to adulterated and defective foodstuffs, particularly meat and milk, as a source of disease.69 The Adulteration of Foods Acts followed in the 1870s, leading to the appointment of professional inspectors and public analysts by most local authorities in the 1880s, to

124

Health and Wealth

the Weights and Measures Acts in 1878 and 1889, and to a final consolidating Sale of Food & Drugs Act 1899. The last third of the century was the classic period in which all the hectic activity of the Public Health political and administrative pioneers finally began to bear fruit and to take concrete effect. Of course, all this was only achieved as a result of innumerable unsung local skirmishes between frequently underpaid health officials, often lacking security of tenure, and their local allies—other sanitary officials, the district registrars of births and deaths, perhaps the town’s press and occasionally some members of the local councils themselves—as against the parsimonious representatives of the majority of ratepayers. It is precisely the importance and necessity of this slow, dogged campaign of a million Minutes, fought out in town-halls and the local forums of debate all over the country over the last quarter of the nineteenth century, that has been missing in our previous accounts of the mortality decline (see this volume, ch.9).70 A. S. Wohl has noted that Sir John Simon himself always regarded the extent of public works loans contracted by local authorities from the central government funds as the true barometer of sanitary progress and real local activity.71 This was the system whereby local authorities were enabled to borrow long-term loans of cash at lower than market interest rates for provision of sanitary facilities and services. Between 1858 and 1870 only £11 million in such loans was requested, whereas between 1871 and 1897 £84 million was borrowed, £65 million of it by urban authorities.72 In addition, in the town-hall-building age of the civic gospel of municipal progress symbolized by Joseph Chamberlain’s goahead Mayorship of Birmingham, 1873–76, there began the deliberate development of municipal trading activities in gas, electricity, and transport in order to generate funds and revenue for municipal social services and facilities independent of the various strings attached both to central government sources of finance and to the local rates. Charles Feinstein’s figures for gross domestic fixed capital formation show that whereas local authorities were only spending about £5 million per annum on such enterprises in the period 1856–71, this rose to an average of £12–14 million per annum for the period 1874–94, and by the Edwardian period had reached an annual expenditure of about £30 million per annum.73 Furthermore, and despite the expanding revenues of municipal trading, by 1890 subventions from the imperial exchequer to local authorities

The Importance of Social Intervention in Britain’s Mortality Decline

125

represented 6.7 percent of total national revenue and by 1913 this figure had risen to 11.6 percent, by which date local government spending represented virtually one-half of total government expenditure.74 I would argue, therefore, that there is a sound prima facie case that the decline in mortality, which began to be noticeable in the national aggregate statistics in the 1870s, was due more to the eventual successes of the politically and ideologically negotiated movement for public health than to any other positively identifiable factor. The resulting implementation of preventive measures of municipal sanitation and regulation of the urban environment and food market actually arrived on the ground in the many new cities throughout the country during the last third of the nineteenth century and the first decade of the twentieth.75 The all-but-complete eradication by the end of the century of typhoid, cholera, and smallpox each testify in different ways to the importance and effectiveness of various aspects of the large-scale strategic public health measures that were introduced during this period. Provision of a sufficiently clean local water supply was essential in the cases of both typhoid and cholera. Due to their epidemic nature, elimination of cholera and smallpox additionally required a properly functioning national system of surveillance to identify and snuff out local outbreaks that could otherwise quickly become major incidents. Port sanitary authorities established by the 1872 Public Health Act, alongside the initiative of the GRO in establishing regular communications with foreign authorities so as to gain advance warning of any outbreaks abroad, helped to ensure—in the absence of an entirely secure national water supply—that Britain successfully evaded all three subsequent European visitations of Asiatic cholera in 1873, 1884–86, and 1892–93.76 Smallpox continued to appear despite its preventability because of the unfortunate involvement of the unpopular Poor Law as the official agency of compulsory vaccination. As a result vaccination was far from universal, especially amongst the Metropolitan poor where a particularly virulent form was in evidence at this time.The final eradication of smallpox, therefore, was in fact further testament to the efficiency of the Metropolitan Medical Officers of Health: their effective operation of the Notification of Infectious Diseases Act of 1889 allied to the provision by the Metropolitan Asylums Board of isolation facilities on hospital ships in the Thames.77

126

Health and Wealth

By contrast, the apparent rise in the bronchitis group of airborne respiratory diseases may well be evidence that in those areas of the urban and industrial environment where preventive legislation and action was not forthcoming, serious consequences followed. Clean air was one obvious omission from the late nineteenth-century sanitary reform arsenal and one need look no further than the appalling urban smogs to explain such anomalously high levels of respiratory disease in the Victorian period. Although there was a Metropolitan Smoke Nuisance Abatement Act as early as 1853 and relevant sections in many other towns’ Improvement Acts, these often unenforced clauses applied only to commercial premises. However, it was not factories so much as coal-burning domestic fires that caused the smogs; hence London’s were reputedly the worst, rather than those of the northern industrial towns.The Great Fog of 1886 sent the Metropolitan death rate up to almost equal that of the worst years of cholera epidemics, as over 11,000 inhabitants in the capital were recorded as dying of bronchitis alone that year.78 Furthermore, in many northern and midland industrial towns an entirely separate and also continuing source of respiratory disease (including TB: see Cronjé’s work, noted above) was the unregulated factory atmospheres of textile, pottery, and especially metal-grinding industries, demonstrated in the differential occupational death-rates of those employed in these industries. For instance, male textile workers in the 1890s, a numerically large segment of the factory working class, had a two-and-a-half times higher death-rate from respiratory diseases than agricultural laborers, despite their considerably higher pay and better access to a varied diet—the main factors stressed by McKeown in accounting for secular falls in the incidence of airborne diseases.79 It is a well-rehearsed observation that the average expectation of life improved more slowly in the three decades before 1901 than in the three following because improvement was confined primarily to the age-groups 2 to 34 for males and 2 to 54 for females. Infant mortality (i.e., age 0 to 1) remained stubbornly high at about 150 per thousand throughout England and Wales in the later nineteenth century. However, almost exactly at the turn of the century the nation’s infant mortality rate suddenly plummeted, already reaching 110 per thousand by 1910–12 and then 80 per thousand by 1920–22, despite the intervention of World War I, and thereafter continuously declining at a somewhat slower rate down to the

The Importance of Social Intervention in Britain’s Mortality Decline

127

present minimal level, reaching 18 per thousand in 1970–72.80 How, then, does this fit into the general interpretation being presented here? As McKeown himself noted, it was the water- rather than food-borne diseases that had declined first, in the period before 1901: “It is worth underlining the fact that the rate of decline of mortality before the turn of the century was much greater for the enteric [intestinal] diseases, then spread mainly by water, than for the diarrheal diseases spread mainly by food.”81 This reflects the limits of what was possible through the “municipal sanitation” movement alone. Although improvement of the urban environment at the strategic level by providing pure water, paved streets, refuse collection, and a proper mains sewage system could eradicate the waterborne diseases that thrived where collective sanitary facilities were defective, such measures could not alter the shortcomings of living conditions and especially food preparation in the overcrowded, working-class domestic environment of the back-to-back. Nor could they educate a populace into more hygienic habits of food preparation for weaning infants, hence McKeown’s observation that before the twentieth century there was relatively little decline in food-borne diarrheal diseases. However, several relevant developments affecting the working-class home environment were beginning to take noticeable effect by the first decade of the twentieth century. First, and most importantly, the problems of housing quantity and quality were gradually being alleviated. There was an ever stricter enforcement of minimal standards of design and especially insistence on the provision of basic sanitary and hygiene facilities in the new homes being built or improved during the long boom in house-building 1897–1907.82 For instance, whereas in London the Metropolitan Management Act as long ago as 1855 had in theory empowered vestries to compel landlords and builders to connect houses to mains drains (a provision extended to the whole country by the flawed 1866 Sanitary Act), one of the few local studies that has been completed found that in Camberwell such regulations were consistently hoodwinked until by-laws in 1889 brought in official on-site inspections before drains were covered over by builders.83 A further significant step forward in metropolitan housing standards came two years later with the Public Health Act (London), which stipulated that every single new and rebuilt house should have its own “proper and sufficient water supply.”84 Following the 1890 Housing Act, expansion in the provision of municipal housing itself was at

128

Health and Wealth

last made financially feasible, incorporating minimum crowding and sanitary standards following earlier private philanthropic initiatives (such as the Peabody estates and Rothschild buildings).85 Between 1895 and 1907, for instance, the number of occupants municipally housed rose by a factor of 5 in Manchester, to 3,500; by a factor of 7 in Liverpool to 7,500; by a factor of 14 in London to 36,000.86 These were admittedly as yet small numbers. However, there are also the ambitious philanthropic and municipal town-planning initiatives to be included, such as Bournville or New Earswick, and Hampstead or Letchworth Garden Cities, respectively. If it is reasonable to assume that the very worst houses and slums tended to be the first to be knocked down and, in effect, replaced by these schemes and by the private building boom, then overall the average quality of the housing stock available, especially in terms of provision of basic utilities for effective domestic hygiene, may have been improving substantially from the 1890s onwards as a net result of all these various factors.87 For instance, P. J.Waller cites an interwar survey of a sample of northern and midland industrial towns, which estimated that between 1894 and 1914, the proportion of homes with a fitted bath multiplied fourfold from 5 percent to 20 percent.88 The second development affecting the working-class domestic environment was the expansion of local health and maternity services. As I. H. Buchanan’s highly effective study of eight mining communities has shown, although actual clinics were rare before World War I, the health-visiting system, while by no means universal, was well established throughout much of the country and could have a considerable educational effect.89 This activity had a long prehistory in certain towns, such as London, Brighton, Newcastle, and Manchester.90 But it was not until the 1890s and 1900s that Lady Health Visitors, alongside midwives, became a more professionalized occupation and began to form an integrated component of a growing network of health services organized by local authorities. By 1909 the official committee reporting on the working of the Midwives Act of 1902, was able to note that a formal division of responsibilities had become a practical norm in many places, with midwives involved for the first ten days after a birth and health visitors thereafter.91 Services were coordinated in the larger authorities under the direction of the local county or borough Medical Officers of Health, whose coverage of the local community was increasingly comprehensive

The Importance of Social Intervention in Britain’s Mortality Decline

129

once adoption of the 1907 Notification of Births Act enabled them quickly to locate and follow up all births (this Act became compulsory for all local authorities in 1913). A third possibly important contemporaneous development, stressed by McKeown himself, was the regulation of the urban milk supply, facilitated greatly after the Dairies, Cowsheds and Milkshop Order of the Local Government Board in 1899. However, this development in isolation probably should not be accorded any particular significance. Despite the considerable attention given to the issue of artificial feeding by the contemporary middle classes, it seems probable that breast-feeding was still the norm for the vast majority of the working-class population, although reliable information is unusually hard to find on this subject.92 Furthermore, Dwork has recently pointed out that although purity of the milk supply at source was a necessary step, it was not sufficient in itself to bring about reduction in infant mortality rates, as it was no remedy for the absence of domestic hygiene surrounding the subsequent preparation of infant feeds from that milk.93 A safe milk supply had to be combined with new practices of more hygienic preparation of feeds for infants, before any benefits in terms of lives saved might reasonably be expected to follow. This, then, leads us back to the fundamental importance of the two factors already mentioned: housing and instruction in hygiene. Although breast-feeding would certainly confer some protection in the first months before weaning, the root of the general problem of infants’ vulnerability lay in the fundamentally unhygienic conditions and associated practices of the urban working-class home, virtually inevitable in small, overcrowded households lacking their own water supply and water-closet. Until it began to be improved from the 1890s onwards, such an environment was continuously introducing infants to bacterial organisms (in particular some strains of Escherichia coli) which, although not harmful to the more developed digestive system of elder children and adults, could produce fatal diarrhea attacks in infants.94 This was a particularly unfortunate problem since it was commonsense practice among working people that food that was safe for adults was safe for infants. It may be helpful to point out here the significance of making a conceptual distinction between mal-nutrition (food-poisoning) and under-nutrition as two separable causes of what is normally referred to simply as “malnutrition,”

130

Health and Wealth

meaning lack of adequate nourishment, without distinguishing the cause. The implication of the distinction in this context is that in order to explain high infant mortality and its subsequent improvement in Britain, it is not enough to consider, as McKeown did, only issues of per capita nutritional intake (the issue of under-nutrition) because a greater intake of food could be counterproductive for the preservation of infant life, when that food is inappropriate and crawling with pathogens (the issue of mal-nutrition, or chronic food-poisoning). This general interpretation receives further support from one or two local studies that have been reported recently. For instance, Parton has given an account of Huddersfield’s pioneering “Special Scheme Against Infantile Mortality” established by its energetic mayor, P. Broadbent, through a local Act of Parliament in 1905.95 It was to become a model for the future operation of the Notification of Births Act 1907. A combination of volunteer Lady Health Visitors worked in partnership with local government officials under the direction of the Medical Officer of Health, Dr S. G. H. Moore, sanctioning payments to parents who gave notification of births within forty-eight hours (although a projected milk depot was not established nor a day nursery). Huddersfield’s infant mortality rate (IMR per thousand) was already much better than many large towns even before these initiatives, standing at 134 per thousand in 1900–1902 (Broadbent had been chairman of the town’s Health Committee since 1893: the IMR had been a little over 150 per thousand until the latter 1890s).96 However, apart from the notoriously bad year of 1911 (a nationwide problem due to a severe winter followed by a long hot summer), Huddersfield succeeded in continually improving on these successes after 1906, recording rates between 95 per thousand and 111 per thousand each year between 1907 and 1915, and thereafter even lower.97 In another study, G. M. Nolan has found that in Derby the most important identifiable factors responsible for a drop after 1900 in the infant mortality rate were the better feeding practices promoted by health visitors and, to a lesser extent, urban improvements.98 Other factors addressed, such as changes in levels of earnings, in the birth-rates, or in the quality of the milk supply alone, were found to have less influence.The infant mortality rate fell dramatically from 154 per thousand in 1900–1902 to 91 per thousand in 1912–14, although, unlike Huddersfield, there was then no further improvement in infant mortality in Derby until after World War I. Thus, whereas the reduction in the mortality of elder children and

The Importance of Social Intervention in Britain’s Mortality Decline

131

younger adults throughout the last third of the nineteenth century reflected improvement of the urban environment at the strategic level outside the home, that of infants had to await the more probing and detailed regulations and the expansion of skeletal social services, which had only just begun by the turn of the twentieth century to penetrate into and improve the conditions existing in the infant’s “environment”: the working-class domestic household itself. That this should have been “the last frontier” for the public health movement will perhaps come as no surprise, when we recall that this is the culture where “an Englishman’s home is his castle.” A strong libertarian respect for domestic privacy was the twin to the ideological position that took it as a matter of patriotic duty to resist despotic “Bonapartist” centralizing government officials, as Chadwick had found to his cost. It seems probable, then, that part of an explanation for the popularity of the anti-contagionist aetiology of miasmata, dominant in mid-Victorian England, was its convenient policy implication that it was the public environment of the streets and courts, and not the domestic space, that required regulation and control. However, once contagionism had eventually gained general acceptance during the 1880s and 1890s, as a result of the publicizing of the microscopic findings of bacteriological science, the castle’s drawbridge was hauled down. Still, the portcullis might yet remain lowered by the occupants inside. To be truly effective any increased intervention by “middle-class” agents of local authorities inside the “working-class” home would have needed a reciprocal positive attitude from the recipients of this attention: active learning on their part in response to the teaching by their social superiors. It seems quite possible that there was indeed some kind of sea-change in the relevant aspects of class relations in the wake of the turbulent 1880s; but this must remain only a speculative inference, as there seems to have been little research done as yet on working-class attitudes to the preventive health services or to local authorities in general during this period.99

Conclusions As the Professor of Social Medicine at Birmingham University, only the second such department to be established in the country, McKeown was

132

Health and Wealth

one of the leading members of a postwar generation who rose high and fast into this new discipline, even while academic enthusiasm for public health waned.100 For McKeown and his colleagues, “public health” symbolized an obsolete approach to looking after the nation’s health, a system in which disparate local government departments were charged with various duties aimed at preventing known pathogens from entering the environment.The institutional and administrative character of public health was formed during the difficult Victorian adolescence of public preventive medicine in Britain, when it had had to come to terms with the awkward political constraints of the prevailing ideology of laissez-faire and local autonomy, as discussed above. “Social medicine” provided an altogether grander vision of positive health enhancement for the populace through deployment of the resources and organization of the state, guided by the requirements and recommendations of modern medical science. McKeown’s professional and political battle was primarily directed against those who argued for ever greater diversion of the new National Health Service resources into curative, technical, medicine, invasive surgery and biochemical “treatments” at the expense of preventive, humanist medicine—that is, of efforts to understand and modify the health implications of the environment in its widest sense, including lifestyle, behavior, and diet.101 McKeown’s exploration of the historical record was fantastically effective in these professional, political terms, thoroughly puncturing the inflated claims to importance, on the grounds of a supposed long history of life-saving achievements, of the medical “technocrats.” However, in the course of this most brilliant attack on the historical claims of his main target, “scientific medicine,” McKeown’s detailed historical research work led him to produce an ambitious general interpretation of the causes of mortality decline, which minimalized the role of directed human agency in general, not just that which could be identified as the precursor of modern hospital and clinical practice. Ironically, the innocent passenger-seat victim of McKeown’s reckless driving was itself the historical ancestor of that kind of preventive and humanist medicine, which McKeown was himself advocating from the 1940s onwards. Perhaps because of his lack of a formal background in the public health tradition itself, McKeown seems to have been particularly opaque to the existence and significance of a long historical record of professional and

The Importance of Social Intervention in Britain’s Mortality Decline

133

political struggle to implement a program of health reforms informed by an environmentalist, humanist, and legislative approach to health and medical services similar to his own, albeit constrained by a different political and ideological climate.102 As a result, his account, while motivated by the promotion of the best interests of social and preventive forms of medicine in the present, takes on the historical aspect of a parricide! I have argued here that the historical epidemiological evidence presented by McKeown et al. does not in fact offer the conclusive and exclusive support, which it has long been assumed to do, for the contention that rising living standards and associated nutritional improvements have been the predominant source of mortality decline in Victorian and Edwardian Britain. It has been shown that a completely alternative interpretation of the same evidence is much more plausible, even within the same analytical terms of reference set by McKeown. This revisionist interpretation departs from a significant redefinition of the timing and character of the mortality decline itself to take into account first, our new knowledge, now extended well back into the pre-industrial past, of long-term movements in the average expectation of life and, second, the simple point that urban and rural experiences differed, indeed diverged, during the nineteenth century. The revised account indicates a primary role for those public health measures that combated the early nineteenthcentury upsurge of diseases directly resulting from the defective and insanitary urban and domestic environments created in the course of industrialization. If the broad outlines of this reappraisal of the quantitative epidemiological evidence are accepted, then it directly follows that the true motivating “causes” of the modern mortality decline lie in those agencies that brought about the implementation of these preventive health measures throughout the length and breadth of the country.This recognition, therefore, entails a radically alternative concept of the nature of the causation involved.The “invisible hand” of rising living standards, conceived as an impersonal and ultimately inevitable by-product of general economic growth, no longer takes the leading role as historical guarantor of the nation’s mortality decline. Indeed, economic growth in itself, even with rising real wages, seems just as likely to harm as to benefit the nation’s health, as witness the urban experience of the first two-thirds of the nineteenth century. It seems, then, that it all depended on how the fruits

134

Health and Wealth

of that growth were deployed—which, in turn, depended on the cumulative net outcome of a rich history of political, ideological, scientific, and legal conflicts and battles at both national and local levels throughout the period under review.103 Fallible blundering, but purposive human agency is returned to center stage in this account of the mortality decline. Furthermore, support for such an interpretation does not derive solely from scrutiny of the nationally aggregated epidemiological evidence. There has been a prevalent tendency among the generation of postwar historians who were McKeown’s contemporaries to undervalue the expansion of public health activity at the local level in the latter part of the nineteenth century, giving pride of place in their accounts instead to an earlier “heroic age” in which the intellectual origins of the grand administrative approach to national health could be discerned. In a sense this can be seen as the direct historiographical effect of the rapid postwar decline in academic enthusiasm for “public health” due to the competing attractions of “social medicine.” However, the fourth section of this chapter has shown that once the focus of attention is shifted away from the central government departments and out to the provinces, then there is already considerable evidence, even from the modest amount of research that has so far been completed by a new generation of historians of public health, to demonstrate the importance of increasingly effective public health activity administered through local government. This trend was gathering momentum throughout the last half of Victoria’s reign and on into the new century pari passu with the now-revised chronology of urban-dominated mortality decline. Thus, the proliferating density of local government functions in this period may well have played a much more important and instrumentally effective role in shaping the course of our recent history than has perhaps been previously appreciated, even with respect to such a large-scale phenomenon as the mortality decline. Although national enabling and compulsory legislation occurred at specific points in time, its effective adoption was a locally mediated matter and varied greatly from one local authority to another—some even implemented measures in advance of such parliamentary legislation.104 These complications of local political and administrative history will confound any attempt to test rigorously the interpretation being offered here through analysis of aggregate national- or even county-level statistics, alone. Properly researched local studies are required, where there is the chance of refining

The Importance of Social Intervention in Britain’s Mortality Decline

135

our detailed understanding of the nature of the relationship between the deployment of specific preventive services and facilities and the changing local social and epidemiological patterns.105 However, such studies are still all too rare and are unlikely to be perceived as attractive research projects until there has been a conceptual emancipation from the orthodox assumptions regarding the primacy of a “nutritional determinism.” It has been my principal aim in this chapter to encourage the exploration of such a new approach, which examines agency not process. In order to reopen the question of causation, it has been necessary to expose to the full the limitations and inadequacies of the established orthodoxy. In view of the sustained nature of the attack mounted here on the conventional wisdom, I should emphasize that my argument is not that improving nutrition and living standards were entirely unimportant in accounting for the mortality decline, but that the role of a battling public health ideology, politics, and medicine operating of necessity through local government, is more correctly seen as the principal causal agency involved. It is necessary to rescue those who gave their lives to the struggle for the nation’s health from “the enormous condescension of posterity,” to borrow a famous historiographical clarion call. Finally, a comment on the wider context of the subject-matter. As I mentioned in the introductory section, the McKeown thesis continues to animate debate beyond the bounds of British historiography, among economists, demographers, and policy scientists generally. Britain’s experience of industrialization continues to be a particularly influential model, not just because it was the first industrial nation but because its history in these respects is considered to be established on an unusually firm and extensive empirical basis.The quantitative data available are particularly rich and of high quality, perfectly exemplified in the detailed epidemiological evidence analyzed by McKeown. Much of this was generated by all the government-sponsored surveillance and inquiry undertaken throughout the nineteenth century by a host of departments and agencies,106 which is a nice irony since Britain is supposedly a leading and extreme example of successful economic and demographic growth achieved mainly through the operation of free market forces and with a minimum of effective state intervention.107 Indeed, McKeown’s work on Britain continues to provide the only thoroughly researched empirical support for the extreme laissez-faire

136

Health and Wealth

position that health and welfare gains may be generated most effectively merely as a by-product of economic growth and that government policies should, therefore, simply be directed at maximizing economic growth alone (which for the liberal economic purist means minimizing government in general, and all forms of market intervention). If it should emerge, however, that, to the contrary, even in this historical case, per capita national income growth and associated real wage gains were no guarantee of higher life expectancies and that it was, after all, social and medical intervention, albeit unevenly implemented and only weakly centralized, that was the principal source of the nation’s health improvements before World War I, then clearly the authenticity and “realism” of the case against interventionist social welfare and health policies must suffer some loss of intellectual credibility. If the British historical case has any direct lessons to offer, it would seem to be that a significant life-saving “expansion in the health infrastructure” of a country does not necessarily require advanced “medical technology” nor necessarily require, at least initially, the political act of “creating a universal free health service.”108 Of course, the latter must certainly remain an ultimate and highly desirable goal, at least for any society that actively seeks the positive promotion of its citizens’ health, not normally a politically contentious aim. It may also be crucial for achievement of the quickest route to low mortality. However, there may be other effective, albeit slower, paths available, especially in circumstances where either economics or politics are against the speedier but more expensive and centralized route, as was the case in Victorian Britain. Here, the history of mortality decline shows that committed local government, or its analogous parochial institutions, can have quite considerable potential and scope as an agency to promote health improvements and general social change, if led by appropriately exhortatory but flexible central direction.

Notes 1.This essay is a revised and expanded version of Discussion Paper No. 121, in the series issued by the Centre for Economic Policy Research (CEPR). I am grateful to the editors and the anonymous referees of Social History of Medicine 1, 1 (April 1988) for their helpful suggestions, and also to Sir George Godber for much valuable

The Importance of Social Intervention in Britain’s Mortality Decline

137

comment and stimulation.The terms “Britain” and “British” are frequently employed instead of the tiresome use of “England and Wales,” with apologies to the Scots since most of the evidence discussed relates only to the area south of the Tweed. 2. Registrar-General (R-G) (1905), xii. John Francis Walkingame Tatham (1844–1924), FRCP, a former Medical Officer of Health for Salford (1873–88) and Manchester (1888–93), was William Farr’s second successor, after William Ogle (1827–1912), at the General Register Office (GRO), holding the key post of Superintendent of Statistics 1893–1908. 3. It was somewhat surprising to see repeated in Farrow’s review (Farrow 1987), certain critical assumptions of the “McKeown thesis” that have now been rendered obsolete by the important findings of historical demographic work: Wrigley and Schofield (1981). In particular, the statement early on in the review that “The rise (in population) is generally agreed to have been caused by a fall in mortality rather than an increase in birth rates” is precisely the opposite of our new understanding of these matters since 1981. 4. The major earlier reports of this research were: McKeown and Brown (1955); McKeown and Record (1962); McKeown, Record, and Turner (1975). 5.This previous orthodoxy derived principally from historical documentation in two works, both published in 1926: Griffith (1926); Buer (1926). 6. McKeown and Record (1962), 120. 7. McKeown (1976), chap. 9, “Conclusions.” See McKeown and Record (1962), 118–22 for the original statements. 8. See, in particular, Preston (1975); Preston (1976). Another early report of this comparative work was: Preston and Nelson (1974); Preston and Van de Walle (1978) was also an important pioneering comparative local study illustrating the impact of differing public health measures on mortality rates in three French cities. 9.Woods and Woodward (1984), 32. See also, for instance, the useful introductory essay to the subject by Winter (1982), 101–20.This provides a particularly judicious introduction to the field, observing many flaws in the “McKeown thesis” and yet still coming down firmly in favor of living standards and nutrition as the driving-force behind mortality decline. But note that in Woods’ most recent work there has been a decided shift away from any sympathy with the “McKeown thesis.” See below, note 75, and also Woods and Hinde (1987). 10. Luckin (1986), 2. 11. McKeown (1976) tends to refer rather imprecisely to expansions in the “food supply.” However, it is clearly acknowledged in at least one place in the 1976 text that the essential meaning intended is that of increases in per capita nutritional consumption:“Whether the population was better fed in the eighteenth and nineteenth centuries is . . . central . . . in this context . . . whether nutrition improved during the period.” McKeown (1976), 130 (emphasis added). 12. The work of the ESRC Cambridge Group for the History of Population and Social Structure, systematically exploiting a 4 percent sample of the 10,000 parochial registers of baptisms, burials, and marriages in England and Wales, has

138

Health and Wealth

put our understanding of the changing demography and economy of British society in the period before the first census, 1541–1801, at an entirely new level of sophistication.The major publication to date has been:Wrigley and Schofield (1981). 13. Ibid., chaps. 7 and 10; see also Goldstone (1986) for an important further refinement of this interpretation. 14.Wrigley and Schofield (1981), chaps. 7 and 10. 15. The GRO was established by parliamentary statute in 1836 for the express purpose of administering a nationwide compulsory system of vital registration in England and Wales.Acts for Scotland and for Ireland followed in 1854 and 1863, respectively. For further details on the system’s development, see in particular Glass (1973a). 16. McKeown’s summary analysis commences with the years 1848–54 because of certifying and recording inadequacies in the early years. Of course nosological practices have changed dramatically over the last 150 years. A good example of this is typhus, a disease spread by the body louse, and typhoid fever, which is due to a water-borne microbe. In this case their similar names reflect the fact that they were at one time indistinguishable to medical science; they were not separated in the R.-G.’s reports until 1869: McKeown (1976), 50. 17. To take an important example, Sir Robert Philip concluded that natural immunity to respiratory tuberculosis can be inherited to some extent across generations: Clayson (1957), 1505. See also McKeown (1976), 83–85. However, since we do not know what the prior pattern of incidence was before the mid-nineteenth century, there is no way of assessing the dimensions of this effect on the subsequent patterns: those that we are observing in the R.-G. ’s data series from 1848 to 1854 onwards. 18. McKeown and Record (1962), 119. 19. McKeown (1976), 82–83, 89. 20. Cf. ibid., chap. 9, “Conclusions,” points 4 and 6 on p. 153, with references cited in previous two footnotes. 21. Ibid., 150, referring to McKeown and Brown (1955), 119. It is to be noted that this harsh judgment is not one that has been entirely endorsed by more recent research. See, for instance, Cherry (1980). 22. The overall strategy in the presentation of the argument in McKeown (1976) is not explicitly set out in the manner summarized here. However, it can be discerned by consulting the following pages: 53, 73–74, 91–92, 110–17, 126–27, 128, 152–54, 159. 23. Razzell (1974); Oddy (1970). 24. McKeown and Record (1962), 94; McKeown (1976), 128. 25. See Woods and Woodward (1984), chap. 1, for a helpful graphical illustration of this. 26. Caldwell (1986), 205. 27. McKeown (1976), 68. 28. Ibid., 61; Luckin (1986), 103.

The Importance of Social Intervention in Britain’s Mortality Decline

139

29. Razzell (1965); (1977). See also Hardy (1983). Hardy emphasizes the continuing importance throughout the nineteenth century of public health officials’ vigilance in finally eradicating the disease in the face of relative public apathy. 30. McKeown (1976), 82–83.There was a probable shift in the immunological complexion of the population which did not suit the streptococcal bacteria involved (Strep. pygenes). 31. See, for example, Rich (1951). A new general historical study by Bryder of TB in Britain in the twentieth century is to appear shortly: Bryder (1988). 32. Chalke (1959), 93. 33. Cronjé (1984), 93–94 and 99–100. 34. Indeed, the available evidence suggests that working-class wives tended to sacrifice their own dietary requirements to maintain their husbands’ health and morale, as the family’s main breadwinner. See, for example, Oddy (1970), 320–21; Burnett (1983), 161, 185; Pember Reeves (1913), chap. 10. 35. Of course, this should not be taken to mean that repeated childbearing alone can cause greater susceptibility to TB. However, in combination with the generally unsatisfactory environment in which the majority of the laboring population continued to live, it may well have been a significant factor. 36. McKeown (1976), 68.There is a similar assertion on p. 56. 37. McKeown and Record (1962), 113. 38. As late as 1860 possibly as many as 20 percent of all deaths were still being registered without any certificate from a medical practitioner.This situation was formally remedied by the 1874 Registration Act. See Eyler (1979), 62; Glass (1973a), 188. 39. McKeown and Record (1962), 113. 40. Ibid., 112. 41. Ibid., 108, fig. 9. Great care should be taken when inspecting this graph, as the authors have included a suppositional pecked line for the period 1838–47, despite their own warnings against placing any reliance on that information. It is this invalid pecked line that gives the visual impression of an apparently obvious fall in train before 1866–67. 42. Razzel (1977). 43. Such an interpretation would also satisfy an independent reason for treating the two diseases together, supplied by informed contemporary medical opinion: Dr John Hogg specifically pointed out, in his work of 1860, that whilst bronchitis was often recorded as the actual cause of death, in many cases active tuberculosis was the crucial predisposing factor. Hogg (1860), 41. 44. See discussion in text, above, at note 28. 45. I am grateful to Sir George Godber for pointing out to me that this would be in accord with clinical experience of the nature of respiratory TB gained in the course of the twentieth century. For instance, a London survey of 1930 cited by Cronjé (1984), p. 81, found TB still present in 82 percent of 14- to 15-year-olds. This suggests that most urban adolescents and adults in the nineteenth century

140

Health and Wealth

would have already suffered and survived a primary infection in early childhood. Actual death from TB, which was especially high in the age groups 15 to 35 in the nineteenth century, would usually, therefore, have been the result of subsequent breakdown disease, rather than a first contact, and would be triggered by a weakening in the body’s normal equilibrium as a result of the strains imposed by other nonlethal disease episodes. It is certainly interesting to note that the two recorded phthisis peaks of 1853–55 and 1866 both coincided with cholera epidemics, although this was apparently not true of the largest cholera crisis of all, that of 1848–49. 46. 1st ARRG, 108–18; 5th ARRG, 408. (ARRG: Annual Report of the Registrar-General of England and Wales). 47. 1st ARRG, 110. 48. Ibid. See especially tables C and D, 148–51; 5th ARRG, 403–5. 49. 1st ARRG, 111. 50. Even as late as 1851, Birmingham (population 233,000) still had only eight miles of main sewers. By comparison, the square mile of the City of London, with only about half the population, had already constructed about forty-five miles of sewers by this time. Lambert (1963), 81–82. 51. McKeown (1976), 68–69. 52.Wrigley and Schofield (1981), chap. 7.The protracted nineteenth-century discontinuity was not known to McKeown in 1976, who assumed that there was a linear trend of continuous fall in mortality down to the present day beginning at some point in the mid-eighteenth century. For twentieth-century figures, see table 1 of Winter (1982). 53. Real wage trends form the best available single index for historical changes in “the standard of living” in McKeown’s sense, since they aim to measure changes in average money wage-rates deflated by a cost-of-living factor, in which subsistence food prices play a predominant role (especially the price of wheat, as bread was the main staple at this time). Flinn (1974) first identified the second decade of the nineteenth century as a turning point, due primarily to falls in food prices. Recent econometric work has substantially confirmed this chronology: Lindert and Williamson (1983); Flinn (1984), 88–92. Of course, regional variations are also very important: see, for example, Hunt and Botham (1987). 54. See McKeown (1976), 64–65 for his own conjectures on the subject. 55. Note that this point stands regardless of whether or not there was an absolute deterioration in urban conditions during this period, which is a matter of dispute. It is perfectly possible arithmetically to show that although the national average figure for life expectancy ceased to rise across these decades, nevertheless, each registration district around the country could have recorded continual improvement throughout.This simple paradox can occur if the different districts all start with somewhat varying figures and it happens to be the case that those with the lowest life-expectancy figures experience disproportionate growth in their population sizes over time, while those with higher figures correspondingly shrink

The Importance of Social Intervention in Britain’s Mortality Decline

141

(at least relatively) in population size.This is broadly what happened at this time as a result of migration from the countryside to the towns.The figure for the overall national average expectation of life is weighted by the relative population sizes of each district and is, therefore, strongly influenced by such an underlying shift in overall population composition towards residence in relatively high mortality districts.Woods has produced some estimates, which illustrate precisely this possibility during the period 1801–61: see table 3 of Woods (1985). However, it must be stressed that Woods’ table offers only hypothetical estimates of possibilities for this earlier period, since unfortunately the censuses before 1851 are not reliable sources for detailed trends in individual districts. Furthermore, and against the implications of Woods’ exercise, must be set the evidence of probably the only town for which adequate data is agreed to be available (as a result of the private initiative of the local physician, John Heysham). This in fact shows a significant increase in mortality across the period: Armstrong (1981). 56. 5th ARRG, 33–37. 57.Wood (1982), 19. 58. Smith (1979), 227. 59. See Eyler (1979), 118–19. Luckin (1986), 88–95, has provided the most detailed recent account of this incident and the water company’s successful subsequent evasion of legal retribution. 60. Sir John Simon was London’s first Medical Officer of Health (1848–58) and then Chief Medical Officer to the Privy Council (1858–71) and finally, the first Chief Medical Officer to the Local Government Board from its statutory inception in 1871. The superb, if somewhat partisan, biography by Royston Lambert is the standard work: Lambert (1963). 61. Lambert (1962–63). 62. Macleod designated 1860–75 as encompassing “the heroic age” of State Medicine: Macleod (1968b), 226–27. 63.This view was first put forward by Simon himself, in his influential publication: Simon (1890). Until very recently, there has continued to be a broad consensus of agreement on this, founded on such major studies as Finer (1952); Lambert (1963); Macleod (1968a); also Macleod (1967). 64. From the mid-1850s on, the GRO produced a list of quarterly returns of the general mortality rates for all the large cities, which was published and discussed in the press: Eyler (1976), 342. More generally, on the important role of the GRO in the public health movement, see chap. 8, this volume, and Szreter (1991b), based on papers presented to a symposium held at the Wellcome Institute for the History of Medicine on 27 November 1987. 65. Hennock (1973). 66. Jenkins (1969), 93. 67. Rumsey (1856). 68.Wohl (1983), 111; Report on Public Health and Social Conditions, PP (1909), 81. 69. Smith (1979), 203–15. Burnett (1983), 99–120.

142

Health and Wealth

70. Some idea of the kinds of problems faced, and often eventually surmounted, by MOHs, assisted by the LGB and by other local proponents of public health, can be gained from Young (1964). Unfortunately, this is not included in the otherwise very helpful list of relevant theses, in the bibliography of Wohl (1983). Two other highly informative unpublished D. Phil. and Ph.D. theses, too recent for inclusion by Wohl are: Wilkinson (now known as Hardy) (1980); Watkins (now known as Porter) (1984).Two other useful unpublished archive surveys are Cooper (1981); Bellamy (1982). 71.Wohl (1983), 112. 72. Ibid., 113 and 162–63. 73. Feinstein (1972, 1976), table 39. 74.Waller (1983), 264.Throughout the period 1879–1914 it was always the cost of works for water supply, drainage, and purification which constituted between half and two-thirds of the aggregate capital indebtedness on utilities of all municipalities, despite the not inconsiderable capital costs associated with gas, transport, and electricity utilities, especially in the Edwardian period. See the table in ibid., 307, which shows water accounting for 19 out of 28.5 millions of such indebtedness in 1879–80 rising to 132 out of 224 millions by 1914–15. 75. The illustrative estimates recently prepared by Woods (see above, note 55) are founded on a much firmer empirical basis for 1861 and for 1911 than for the earlier period.These clearly show that it was the big cities that experienced the greatest falls in mortality across this later period. Woods has therefore concluded that “The importance of that set of administrative advances usually labelled the ‘Sanitary Revolution’ appears to be re-emphasized by these estimates of rural and urban life expectations.”Woods (1985), 651. 76. Smith (1979), 233. 77. Hardy (1983), 131–38. 78. Wohl (1983), 213. For comparison: the final cholera epidemic of 1866 had accounted for 15,000 deaths spread over the whole country. Only the worst cholera outbreak of 1848–49 had accounted for more than 11,000 deaths in the capital (when a total of 62,000 had perished throughout the country as a whole). See Smith (1979), 230–31. The last killer fog in London before effective controls were finally introduced was as recently as 1952, when, yet again, over 10,000 perished. 79. R-G (1897), table on xcvi. 80. On the nation’s health during World War I, see Winter (1985); Dwork (1986). 81. McKeown (1976), 61. 82. An average of about 130,000 houses per year were built across these years, as against only about 80,000 per annum over the previous seventeen years. Mitchell and Deane (1962), 239. 83.Wilkinson (1980), 270–71. 84. Hardy (1984), 274.

The Importance of Social Intervention in Britain’s Mortality Decline

143

85. The 1875 Artizans’ and Labourers’ Dwellings Improvement Act (Cross Act) had similarly stimulated the earlier “five percent” philanthropic dwelling companies and had also been followed by a short house-building boom, with about 120,000 built per annum 1875–78.Wohl (1983), 320. Mitchell and Deane (1962), 239.Tarn (1973);White (1980). 86. Report on Public Health and Social Conditions, PP (1909), table on 22. 87. However, it must be acknowledged that a contraction in the lowest-rent housing stock through slum demolition may not necessarily have had a net beneficial effect in the short term on the welfare of lowest-income sections of the population, given the higher rents that may have been demanded for better-quality housing. State-enforced rent control of some sort might well be a necessary adjunct. This is what subsequently happened during World War I. For similar reasons, the growing practice of family limitation among various groups of the working population may not necessarily have helped alleviate overcrowding since there is no reason why smaller families might not simply be pushed into smaller, perhaps subdivided, tenements if left to market forces in the context of a relatively fixed housing stock. See Englander (1983). Also, more generally, Daunton (1983);Wohl (1977). 88.Waller (1983), 303. 89. Buchanan (1983), 278–84. 90. Missionary Biblewomen were in effect the first paid social workers acting as “Sanitary Missionaries” under the aegis of the Ladies Sanitary Association, founded with Royal patronage in 1857 for “the diffusion of sanitary knowledge and the promotion of physical education.” Dowling (1963), 82. 91. Buchanan (1983), 278. 92. Dwork (1986), 117, cites a rare study, made by the Salford Health Committee in 1905, where only 9.8 percent of 1,595 infants were found to be bottle-fed. If this low rate was general, then it seems quite plausible to suggest that contemporary middle-class animation over this issue derived primarily from the symbolic importance of breast-feeding at a time when the rigid sex-roles established by Victorian bourgeois culture were under cultural and political threat. However, I do not believe that gender conflicts in the middle classes can supply a satisfactory general interpretation of the history of the infant and maternal health movement at this time. For a balanced and stimulating general study of developments in infant and maternal health services, see Dwork (1986), which offers a somewhat different overall interpretation to that of three other well-known recent studies: Lewis (1980); Davin (1978); Dyhouse (1978). 93. Dwork (1987). 94. McKeown (1976), 122. 95. Parton (1983). 96. Ibid., 70–73. 97. All post-1900 IMRs cited here for towns derived from: Winter (1979), table 4. 98. Nolan (1982).

144

Health and Wealth

99. See Smith (1979), 229 for fragmentary evidence on this. For workingclass attitudes to education, see Hurt (1979); there are also some stimulating general insights of relevance in Stedman Jones (1983), 179–238. 100.Webster (1986). 101. The most complete statement of this position is McKeown (1979). Probably the most important political document endorsing this approach has been by Lalonde (1974), in his capacity as Minister of National Health and Welfare in the Canadian government. 102.Thomas McKeown was born in 1912 and came to England from Canada as a postgraduate on a Rhodes Scholarship, completing an Oxford D. Phil. in the Department of Human Anatomy in 1939. He then underwent formal medical training, acquiring an MB in the University of London in 1942. Apparently, he was offered the Chair in the new discipline of Social Medicine at Birmingham in 1944 because he had so impressed the interviewing panel when he unsuccessfully applied for the Chair of Anatomy the previous year (which went to Solly Zuckerman). Hence his academic and medical background was somewhat independent of the British public health tradition, where most of those involved had had extensive practical experience as Medical Officers of Health. I am indebted to Sir George Godber for his recollections of conversations in 1943 with Sir Leonard Parsons, then Dean of the Birmingham Medical Schoo1 (pers. comm., 23 July 1987). 103. One extremely rich vein of recent work and debate concerns issues in the complex history of biomedical science and its changing theory across this period. The seminal English-language contribution here was Ackernecht’s (1948) Garrison Lecture; and a major revisionist contribution was Pelling (1978). Luckin (1986) provides the most recent extended discussion of various relevant aspects of this historiography.The issues involved are too important and complex for a merely superficial treatment, which is all that space would allow here, and so I hope at some point to be able to offer a separate treatment of the significance of these matters with respect to the expansion of public and preventive health measures. 104. Another example of this, apart from the Huddersfield scheme mentioned in the text above, would be the famous “Leicester System” of notification and isolation of infectious diseases pioneered in the mid-nineteenth century by Sir James Simpson. See Hardy (1983), 122–23. More generally on the varied histories of local governments’ politics and administrations in the nineteenth century, see, for example, Hennock (1973), Fraser (1976), and Offer (1981). 105.The Ph.D. thesis by Buchanan (see above note 89) is an exemplary study of this sort, which any prospective research student would benefit from reading. This involved a comparison of eight communities, including two from Scotland. An important novel finding, which could only emerge as a result of the local perspective adopted there, was that at least until 1911–12 the relative incidence of infantile diarrhea seems to have been strongly influenced not simply by general “urban insanitation,” but more specifically by the relative prevalence and behavior of house-flies, as a disease vector, and that this, in turn, was determined by the local

The Importance of Social Intervention in Britain’s Mortality Decline

145

authority’s attitude and policy with respect to the proximity of rubbish tips to residential housing. 106. Such as the vast web of over two thousand paid district registrars who, from July 1837 onwards, relayed quarterly the detailed mortality information collected from their locality to the central office of the Registrar-General, forming the database discussed in this article. 107. A recent example, from two relatively well-informed authors: “Thus, McKeown may be correct in arguing that national public health measures were not very important in the reduction of mortality in England and Wales during the nineteenth century”: Johansson and Mosk (1987), 218. 108. Caldwell (1986), 205; and see fuller quotation cited above, at note 26.

5 MORTALITY IN ENGLAND IN THE EIGHTEENTH AND THE NINETEENTH CENTURIES*

In 1988 I argued that a careful reappraisal of the nineteenth-century historical epidemiological evidence, which Professor Thomas McKeown derived from the Registrar-General’s decennial supplements, showed that it did not, after all, support the view that he had championed.1 I demonstrated that for the purposes of the argument McKeown was making, it was invalid to combine together all the airborne infectious diseases as a single category as evidence in favor of the principal conclusion that McKeown drew, that rising living standards and per capita nutritional intake was the single most important source of falling * This chapter is slightly revised from its original publication in Social History of Medicine 7, 2 (1994). Numbers in brackets in the text refers to pages of Guha (1994).

146

Mortality in England in the Eighteenth and the Nineteenth Centuries

147

mortality in nineteenth-century Britain. I then argued for an alternative thesis, which emphasized the importance of social intervention, mainly in the form of a steadily increasing momentum, from the late 1860s onwards, in the range and penetration of public health and preventive measures, including (but not synonymous with) municipal sanitation. Although the exact timing and character of these increasing interventions were influenced by much local government mediation and negotiation, by the Edwardian period even the inhabitants of the working-class home itself, and not merely the streets outside, were subject to public health efforts and were fast becoming aware of a new appreciation of the health implications of different forms of behavior. The plausibility of this reinterpretation depended critically on placing McKeown’s epidemiological evidence for the Victorian period, valuable as it is, within the context of the most important other relevant historical information available, regarding Britain’s demographic, economic, social, and political history. Given the nature of McKeown’s thesis, this included, first, two long-standing bodies of evidence that he had peculiarly ignored: the knowledge we have of trends in average real wages; and the fundamental social development of this period, whereby a relatively healthy rural majority in the populace of the 1800s was rapidly replaced over the next half century by a new and remarkably unhealthy urban majority. In 1988 it also seemed to me that the most important and rigorously constructed new evidence of primary relevance to our understanding of changing mortality in nineteenth-century Britain was, first, what we now know, thanks to Wrigley and Schofield, of England’s population history over the preceding centuries and, second, the findings of Floud,Wachter, and Gregory regarding changing trends in heights during the period 1750–1914.2 The field of reliable historical evidence of relevance to our understanding of mortality patterns in modern and early modern Britain is, of course, a changing one. As important new information and insights become available, so the alternative thesis that I offered in 1988 may be modified, supplemented, refuted, or superseded. Some examples of such work are referred to in the endnotes for this chapter. However, I do not believe that the 1994 article by Sumit Guha can be characterized as a positive contribution of this sort. It would be tedious in the extreme to refute paragraph by paragraph most of Guha’s article. This could be done and my silence on various

148

Health and Wealth

details should not be taken to signify assent. To avoid monotony, I have selected only the four most important elements: those where Guha’s critique of the credibility of Szreter (1988) may seem most damaging to readers and those which most crucially underpin the alternative, revived McKeownite interpretation that Guha offers. First, in sections II and III, Guha (1994) attempts to discredit in general terms in his readers’ minds the thesis I presented in 1988.This thesis argued that social intervention was the most important source of the improvements in national mortality levels that occurred in Britain in the later nineteenth century. However, Guha does not initially discuss this specific thesis. Instead he attributes to me quite another thesis of his own choosing, which he then proceeds to discredit: this is the untenable general proposition that urban mortality in any time or place can only improve through “medical or sanitary interventions” (Guha 1994, 95). Second, in sections III and IV Guha attempts to promote and to defend the McKeownite interpretation that the main source of improving mortality in eighteenth- and nineteenth-century Britain has been a rising standard of living and associated increased nutrition. In support of this, Guha argues that the most likely cause of London’s eighteenth- and early nineteenth-century health improvements was a McKeownite rise in living standards. Guha also takes issue with some of the specific criticisms of McKeown I raised regarding the epidemiological record of respiratory tuberculosis in the nineteenth century. Third, in section V Guha reasserts the validity and utility for historical research of the McKeownite analytical apparatus, which offers a distinction between the extent to which a population is exposed to a disease, the extent to which its members succumb and manifest symptoms of the disease and, finally, the extent to which those manifesting symptoms actually die from the disease. Although noting the difficulties that the use of this analytical system poses for historical research, Guha is nevertheless encouraged to believe that the historical investigations of J. C. Riley have successfully established the course of morbidity patterns in Britain in the nineteenth century. He claims that the results of this work therefore enable the analytical scheme to be tested and that they support a McKeownite interpretation of the mortality decline. Fourth, having to his own satisfaction demonstrated the continuing validity of the McKeown thesis and approach, in section VI Guha argues

Mortality in England in the Eighteenth and the Nineteenth Centuries

149

that the specific alternative interpretation of mortality decline in the late nineteenth century that I offered in 1988 is disproved by its supposed failure to account for the historical course taken by infantile diarrhea mortality. According to Guha, because this was a classic sanitation disease, its failure to fall before the end of the nineteenth century shows that, pace Szreter (1988), public health measures and social intervention did not achieve any general reduction in exposure to infectious disease during the late nineteenth century. I will address each of these four elements in the above order. First, there could be no question that my emphasis on the primary importance of public health measures in the later nineteenth and early twentieth centuries was period-specific, as proclaimed by the title of the article and as Guha concedes right at the start, when setting up his own straw man (91). It was central to the argument I presented in 1988 that an eighteenthcentury, prior national trend of improving mortality was curtailed by the new health dangers arising from an unprecedented rapidity of provincial urban growth in centers of industry, even resulting in the appearance of new kinds of disease, such as typhoid and cholera (and, I would argue, the exacerbation of others such as respiratory tuberculosis or typhus). For this reason alone it is logical to look to those measures that dealt directly with these new urban health problems as the primary cause of their subsequent removal and the eventual reduction in these new sources of enhanced mortality. Furthermore, it could not be a more obvious entailment of this argument that the disease ecology of urban England was quite different in the nineteenth century from what it had been in the eighteenth century. It is Guha and not Szreter who believes that the two periods are epidemiologically comparable and this is a fundamental weakness that vitiates the interpretation he offers. It leads, for instance, to the meaningless statement in his conclusion that “Large cities in the early nineteenth century were substantially healthier than in the early eighteenth” (113). There was only one comparable large city in England in the earlier period. Is Guha seriously suggesting that there is any comparability between Bristol and Norwich in the 1720s and the likes of Liverpool, Manchester, and Birmingham in the 1820s? Or does he mean that the latter are comparable with London in the 1720s? The point, of course, is that the industrial cities of the nineteenth century were absolutely novel in their scale and speed of growth and so were their health problems.

150

Health and Wealth

The population of London at the earlier date was also at a uniquely unhealthy point in its modern epidemiological history, intimately related to its position at that time within the developing national and international trading systems that sustained its singular growth. London’s subsequent health improvement is most likely to have been caused by adaptive changes in immunity in the national population. However, Guha seeks to account for London’s falling mortality during the second half of the eighteenth century primarily in terms of rising living standards (95). Here we pass to the second of the four elements for consideration. Guha’s McKeownite explanation is quite invalid, simply because it flies in the face of the most important relevant evidence: he makes no reference to Leonard Schwarz’s research on London during this period, which shows no net rise in real wages in the capital throughout the period from the 1740s to the 1840s.3 Guha dismisses to his own satisfaction the case for regarding changes in the population’s immune status during the seventeenth and eighteenth centuries as the main reason for London’s mortality patterns (93–94). But he is only able to do so because he is apparently as unaware as McKeown (more justifiably) was in 1976 that Wrigley and Schofield have shown that England in the second half of the seventeenth and early eighteenth centuries was characterized by a positive rise in overall mortality and that this was due to a rising frequency and multiplicity of localized epidemics throughout the country (rather than an increase in national-scale epidemics).4 This fulfills exactly the condition Guha sets (which he answers in the negative) on page 94: “If, therefore, urban death-rates were falling because immigrants were immune then rural death rates would have risen as the new diseases established themselves.” It has been convincingly argued that the latter seventeenth and early eighteenth centuries was a period in which a range of infectious diseases, formerly only endemic to the large population in the capital, became endemic throughout the entire extent of the country because of the increased level of contact associated with the rising volume of trade and communication due to economic growth.5 As John Landers has argued, from an immunological point of view the communities of England were coalescing into a single population.6 Once the process of “endemicization” had occurred—by the middle of the eighteenth century—mortality attenuated in this generally adapted population, as infectious diseases

Mortality in England in the Eighteenth and the Nineteenth Centuries

151

became less virulent within the general population and so became primarily child-killers. London’s mortality fell and so did the rest of the country’s. Guha does not find plausible the immunological explanation for falling mortality in the eighteenth century but, according to the reasons he gives, this is largely because, as noted above, he apparently does not know of the earlier rise in (rural and urban) mortality shown by Wrigley and Schofield. He also argues that “It does not seem likely the settlement structure of the rural populations from which London immigrants were drawn changed sufficiently in the later eighteenth century for such “endemicisation” to become really possible” (94). The latter argument fails to comprehend the essential point that it is not settlement size or structure but volume and frequency of contact and communication between physically distinct communities, which is the crucial variable determining whether or not a population is unified or divided in immunological terms. Here Guha fails to cite the important research work published directly on this subject by John Landers and by Mary Dobson.7 In his conclusion (113) Guha argues that his McKeownite explanation, that mortality improves mainly because of improvements in the population’s capacity to resist infection (consequent on rising living standards and enhanced nutritional status), “has the advantage of being able to account for the eighteenth- as well as the nineteenth-century improvement in mortality.”This links back to his assertion at the outset in section II (91) that “the disease ecology of urban England under George III should vary in the same ways as under Victoria.” Yet the work of the authors cited above shows that, according to the most rigorous historical research currently available, the only plausible and rational assumption is precisely the opposite of this: that the disease ecology of the British population in the eighteenth century was fundamentally distinct from that of the nineteenth century. The other aspect of Guha’s defense of the McKeown thesis was in his consideration of the epidemiological record for respiratory tuberculosis. However, Guha’s analysis here, in fact, carries the opposite interpretative significance to that which he claims for it.This is because he has failed to consider much the most important aspect of this part of the critique of the McKeown thesis in Szreter (1988), which related

152

Health and Wealth

to the airborne category of diseases as a whole and in particular to the very substantial absolute rise in fatal incidence of the bronchitis/pneumonia/’flu group of airborne diseases. The latter constituted a major problem for the credibility of the entire McKeownite case because the evidential basis of McKeown’s claim for the primary importance of rising nutrition and living standards rested on the argument that the incidence of airborne diseases could be reduced only by the nutritionally enhanced resistance of victims rather than by any effective environmental interventions to diminish levels of exposure to infection (the public health strategy of prevention). According to McKeown the epidemiological evidence showed that a fall in airborne diseases was the most significant feature of the nineteenth-century historical record and therefore he was able to argue, apparently convincingly, that improving nutrition through rising living standards was the most important cause of falling mortality, rather than public health interventions. The fact that bronchitis/pneumonia/’flu—the second most quantitatively important cause of death in the 1850s (accounting for 10 percent of fatalities)—had increased in absolute incidence by over 20 percent by 1901, so becoming the nation’s principal killer (taking 16 percent of all deaths) was, to say the least, an embarrassment for McKeown’s case and one that he himself largely ignored. Furthermore there are specific reasons (acknowledged by McKeown, en passant,but never incorporated into his summary statements) that account for the fall in each and all of the other diseases within his airborne category without invoking the argument about enhanced resistance through improved nutrition and living standards. The positive evidential basis of McKeown’s thesis in fact collapses to the single case of falling respiratory tuberculosis, against which is to be balanced the counter-evidence of rising bronchitis/pneumonia/’flu. Even if McKeown had been correct (which he was not) that respiratory tuberculosis and bronchitis/pneumonia/’flu could only have decreased in their incidence in the nineteenth century as a result of the population’s enhanced nutritional status, the fact that they move in opposite directions destroys the empirical basis for any belief in rising real wages and per capita food intake as the primary source of health improvements in the latter nineteenth century. In 1988 I suggested that it might be possible for McKeownites to seek some alleviation of this problem by arguing that the rise in bronchitis/pneumonia/’flu was primarily

Mortality in England in the Eighteenth and the Nineteenth Centuries

153

a statistical artefact of changing diagnostic and classificatory practices. However, as I pointed out, this would inevitably diminish the quantitative importance of the fall in respiratory tuberculosis, since it was the principal candidate to receive the misclassified deaths. Guha has now produced some calculations of the differential age-incidence of the two causes of death, which indicate that such misclassification was unlikely to have been extensive. While Guha’s work therefore shows that the recorded fall in respiratory tuberculosis was probably genuine, it also confirms the full extent of the contradictory rise in bronchitis/pneumonia/’flu. Because he did not place his arguments within the proper interpretative context, Guha is able to present his results as if they were a vindication for the McKeownite interpretation.Whereas, if anything, they constitute more of a problem for the plausibility of the McKeownite case than if he had found the opposite (i.e., that misclassification was likely and that no rise in bronchitis/pneumonia/’flu had occurred). I also pointed out in 1988 that McKeown gave a misleading gloss on the trends visible from the civil registration data, regarding the exact chronology of decline in respiratory tuberculosis.8 Whereas it suited McKeown’s case to argue that a decline in respiratory tuberculosis had set in substantially before any other important infectious disease (though this was never very convincing in view of the well-documented earlier reduction in smallpox),9 the epidemiological evidence collected by the Registrar-General and analyzed by McKeown did not in fact show a definite downturn in the national incidence of respiratory tuberculosis until after 1867. MeKeown instead had given the impression that the data showed a continuous decline from its beginning, in the years 1848–54, and that therefore it was not unreasonable to assume an even greater decline from a higher level of incidence, having its origins earlier in the nineteenth century or even somewhere in the eighteenth century.While not disputing the validity of these cautions on McKeown’s use of the Registrar-General’s data, Guha has attempted in section IV to resurrect the impression of greater and earlier decline in respiratory tuberculosis by instead directing readers to certain other, technically inferior sources of evidence. For example, in his Table 3 Guha ill-advisedly cites Dorothy George’s summary (from the 1920s) of the London Bills of Mortality, with Mary Matossian’s approval for their validity. The Matossian article

154

Health and Wealth

from which Guha draws his approving quotation has been quite correctly described as “an excellent example of the misuse of eighteenth- and nineteenth-century statistics” in a careful review by Anne Hardy of the pitfalls of all such statistics.10 Hardy further warns of the particular problems involved with all “phthisis” statistics during the early and mid-nineteenth century, including the other contemporary source Guha cites (Guha’s Table 4). Hardy’s article was published in 1988 in the same journal as Matossian’s piece. Finally, also on the issue of respiratory tuberculosis Guha (102–3) makes a mountain out of a molehill on the question of sex-differential rates of incidence as between town and countryside in the late nineteenth century.As if it were a vital part of the case against the McKeown thesis, Guha has seized on a paragraph in which I was discussing the multiple causal factors, which medical authorities today believe to be involved in the aetiology of respiratory tuberculosis.11 In this paragraph I speculated upon the possible evidence for this in the nineteenth-century record. However, the issues addressed in this paragraph were not in any way an essential part either of the case against McKeown’s interpretation or of the case for the interventionist interpretation, as can be readily appreciated by the simple test that if the entire paragraph was removed it would not affect at all the essential content or the strength of the argument presented in Szreter (1988). It is important for Guha to make as much as possible of the supposed weakness in this more speculative paragraph because he wishes to establish in the reader’s mind the impression that Szreter (1988) may not be a reliable guide to the secondary literature and the evidence. Guha claims that because I was “extremely anxious to minimize the importance of nutrition” I “quietly suppress[ed]” those of Gillian Cronjé’s observations that would have supported such a view.What I left out was: first, Cronjé’s opinion that dietary standards improved in the second half of the nineteenth century, especially after 1870; and, second, her reference to a report of the Registrar-General’s, which argued that excess tuberculosis mortality among young adult rural females might be due to migrant female domestic servants in the big cities disproportionately (relative to male migrants) returning home to die once afflicted. On the first issue: Cronjé is not, of course, an authority on diets in the nineteenth century and she was merely offering her own gloss on the work of others, which I would argue is an unhelpful gloss.What I did do,

Mortality in England in the Eighteenth and the Nineteenth Centuries

155

instead, at precisely this point in the text (which Guha doesn’t mention), was to cite the views and evidence of three such authorities (Derek Oddy and John Burnett, along with the contemporary document authored by Maud Pember Reeves).12 They have all pointed out that urban workingclass women continually sacrificed their own and their children’s dietary requirements throughout the period before the Great War, principally to keep the adult male breadwinner in work. As Oddy has recently concluded, the most compelling evidence for this is in the high prevalence of rickets and poor physical stature still prevalent among children of the poor even as late as 1916, when conscripts were physically assessed.13 Despite these nutritional sex-differentials, urban adult males suffered much worse mortality from tuberculosis than their wives, who continued to experience a differentially decreased vulnerability to tuberculosis throughout the period.This seemed to me to be important evidence that showed, as I concluded, that “It would certainly seem presumptuous, therefore, to attribute a long-term reduction in tuberculosis mortality to one single factor, such as improving nutritional standards.”14 Guha thinks I should have cited Cronjé’s gloss but I think Guha should have cited Oddy’s own summary of the available evidence, presented on the same page (101) from which Guha has drawn other information from Oddy.15 Oddy’s considered opinion is that such general improvements in diet as had occurred by the Edwardian period were insignificant, as regards health status and resistance to most forms of infection. On the second issue: I did not report Cronjé’s summary of the Registrar-General’s conjecture and instead referred only to Cronjé’s opinion that higher tuberculosis mortality for rural females might have been caused by the more stressful lives that they lived, as a result of their more extreme poverty and, on average, higher rates of childbearing that they continued to experience. My reasons for this were that while the latter are both indisputable facts about which all social historians would agree, the former was only a putative inference on the part of John Tatham at the Registrar-General’s Office. On consulting Cronjé’s reference, I found no empirical evidence offered by Tatham for his view, which was purely a supposition. Guha rushes to the conclusion that on the basis of these official conjectures (he includes one further passage from another report by Tatham repeating the same inference) “Return migration is thus a sufficient explanation of the phenomenon observed by Cronjé” (103). In

156

Health and Wealth

my opinion it was not a convincing supposition because it would have to have been occurring on a quite extraordinary and systematic scale all over the country, such as should have left some record and to the best of my knowledge there is no positive historical record of this happening with any frequency. Indeed, Ann Hardy has recently cited two contemporary studies by medical professionals from the 1890s, each of which empirically investigated precisely this hypothesis of return migration among tuberculosis victims inflating tuberculosis mortality in rural parts of the country, and found no statistical evidence to support the hypothesis.16 It has since come to my attention that there may well be a satisfactory explanation for this sex-differential and rural-urban differential incidence of respiratory tuberculosis, as observed in the civil registration data. Apparently a female excess in tuberculosis mortality among young adults (aged 15–25 or 15–35) has been found to be a relatively common feature in developing agrarian and industrializing societies: for instance the U.S. in the decades around the turn of the century, Ireland in the interwar period or, more recently, South India in the postwar era.17 As the excess is only at these ages, the phenomenon has been attributed to the culturally and ideologically created underprivileging or neglect (even self-neglect) of this section of the population (in A. K. Sen’s sense of lack of entitlements) and also possibly to the strains of childbearing under such adverse conditions.18 Rural England during the last third of the nineteenth century therefore fits this typical pattern. According to this perspective, the high female rural TB rates do not require a special explanation, in the sense in which Tatham was searching for one (he, of course, could not have been aware at the time that the pattern he was observing was not atypical). In fact it is, rather, the unusually high death rates among young adult urban males in England at this time that require special explanation. As Cronjé envisaged and as F. B. Smith has more recently proposed, this may be due to the urban male workers’ greater exposure to the crowded and dusty conditions in factories and workshops. Hence, urban female phthisis rates were, unusually, as high as the (very high) male rates only in communities such as the Lancashire textile towns and in Dundee (the home of the jute industry) where women worked in the dusty factories to the same extent as men.19 Third, Guha advocates that research into the historical epidemiology of infectious disease should continue to approach the subject through the

Mortality in England in the Eighteenth and the Nineteenth Centuries

157

McKeownite analytical framework.This is premised on what appears to be a perfectly logical distinction among, first, those factors related to initial exposure to the micro-organisms responsible for diseases, second, those related to an individual’s contraction of disease symptoms, and third, those related to a fatal outcome. There is, however, one completely debilitating problem with this approach.Although these can be formulated in language as three separable logical gates, it is not legitimate to assume that their empirical outcomes are causally independent of each other. For instance, to give a highly relevant and important example for the nineteenth century, the conditions of chronic and unventilated overcrowding in the home or at work, which determined whether or not individuals were exposed to relatively large and frequent doses of a range of droplet-transmitted airborne infectious diseases, simultaneously strongly determined both the individuals’ initial exposure to the disease, their chances of resisting infection (related to dose size and frequency) and their likelihood of a fatal outcome (again related to dose size and frequency). Guha encourages us to believe not only that the analytical model can be used for historical research but that it already has been for Britain in the nineteenth century and that the results of such research are supportive of a McKeownite interpretation. Here Guha (105–6) entirely relies on J. C. Riley’s work on samples of the sickness records of the Odd Fellows Friendly Society.20 Riley has found that by the 1890s members of the Odd Fellows had developed an increased propensity to claim sickness benefit relative to the pattern of claims throughout the period from the 1840s to the 1860s. Primarily this was because the average period of each sickness claim was longer at the end of the century (while the frequency of claims remained stable). Guha notes (105) that Riley found an increased propensity to claim sickness at all ages in the 1890s but that this was especially pronounced among the young adults who were members of the Society. Guha follows Riley in offering a simplistic interpretation of this evidence; he treats it as an unproblematic testimony to changes in the objective states of relative health and morbidity prevailing among the members of this friendly society (and also indicative of such changes in British society more generally).This will not do at all. It is methodologically inadequate to treat historical changes in the extent to which individuals in a society perceive themselves and others to be sick as straightforward correlates of changes in their physiological status.

158

Health and Wealth

As Sheila Ryan Johansson has correctly pointed out in debate with James Riley, the condition of illness, quite unlike that of death, is culturally constructed and negotiated.21 Changes in the social and economic rewards and punishments for declaring oneself to be unfit for remunerative work will have significant influences over the extent to which people do or do not define themselves into and out of this state. Similarly changes in the medical profession’s understanding of symptoms and aetiology and changes in the extent and manner in which the profession is remunerated—both by individuals and by institutions such as friendly societies—for dealing with sicknesses and illnesses, will affect the perceived range and severity of illnesses acknowledged in this society.The fact that it was the younger members who in the 1890s were most likely to submit the longest illness claims strongly suggests the importance of generational changes in workers’ perceptions of what constituted an illness sufficient to justify time off work (which is not to say that these perceptions may not have been entirely justified: one part of the reason for falling mortality may well have been workers’ decreasing willingness to subject themselves to undue stress). But Riley’s research and the evidence it is based upon certainly cannot be used as direct empirical input for the McKeownite analytical scheme, permitting the construction of absolute measures of morbidity trends over time. Thus, the formal distinctions between exposure, resistance, and outcome, for all that they may be helpful under certain relatively controlled experimental or clinical conditions, are quite inappropriate and, indeed, are positively misleading as a conceptual and methodological standpoint from which to approach the epidemiological history of nineteenth-century Britain and the possible causes of change. Finally, the fourth element of Guha’s article is again characterized, like the first, by a misleading representation of Szreter (1988). In section VI Guha presents the findings of a valuable case study of Mansfield published in 1910 by O. H. Carter to help explain why infant mortality fell so late in Britain. Guha uses the study to show that this was because it required the novel recognition on the parts of both officials and proletarians that “domestic micro-sanitation” was as vital as “urban macro-sanitation” in order to preserve infant life. This came relatively late in the day because it required the lessons of the bacteriological revolution to be fully absorbed and disseminated. This is fine, as far as it goes. However, Guha’s accompanying interpretative gloss presents this

Mortality in England in the Eighteenth and the Nineteenth Centuries

159

both as if it were a new interpretation and as if it were an important contradiction of Szreter (1988). Readers will remain unaware from Guha’s presentation that this thesis is fully rehearsed in a discussion about twice as long as his in Szreter (1988).22 The thesis that he spends about three pages presenting has already been developed in a more complex form in the very work that he claims it contradicts. It is perhaps forgivable to detain readers with a brief résumé of this section of Szreter (1988), to redress the balance of Guha’s omission.The distinction between what Guha terms “micro-” and “macro-sanitation” was there introduced exactly in order to explain why one set of social interventions—the public health and preventive measures of the latter Victorian decades—could not reasonably be expected to have influenced the infant’s environment, notwithstanding their positive impact in reducing mortality from contagious diseases at higher ages. The discussion departed from a distinction between improvement of the urban environment at the strategic level outside the home, as opposed to improvement in the conditions prevailing within the home. I pointed out that the latter, alone, constituted the relevant “urban environment” for most infants. In relation to this, I raised the further distinction between under- and malnutrition and pointed out that the continuing prevalence of diarrhea as a major component of the stubbornly high infant mortality was evidence for the importance of the latter problem. This in turn raised the issue of the feeding and hygiene practices of the urban working class: I pointed out that though these customs were in themselves “rational” (for instance, the idea that food that was safe for older children and adults could be presumed safe for infants), they could nevertheless be harmful for all that. I argued that because the causes of infant mortality were so locked into the intimate, domestic, and customary behavior of the urban working classes—these practices themselves representing an adaptation to the inadequate provision of domestic hygiene facilities in many of their homes—that the problem of infant mortality could only he reduced once both improved domestic hygiene facilities became available and also once a change in customs and behavior had occurred. I further contended, in relation to the latter development, that the increasing attentions given to working-class communities by local officials and health visitors may have been a vital influence. Finally, I offered a set of explanations for the relative lateness of such probing attention to the health problems of the

160

Health and Wealth

working-class domestic environment, including the changes in aetiology referred to by Guha, but also invoking the libertarian political and constitutional sensitivities of the Victorian age, along with the associated fierce sense of independence on the part of the working classes.Thus, far from infantile diarrhea being a classic sanitation disease as Guha has characterized it (if by this it is meant that it is susceptible to amelioration through environmental sanitation at the strategic or municipal level), it is a classic personal and domestic hygiene disease. As such, as I wrote in 1988, its continued prevalence signifies the limits of what was achievable at the strategic level alone, without a more probing and comprehensive form of social intervention against mortality, such as the public health movement, politicians, and the populace at large were finally developing in the decades around the turn of the century.23 To summarize: there is little of substance that stands up to scrutiny in Guha’s critique of Szreter (1988). I do not believe that Guha has mobilized an effective case against my argument or for McKeown. Indeed, the positive scholarly contributions offered by Guha further diminish the viability of the McKeown thesis and further illustrate the arguments presented in Szreter (1988). I am grateful for the calculations that established greater certainty in the rise in mortality from bronchitis/ pneumonia/’flu and for drawing our attention to O. H. Carter’s study. I am also aware of a valuable and interesting article that Guha has contributed on mortality among British soldiers serving in India, which, in a different climate and disease ecology, documents the importance of personal hygiene practices and which, interestingly, finds little support for “the possible effects of nutritional status—so important in McKeown’s hypothesis.”24 Nevertheless, as I have shown, Guha’s approach has resulted in his developing at considerable length an outdated and fundamentally flawed interpretation, premised on the mistaken notion that the disease ecologies of England in the eighteenth and the nineteenth centuries are in any way comparable.

Notes 1. My 1988 article is reproduced as chapter 4 of this volume. For Guha’s critique, see Guha (1994). 2.Wrigley and Schofield (1981); Floud,Wachter, and Gregory (1990).

Mortality in England in the Eighteenth and the Nineteenth Centuries

161

3. Schwarz (1985); Schwarz (1992). 4.Wrigley and Schofield (1994), 228–36, 683–95. 5. Ibid., 656;Walter and Schofield (1989), 58–61. 6. Landers (1990). 7. Landers (1990); Dobson (1989). See also both authors’ contributions and the other assembled papers in the excellent collection: Landers (1992); the full scale monograph on London by Landers (1993); and the imminent publication of Dobson (note this was in fact subsequently published in 1997). 8. Chap. 4, this volume, 113–14 and note 41. 9. Mercer (1990), especially chap. 3; Razzell (1977). 10. Hardy (1988), 387. 11. Chap. 4, this volume, 112. 12. Cronjé (1984), 94–95, 97–98; chap. 4, this volume, 112 and note 34. 13. Oddy (1990), 275–76. See also the interesting article by Riley, which presents new evidence on weights as well as heights, supporting the hypothesis that working-class adult males tended to be relatively well-fed, by comparison with children. Riley (1994). 14. Chap. 4, this volume, 112. 15. Oddy (1990), 275. 16. Hardy (1993), 251. 17. Fine (1994), 55–56; Smith (1988), 220. 18. Fine (1994), 56; Sen (1981); and for a chronologically wider consideration of these issues, see Johansson (1991). 19. Smith (1988), 18, citing Guy (1923), 12. 20. Riley (1989). 21. Johansson (1991); Riley (1992); Johansson (1992). 22. Chap. 4, this volume, 126–31. Guha’s laconic acknowledgment of this in his final footnote, with the bald observation that his thesis corresponds to “A point made by Szreter” is, in view of the extensive discussion there, a form of being economical with the truth. For an important further exposition and amplification of these arguments in the case of another country, see Ewbank and Preston in Caldwell (1990). 23. See chap. 9, this volume. Approaching the matter from a more purely demographic angle, Bob Woods has similarly recently argued that the nineteenthcentury British evidence shows that the influences responsible for infant mortality and for its amelioration were qualitatively distinct from those responsible for early childhood mortality and for adult mortality. He has further argued that this is probably a generalizable phenomenon, with important implications regarding the limitations of the standard demographic technique of using the Princeton model life tables to reconstruct the full mortality experiences of populations from partial evidence:Woods (1993). 24. Guha (1993), 399–400.

PART II HISTORICAL STUDIES OF THE RESPONSE TO THE PUBLIC HEALTH CHALLENGES OF ECONOMIC GROWTH IN NINETEENTH-CENTURY BRITAIN

6 URBANIZATION, MORTALITY, AND THE STANDARD OF LIVING DEBATE* New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities1

The modern standard of living debate has been conducted throughout the last forty years predominantly in the absence of any direct, detailed, and empirically based consideration of the mortality experience of the British working population during the industrial revolution era.2 This is somewhat surprising in that, when setting out the basis for a “pessimistic” view in his seminal contribution to the debate of 1957, Hobsbawm gave pride of place to evidence bearing on mortality and health, which he envisaged as ideally including “mortality rates . . . morbidity rates and *

1 This chaper is slightly revised from its original form in Economic History Review 50,1 (Feb. 1998).

165

166

Health and Wealth

anthropometric data.” 3 The last category of evidence, in particular, has certainly been brought into the debate with great ingenuity and to great effect during the past ten years, as will be considered below. But where the study of mortality in British towns and cities is concerned, Armstrong’s valuable work on Carlisle has remained until very recently a lone contribution; and even now, with the addition of Huck’s work, information is available on only a handful of small towns.4 This is almost certainly because of the relative paucity and inaccessibility of reliable, relevant demographic evidence for this particular period, the “dark age” of Britain’s modern historical demography, 1780–1850. As a result, the only publication that has attempted to construct a general demographic measure of urban mortality trends for this period with which to inform the standard of living debate, has in fact deployed a primarily conjectural, rather than an empirically grounded model.5 While the problem of partial evidence undoubtedly continues, this chapter attempts to show that it is, nevertheless, possible to construct a much more empirically based assessment of the most likely course of the general mortality trends experienced by Britain’s urban workforce during the industrial revolution era.

1 In 1985 Woods published a set of conjectural estimates offering a detailed hypothetical model of the general relationship between changing levels of mortality and degree of urbanization in England and Wales during the period 1811–1911.6 Woods used this model to demonstrate the important logical point that, in trying to explain national trends in health and mortality during a period of intense population growth and urbanization, it is essential to take into account underlying compositional shifts in the population’s experience of different kinds of environment, which he demonstrated with respect to a broadly urban-rural differentiation. His conjectures showed that, given only a series of known values for the overall life expectancy at birth for the nation as a whole for each decade of the nineteenth century, combined with a set of census-based indicators of the changing proportions of the population residing in four different categories of environment (London; large cities above 100,000;

Urbanization, Mortality, and the Standard of Living Debate

167

towns of 10,000–100,000; and the “rural” residual), it was possible that each of these four kinds of environment could have experienced a continual process of very gradual increase in life expectancy at birth (implying continuous reduction in mortality) throughout the entire period 1811–1911, even though the overall national figure for expectation of life at birth registered little, if any, significant increase from the 1820s until the 1870s. The model demonstrated that this was arithmetically possible because ever larger proportions of the national population were residing in the relatively high mortality urban environments (even though these environments were portrayed as continually marginally improving, with respect to mortality). The danger with a hypothetical model of this sort, initially developed as an heuristic device, is that it should not then be used as if it presented a set of empirically derived estimates, or historical “best guesses,” unless their accuracy has been carefully evaluated. Do these hypothetical estimates published by Woods in 1985 fit the available historical evidence better than any alternative? Unfortunately, without any such validation exercise, leading scholars have apparently begun to treat Woods’s conjectural trends as if they were the best available summary of the known historical evidence during the nineteenth century, and a summary of them has even been reproduced in this way in the second edition of Floud and McCloskey’s standard textbook.7 Woods’s model was in fact empirically anchored only at two dates. The mortality figures for each of the four categories of environment in 1911 were taken from the relevant census publications relating to that year; and the figures for 1861 were derived from the author’s examination of the range of life expectancy values exhibited by registration districts representative of each of the four environments during the years 1861–63.8 Woods’s model, however, portrays trends for each kind of environment from 1811 through to 1911.This was done by extrapolating back from 1861 to 1811 (but at a necessarily slower pace) the same linear trends of improvement over time that result from comparing the empirically based values for each type of environment for the two later dates, 1861 and 1911. If there were no other relevant historical evidence available for the nineteenth century then Woods’s conjectural procedures would be as good as any other. But there has always been a certain amount of reasonably robust demographic evidence on urban mortality even for the late

168

Health and Wealth

eighteenth century, as well as the first half of the nineteenth. This was generated by concerned contemporaries both in England and Wales and in Scotland, and included the early work of the pioneer of official vital statistics, William Farr. Crucial elements of Woods’s conjectural trends are flatly inconsistent with the historical information provided by these contemporaries. In particular, the picture conveyed by the Woods model of “continuous, albeit slow, improvement in mortality conditions” throughout urban Britain from the beginning of the nineteenth century onwards appears extremely implausible in view of this contemporary testimony.9 It is, of course, this feature of the Woods model that is of greatest interpretative significance for the standard of living debate, as Woods himself emphasized, noting the consistency between his model’s implications and Williamson’s work.10 The best comparative, single, summary measure of mortality conditions prevailing among any population at any time is the figure for its expectation of life at birth (e0 in demographic notation). To calculate this figure it is necessary to be able to construct a life table for the population in question. The period life table uses historical information on the numbers at risk in each age group and the numbers dying in each age group to produce a comprehensive set of age-specific mortality rates, expressing the chance of dying at each age. The life-table technique enables all these age-specific rates from the first year of life through to the last age group (defined as “age 75 and upwards” in most of the sources used here, which are mainly derived from the publications of the Registrar-General for England and Wales) to be arithmetically summed correctly so as to produce a single summary figure, the expectation of life at birth, or the most probable number of years that will be lived from the moment of birth by a random individual born into the population in question, given all the age-specific rates of mortality prevailing at that point in time.11 It is measures of the expectation of life that are essential for making reliable comparisons of the mortality conditions prevailing in different times and places because they have taken into account the powerful effects of age-structure differences between different populations that, for example, the crude death rate does not.12 Apart from a small number of life-table calculations made by contemporaries in the nineteenth century, which will be reviewed below,

Urbanization, Mortality, and the Standard of Living Debate

169

there have been no previous systematic attempts to produce rigorous comparative estimates of life expectancies for the growing cities of Britain during the transforming century of industrialization.13 Fortunately, however, the information published in the decennial supplements of the Registrar-General for each decade from the 1850s onwards is sufficient to enable abridged life tables to be calculated for the registration districts of England and Wales.14 Table 6.1 therefore displays values calculated in this way for the expectation of life at birth for each decade from the 1850s through to the 1890s for London and for the eight largest provincial cities at mid-century (those that had grown above a size of 100,000 by 1851).These nine cities actually contained just over a quarter (26.8 percent) of the entire population of England and Wales in the mid-1850s, split evenly between the capital and the other eight combined.15 A number of important points can be made in relation to Table 6.1. First, with the interesting exception of the ancient southern port city of Bristol, all the largest cities recorded life expectancies well below the national average throughout the period 1851–1901. Second, it was the northern industrial towns, and particularly the two giants of Manchester and Liverpool, that consistently exhibited the lowest life expectancies. Expectation of life at birth in these two cities was only around 31 years in both the 1850s and 1860s, at a time when the national average was fully ten years higher. Indeed, according to the Cambridge Group’s estimates, throughout the entire early modern period since the 1540s the national average expectation of life at birth had fallen briefly as low as 31 or 32 years on only a small number of occasions.16 Furthermore, by the end of the nineteenth century neither of these two cities had in fact improved much, relative to the higher national average life expectancy then obtaining. On the other hand, Birmingham in both the 1850s and 1860s was notably relatively healthy for such a large city, next in size after Liverpool and Manchester. This tends to militate against any simplistic thesis that mere size and speed of urban growth alone were the principal factors accounting for the relative unhealthiness of Britain’s largest cities or for the substantial differences between them.17 Another counter to this hypothesis lies in the comparison of the two smallest large cities, the long-established ports of Bristol and Newcastle/Gateshead, where the

170

Health and Wealth

Table 6.1: Expectation of Life at Birth in England’s Largest Cities (Population above 100,000 By 1851), 1851–1901 City Bristol Sheffield Newcastle/ Gateshead Leeds Bradford Birmingham Manchester Liverpool London England and Wales Mid-census population of administrative city (‘000) Bristol Sheffield Newcastle/ Gateshead Leeds Bradford Birmingham Manchester Liverpool London England and Wales

1851– 1860

1861– 1870

1871– 1880

1881– 1890

39 36 35

40 35 35

42 37 38

46 40 41

47 42 43

36 37 37 32 31 38 41

35 36 37 31 30 38 41

38 38 39 34 34 40 43

40 42 42 37 36 43 45

41 44 42 36 38 44 46

1851– 1861

1861– 1871

1871– 1881

1881– 1891

1891– 1901

146 160 129

169 213 160

195 263 194

215 305 242

278 353 299

190 105 265 321 410 2,583 19,007

233 126 320 345 469 3,029 21,389

284 165 373 346 523 3,535 24,343

339 200 440 423 535* 4,014 27,488

1891– 1900

399 248 500 525 601 4,389 30,643

Note: see n. 18 for method of calculating values for e0. Sources: Registrar-general of England and Wales, Decennial supplements; Mitchell and Deane (1962), 24–7. *corrected from original article, which stated a value of 592.

Urbanization, Mortality, and the Standard of Living Debate

171

latter returned a significantly lower life expectancy in the 1850s and 1860s despite being the smaller of the two. A further extremely important point to emerge from Table 6.1 is the fact that in virtually all cities mortality conditions in the 1860s were no better—and in several cases even slightly worse—than in the 1850s. It was not until the two subsequent decades that definite and substantial rises in expectation of life at birth were registered in Britain’s largest cities. This finding specifically contradicts the picture of continuous gradual improvements in life expectancy in all environments, including urban ones, throughout the nineteenth century, as depicted by Woods’s model in 1985. Table 6.2 presents a further dimension of analysis for these large provincial cities.The territorial and therefore the population definitions of the registration districts (R.D.s), for which it is possible to construct life tables and calculate life expectancies, are in no case co-extensive with the administrative definitions of the provincial cities in Table 6.1. In all cases, except Bradford, the population of each large city was principally contained within two contiguous R.D.s, each of which is displayed separately in Table 6.2. In each case the population of the R.D. bearing the city’s name was entirely resident within the city’s proper administrative boundaries, this R.D. being composed of the old, central parishes of the city.The second R.D. of each city, listed under the first in Table 6.2, straddled the city boundaries and contained a population part of which was resident within the city and part of which was not. As the lower part of Table 6.2 shows, it was in each case this second, outer R.D., containing much of the expanding suburbs, which in fact grew disproportionately in population size towards the end of the century, such that the outer R.D.s came increasingly to contain a larger proportion of the city’s true population. The life expectancy figures in Table 6.1 were calculated as true “administrative city” values, so as to reflect accurately this changing composition in terms of the two principal component R.D.s of each city.18 As can be seen from Table 6.2, this is extremely important since the mortality conditions prevailing in the inner and the outer R.D.s of each city were significantly different in every decade.This, therefore, gives us a chance to examine mortality conditions in districts roughly representing both the “inner” and the “outer” parts of Britain’s largest cities between 1851 and 1901, which affords a number of further interesting insights. First, the lack of any improvement in the life expectancy figures

172

Health and Wealth

Table 6.2: Expectation of Life at Birth in the Registration Districts of England’s Largest Cities (Population above 100,000 by 1851), 1851–1901 R.D.

1851– 1860

1861– 1870

1871– 1880

1881– 1890

1891– 1900

Bristol Clifton Sheffield Eccleshall Newcastle Gateshead Leeds Hunslet Bradford Birmingham Aston Manchester Chorlton Liverpool West Derby

35 42 34 40 34 37 34 38 37 35 42 30 37 27 38

36 42 33 40 34 39 34 36 36 35 42 29 36 25 35

37 45 35 42 37 39 37 39 38 37 43 32 38 28 39

39 48 38 43 40 42 39 42 42 39 46 35 41 29 40

43 50 39 46 42 44 41 40 44 38 45 36 42 30 41

Mid census population (‘000)

1851– 1861

1861– 1871

1871– 1881

1881– 1891

1891– 1901

Bristol Clifton Sheffield Eccleshall Newcastle Gateshead Leeds Hunslet Bradford Birmingham Aston

66 86 116 51 101 54 109 99 189 193 84

64 111 146 75 121 70 128 118 227 222 124

60 147 173 101 141 93 177 124 285 239 178

57 180 194 126 174 118 207 150 327 246 234

106 167 216 157 214 150 237 179 349 245 283

Urbanization, Mortality, and the Standard of Living Debate

173

Table 6.2: (Continued) Mid census population (‘000)

1851– 1861

1861– 1871

1871– 1881

1881– 1891

1891– 1901

Manchester Chorlton Liverpool West Derby

236 147 264 190

247 190 254 284

255 235 224 410

282 279 184 525

310 319 153 615

Notes: The figures for Manchester R.D. include those for Prestwich R.D., which was formed by splitting Manchester R.D. in 1874. Similarly, the figures for West Derby R.D. include those for Toxteth Park R.D., formed in 1881. Source: Registrar-General of England and Wales, Decennial supplements.

across the 1850s and 1860s is again confirmed by the disaggregated measures in Table 6.2. Indeed, disaggregation further emphasizes the fact that, if anything, many outer as well as inner districts experienced some deterioration in the 1860s, before the more definite improvements of the 1870s and 1880s. Second, the great scale of the difference in average life expectancy between inner and outer areas of residence is quite striking.19 While it might be possible in the 1850s and 1860s to attribute an outer R.D.’s superior life expectancy to the more rural environment of the majority of its population, by the 1880s and 1890s most of the population of the outer R.D. was living within the city’s boundaries, rather than beyond them.Yet Table 6.2 shows that in all cities the mortality differential between inner and outer R.D.s was as marked in the last two decades of the nineteenth century as in the middle two. In other words, although the populations of these outer R.D.s continued to increase in density and became thoroughly urban in environmental terms, they remained as much healthier than those living in the inner cities as they had been at mid-century. This point gestures towards the crucially important set of issues relating to the dynamic forces of class and residential segregation, which Dyos and Reeder famously subsumed within their thesis of “suburbanisation.”20 There is no room here to pursue this complex subject further but it was undoubtedly of central significance in explaining the mortality patterns within and between Britain’s nineteenth-century cities.

174

Health and Wealth

Finally, it seems worthwhile to point out that the very substantial difference between inner and outer R.D.s may also indicate a possible statistical reason that might explain to some extent London’s apparent “healthiness” throughout this period. Having, of course, grown much earlier to a size incorporating a range of both “inner” and “outer” urban and suburban residential areas, and containing within it the greatest concentrations of the wealthiest in British society, the life expectancy value for London may appear so high partly because, analogously to the figure for Bradford, it presents a single figure for expectation of life at birth covering a widely varied range of environments across the capital (although, of course, unlike Bradford R.D., the remaining rural parts of the London area were very limited). Indeed, to describe and account for the diversity of mortality conditions across the nineteenth century in the largest city in the world presents an analytical challenge probably as complex as that entailed in examining the record for the rest of the urban population combined, such that the use of a single life expectancy figure to stand for the experience of the whole population of the capital may be viewed as a highly summary abstraction.21

2 The new evidence presented so far means that it is possible to describe the relationship between urban growth and mortality change in the largest cities of England and Wales with considerable confidence and in some detail for each decade of the second half of the nineteenth century. But there is no equivalent, comprehensive range of demographic information available for Britain’s cities before the 1850s. The RegistrarGeneral did not publish the early mortality statistics collected from mid-1837 onwards in a form that can be used to construct R.D. life tables. However, this does not mean that there is no relevant or helpful demographic evidence available with which to construct a set of plausible estimates for this period. There are, in fact, at least four distinct categories of firm demographic evidence available. First, there is the Cambridge Group’s longterm series for the nation’s overall average expectation of life at birth, which, along with the Chester Beatty values for the period from the mid-1840s onwards, provide a continuous national series from the

Urbanization, Mortality, and the Standard of Living Debate

175

mid-sixteenth century to the present.22 Second, there are a significant number of robust, contemporary and official calculations of life expectancy in different categories of environment, including several important urban centers, for the beginning of the 1840s.Third, there are several local data collections for a number of other towns, including a vitally important series for Glasgow from the 1820s onwards, which are of sufficiently high quality that further estimates of life expectancy at specific dates can be constructed from them. Fourth, there have been a small number of painstaking studies by historians, reconstructing agespecific mortality trends in certain smaller urban communities during the relevant period, encompassing the late eighteenth century and the first five decades of the nineteenth century. Turning to the second of these categories of evidence, Table 6.3 lists the large cities of Tables 6.1 and 6.2 again, together with all other contemporary official and unofficial life expectancy figures for places in England and Wales during the first half of the nineteenth century, mostly related to the year 1841.23 The question of the validity of the official data for 1841 has been critically examined by demographic historians. Despite identifying a number of problems, chiefly regarding under-registration and misreporting of age (age-heaping on round numbers), these evaluations have concluded that the figures for life expectancy calculated by Farr for 1841 are probably well founded, not subject to serious vitiating distortions, and should therefore be treated as approximately correct.24 To render them more strictly comparable to the “administrative city” values calculated for Table 6.1, a similar set of procedures can be applied to these values for Manchester and Liverpool for 1841 to take into account the fact that Manchester and Liverpool R.D.s each contained only about 80 percent of the full population of their respective administrative cities at this date.This produces “administrative city” estimates of life expectancy at birth in 1841 of 28.1 years for Liverpool and 26.6 years for Manchester.25 The unofficial calculation for Bristol in 1825 is less susceptible to critical evaluation and certainly cannot command the same evidential status as the official figures.26 While it is highly unlikely to be a precisely accurate figure, it is reproduced here because it is the only other, empirically derived life expectancy figure available for one of Britain’s large cities in this period; and it is certainly relevant that it is broadly confirmatory, in that it registers a value for Bristol that

176

Health and Wealth

Table 6.3: Contemporary Calculations of Expectation of Life at Birth in England and Wales, 1801–1850 City Bradford Newcastle Sheffield Bristol (1825) Leeds Birmingham Manchester1 Liverpool London Rural Surrey ‘Northampton’2

Population (1841) 67,000 90,000 111,000 124,000 152,000 183,000 235,000 286,000 1,875,493 227,723 7,898

e0 (years) (1825)

(95,000)

29 25.3 25.7 36.7 45.1 37.6

Notes: 1 The life expectancy estimate for Manchester (25.3 years) can be calculated from the information in the first line of the “Manchester population table,” which shows 163,561 persons (both sexes combined) at age zero projected to live a total of 4,141,701 years at the age-specific rates of mortality prevailing in Manchester in 1841: 7th ARRG, pp. 338–9. 2 The life expectancy estimate for “Northampton” relates only to the parish of All Saints (population 7,898 in 1841), one of four principal parishes of the town (population 21,242 in 1841). All Saints parish, according to Farr, contained “the principal portion of the respectable classes of society.” Farr’s analysis was not intended to give a representative estimate of life expectancy for the town of Northampton, but only for this parish. This was because Farr’s objective was to demonstrate that Richard Price’s earlier, much-used “Northampton” life table, also based only on this one parish, was flawed in its construction: 8th ARRG, pp. 315–22. Consequently, this figure cannot be used as representative of Northampton’s population, as it is almost certainly substantially too high. Sources: see text.

is of the same order as the official figures calculated for Liverpool and Manchester fifteen years later. However, of considerably more significance than the Bristol material, indeed arguably of more significance even than the official English data for 1841, are the series of life expectancy figures that can be generated for this period for the city of Glasgow from its bills of mortality.The system of bills of mortality had existed for a number of British cities since the seventeenth century, but in general they are advisedly considered by demographers to be an unreliable source of information for inferring mortality levels and

Urbanization, Mortality, and the Standard of Living Debate

177

Table 6.4: Estimates of Expectation of Life at Birth in Scottish Cities, c. 1841 City

Population (1841)

eo

Perth Aberdeen Dundee Edinburgh Leith Glasgow

19,000 63,000 63,000 138,000 28,000 274,000

40 47 39 37 40 27

Source: Flinn, ed. (1977), tab. 5.5.4, p. 379.

trends.27 However, the Glasgow bills from 1821 are an exception in this regard.This was because James Cleland, the city’s superintendent of public works since 1814, resolved with great thoroughness, diligence, and unrivaled local knowledge of his home town of Glasgow, to emulate John Heysham’s pioneering Carlisle system of comprehensive vital registration combined with accurate census taking. When Cleland died in 1840 he bequeathed to his successor, John Strang, a system of urban vital registration for Glasgow that Joshua Milne (the pioneering actuarial analyst of Heysham’s Carlisle data) hailed as unequalled throughout the world at that time.28 Thus, despite Glasgow’s enormous size and rapid growth, and the poor reputation of bills of mortality in general, it is justifiable to have particular confidence in the accuracy and completeness of the Glasgow data after their reorganization by Cleland from 1821.29 Table 6.4 presents some of these Glasgow data, along with data for four other Scottish cities (Leith being a part of Edinburgh) to give a new set of estimates for expectation of life at birth c.1841, using the same method of abridged life-table construction as for the English cities after 1850. This table is based on information from bills of mortality collated and published by contemporaries in the 1840s, as most of the original data have since been lost (except those for the city of Glasgow). The abridged life tables relate to the age structure of the Scottish cities at the census of 1841 and the deaths registered in the bills during the preceding quinquennium, 1837–41 (civil registration of births, deaths, and marriages did not commence in Scotland until 1855).

178

Health and Wealth

In view of the problems associated with bills of mortality, it is only the Glasgow evidence in Table 6.4 that should be treated as reliable.30 The Glasgow figure certainly confirms the plausibility of the values that can be calculated from the English evidence in 1841 for Manchester and Liverpool. Representing an urban environment very closely comparable to both Manchester and Liverpool in terms of its rapid recent growth, vast size, and economic functioning as both port and early center of mechanized industry, Glasgow exhibits a very low life expectancy at birth, almost precisely equal to its two southern peers. It should, incidentally, be noted that Farr’s official estimates for 1841 also gain broad confirmation by comparing them with the only slightly higher life expectancy values for Manchester R.D. and Liverpool R.D. registered in the 1850s and 1860s, displayed in Table 6.2. Indeed, as late as the decade of the 1880s Manchester’s Medical Officer of Health, Dr John Tatham (who was subsequently to be Farr’s second successor as statistical superintendent at the General Register Office) constructed a set of sectional life tables for Manchester, which showed that at that time e0 was still no more than 30 years in the old central districts of the city.31 If, then, we can push back our relatively certain knowledge to a point around 1841, such that it can be stated with some confidence that life expectancy at birth around that census year was in the range of 26 to 29 years in the three largest, leading industrial and commercial British cities of Manchester, Liverpool, and Glasgow, what of the four decades before 1841 and what of the trends between 1841 and the mid-1850s? There is just one source of direct evidence with which to cast light on these questions: the invaluable series of the Glasgow bills of mortality. Table 6.5 accordingly presents a further set of life expectancy calculations derived from the publication by Flinn and his co-authors of Cleland’s age-specific death rates for Glasgow relating to the period from 1821 onwards.32 This enables the figures presented above in Tables 6.1 through 6.4 to be related to trends across the first half of the century for the city of Glasgow.33 Furthermore, it should be distinctly noted that Cleland ensured that these Glasgow data related to the whole administrative city at the time, embracing not only the ten central parishes of the Royalty but also the populations of the two, outer suburban parishes of Barony and Gorbals (these contributing 77,385 and 35,194, respectively, of Glasgow’s total population of 202,426 in 1831).This Glasgow evidence

Urbanization, Mortality, and the Standard of Living Debate

179

Table 6.5: Estimated Expectation of Life at Birth in Glasgow, 1821–1861 Date (deaths)

Population

e0

1821–5 1826–30 1831–5 1837–41 1851 1861

161,000 188,000 221,000 259,000 345,000 420,000

35.0 34.7 30.1 27.3 29.6 32.1

Note: “ population” refers to the interpolated population size of the city of Glasgow at the midpoint of the period from which the deaths are drawn. Sources: Flinn, ed (1977), 376–9.

does not, therefore, reflect only the harsher experience of the “inner” city but, like the figures in Table 6.1 and the adjusted “administrative city” values of 28.1 years for Liverpool and 26.6 years for Manchester in 1841,34 represents the average life expectancy of all residents. As emphasized in Flinn’s original analysis of this evidence,Table 6.5 shows that life expectancy in Glasgow during the 1820s was much higher than in the following decade of the 1830s; and that the extremely high level of mortality in the 1830s (reflected in the low life expectancy figure in Table 6.5 of just over 27 years for 1837–41), was sustained right through the 1840s. Indeed, Flinn’s analysis showed that it was not until the second half of the 1850s that age-specific death rates in Glasgow fell to a distinctly lower level, though even then this remained somewhat above the levels of the 1820s.35 Table 6.5 therefore confirms that the low life expectancy figure for 1837–41 in Table 6.4 is representative of a prolonged period of extremely high mortality prevailing in Glasgow from the early 1830s until the late 1850s. Life expectancy in Glasgow in the 1820s was certainly already substantially below the national average. This is not surprising for such a vast and rapidly expanding city that had, by the 1820s, accumulated a history of seven decades of ever-accelerating, six-fold growth, since its position, c.1750, as a town of 20,000–30,000 inhabitants.36 But it is the subsequent sharp deterioration and prolonged period of excessive mortality, c. 1830–55, that seems the most remarkable epidemiological feature.

180

Health and Wealth

This nonlinear pattern of mortality trends in Glasgow is consistent with other relevant evidence presented by Flinn and his coauthors, based on the earlier records of the Glasgow bills of mortality during the period 1783–1812. Although inappropriate for constructing life expectancy estimates, this earlier material can be used for the relatively limited purposes of examining the proportion of deaths under age 10 caused by smallpox. In Glasgow at that time approximately 50 percent of all deaths occurred in this age range; and it is, of course, large proportions of these early deaths that exert the greatest influence in generating low values for expectation of life at birth. The hideous symptoms of smallpox were unambiguously identifiable and it is generally agreed that it was consequently one of the most accurately recorded causes of death at this date.37 Smallpox accounted consistently for 19 percent of all deaths under age 10 in Glasgow throughout the 1780s and 1790s, clearly the principal cause of death in this most important age range. However, the Glasgow bills show a dramatic reduction in smallpox mortality associated with the introduction of Jennerian vaccination following its discovery in 1798, such that by the years 1807–12 smallpox accounted for under 4 percent of deaths in this age group.38 A reduction on this scale in the major child-killer would certainly have caused a perceptible rise in life expectancy, ceteris paribus.39 The effect of this well-documented medical intervention is therefore consistent with Glasgow exhibiting a relatively favorable expectation of life at birth in the 1820s. However, by the years 1835–39 the smallpox death rate in Glasgow had once again risen, approximately doubling relative to the low level attained by the beginning of the second decade of the century; and it did not fall back to that low level again until the second half of the 1850s and the early 1860s, a timing coincident with the broader pattern of death rates at all ages, which first registered a significant fall in Glasgow in the second half of the 1850s.40 Overall, therefore, this relative wealth of demographic and epidemiological evidence for the single city of Glasgow indicates a complex chronological pattern. While mortality levels were generally substantially worse than the national average throughout the period, it seems that there was a significant further worsening of the situation in the second quarter of the nineteenth century. In consequence, an appallingly low level of life expectancy at birth persisted for almost three decades

Urbanization, Mortality, and the Standard of Living Debate

181

from the early 1830s until the late 1850s. Furthermore, life expectancy at birth by the beginning of the 1860s was still no better than it had been in the 1820s. There remains to consider one further, important category of relevant historical evidence on trends in urban mortality during the half century or so before 1841: that which relates to a number of smaller English towns. Most of this evidence has been created by demographic historians’ analyses of parish registration materials. But there also exists (in addition to Rankin’s Bristol data for 1825, mentioned in Table 6.3) one other important contemporary compilation, which was undertaken by Dr John Heysham for the town of Carlisle from 1779 onwards. These data have been the subject of careful evaluation by Armstrong, who has also supplemented Heysham’s data for 1779–87 with a most valuable analysis of registration data for precisely the same place, the town of Carlisle, during the years 1838–53, so as to be able to compare age-specific mortality rates for the two periods.41 With 22,000 inhabitants in 1841, Carlisle had retained its rank position as forty-fifth largest town in England throughout the first half of the nineteenth century.The actuary Joshua Milne published in 1815 a calculation of Carlisle’s life expectancy at birth, based on his analysis of Heysham’s data for the period 1779–87, which indicated a value of 38.7 years (Milne’s work has always been considered well founded and basically accurate).42 As contemporaries themselves believed, Carlisle was apparently a relatively healthy place in the 1780s, since Wrigley and Schofield’s value for the national average life expectancy during this period stood at only about 36 to 37 years. Furthermore, as presented by Armstrong, Heysham’s evidence shows Carlisle to have been experiencing a marked trend improvement in mortality conditions across the last two decades of the eighteenth century, which was attributed by contemporaries to a dramatic fall in smallpox, partly associated with (but also antedating) Jennerian vaccination. However, Armstrong’s two separate analyses of death registration records for 1838–44 and 1849–53 both show a very significant deterioration across the range of age-specific mortality rates for the town of Carlisle compared with those of the 1780s, especially among those aged 0–4 (16–21 percent higher) and among all adults over age 15 (about 25 percent higher).43 Using once again the abridged life table method, the age-specific mortality rates

182

Health and Wealth

published by Armstrong can be used to construct estimates of life expectancy at birth in Carlisle, which show that e0 had fallen from between 38 and 39 years in the 1780s to just 33 years in the period 1838–53, now substantially below the national average.44 On the basis of Heysham’s continued assiduous collection of vital statistics for Carlisle after 1787 and Milne’s publication of these data as annual death rates for the period 1779–1813, Armstrong has been able to conclude that, “it appears likely that the adverse trend in mortality was confined to the post-1813 period” (italics in original).45 Indeed, before that point there may even have been slight continued improvement since the 1780s, as Heysham himself believed to have been the case, noting the virtual cessation of deaths from both smallpox and typhus fever during the first decade of the new century.46 In view of the positive evidence from Glasgow, it may be that the severe deterioration in Carlisle did not in fact occur until the late 1820s or early 1830s.With the evidence available, Armstrong was clear that it was not possible to judge precisely when, after the first decade of the nineteenth century, the worsening in mortality set in. He attributed the subsequent deterioration partly to overcrowding and unplanned, insanitary overbuilding in Carlisle, which tripled in population from the 1780s to the 1840s, and partly to the income loss and unemployment suffered by handloom weavers and their families once power looms arrived in Carlisle at the beginning of the second decade of the nineteenth century. A second relevant body of research has recently been reported by Huck, based on an analysis of registration data for nine parishes of varied character in the West Midlands and Lancashire during the period 1813–46.47 Huck’s work indicates that in all the parishes studied, except two relatively rural ones, infant mortality rates were higher (25–50 percent higher in most cases) in 1831–36 than they had been in 1813–18; and they remained higher in the final period studied, 1839–46 (there were no data available for 1837 and 1838). The 1820s exhibited a slightly more mixed pattern but in virtually all cases the rates were consistent with a trend rise across the period 1813–30 as a whole. Huck’s sample included five industrial townships: Walsall, West Bromwich, and Sedgley in the south Staffordshire Black Country (all recording fast-growing populations of 15,000–20,000 in 1831); the

Urbanization, Mortality, and the Standard of Living Debate

183

Lancashire cotton town of Ashton-under-Lyne (31,500 population in 1831); and Wigan, a Lancashire cotton and coalmining town, already numbering 45,000 inhabitants in 1831. Huck’s research suggests that by the 1840s several of these towns were exhibiting infant mortality rates of 200 or more per 1,000 live births, a figure consistent with life expectancy at birth values of little more than 30 years.48 Although this may well be a slight overestimate of the severity of the level of infant mortality in these towns at this point, the downward trends reported in Huck’s research are substantial and robust.49 They depict a trend in urban mortality consistent with the other independent sources of detailed evidence available, that for Carlisle and Glasgow, indicating a marked deterioration in mortality conditions during the second quarter of the nineteenth century. Both confirmation of this pronounced deterioration in mortality in the second quarter of the nineteenth century and a proximate explanation for it, in terms of age-specific mortality patterns, have emerged in the most recent work of Woods, and also as an implication of the new findings from the Cambridge Group’s study of English population trends from family reconstitutions of twenty-six parishes in the period 1580–1830. In a contribution of fundamental importance, Woods has shown that both in England and in Sweden (where the quality of the historical data is sufficient to show it) there was a dramatic transformation in the second quarter of the nineteenth century in the ratio, infant: child mortality (mortality in the first year of life, or 1q0 in demographic notation, in relation to mortality in the second to fifth years inclusive, 50 4q1), resulting from a marked rise in child mortality (ages 1–4). Wrigley, in comparing the Cambridge Group’s parish register reconstitution results with Woods’s work and with the official civil register data for the period after the 1830s, has concurred that there was a “striking change” in the nation’s mortality regime across the 1830s.51 Given the more precise analysis possible with reconstitution data,Wrigley and his coauthors have been able to show that during the previous century, whereas mortality in the first three months of life fell continuously from an historic peak in the 1740s, mortality at 3–24 months did not. Mortality in this age range had risen continually and substantially from the early seventeenth century onwards to a peak, in common with most other age-specific rates, in the lethal second quarter of the eighteenth

184

Health and Wealth

century. Unlike most other age-specific rates, however, it then fell back only relatively gradually until the first quarter of the nineteenth century. Furthermore, in the second quarter of the nineteenth century, although mortality at 1–3 months continued to fall, mortality at 3–24 months rose sharply, providing the striking change in the ratio first detected by Woods.52 Thus, in light of the available evidence on mortality patterns in England during the first half of the nineteenth century, it seems most likely that the firm evidence available for Glasgow can be used as a reliable guide to make inferences regarding levels and trends of mortality in the largest English industrial cities of this period. In particular, it would be highly plausible to envisage an essentially similar pattern for mortality levels and trends during the first half of the nineteenth century in Manchester and Liverpool. All the verifiable demographic evidence for the three cities matches almost exactly. The average life expectancy for each full administrative city, including its suburbs, was almost identical in each case at the time of the 1841 census. The relevant history in relation to smallpox was also common to all three cities, as to most large urban centres at that time: failure to adopt inoculation against smallpox earlier in the eighteenth century followed by rapid take-up of vaccination after 1798, including widespread free provision by charities, but thereafter a fall-off in vaccination rates and rising incidence of the disease once again.53 Finally, in all three cases there was a fall in overall death rates at all ages in the second half of the 1850s (but this fall was not sustained as a trend of further improvement across the 1860s).54 Given that Tables 6.1 and 6.2 show, for the period from the 1850s onwards, the other six large English provincial cities and their component R.D.s with a consistently higher range of life expectancies than both Manchester and Liverpool, it seems most reasonable to envisage them as exhibiting slightly higher values for life expectancy for the earlier period before 1850 as well (and this principle is followed in the next section). Nevertheless, it does seem most likely and plausible, in view of the strong corroborating evidence for the much smaller industrial towns studied by Armstrong and by Huck, to propose that they would all have experienced broadly the same sequence of trends, with mortality higher throughout the second quarter of the century than it had been during the first quarter.

Urbanization, Mortality, and the Standard of Living Debate

185

3 On the basis of the evidence presented above, the upper line of Table 6.6 gives the overall trends in life expectancy at birth for each successive decade of the nineteenth century when the rapidly growing proportion of the populations of the largest industrial cities of England and Wales (those returning above 100,000 inhabitants at the census commencing each successive decade) are grouped together. No figures are given for the first two decades of the nineteenth century because no relevant, robust evidence has been found. The figures for the two decades of the 1820s and 1830s have been estimated in the following way.Apart from London, there were only three cities above 100,000 in England and Wales in these two decades: Liverpool, Manchester, and Birmingham.The historical evidence for Glasgow has been used as the basis to provide the values for these two decades, on the grounds that all the available evidence, reviewed in the previous section, indicates that Liverpool and Manchester experienced mortality levels and trends extremely similar to those of Glasgow during the immediately following period, 1841–60. Birmingham probably had a somewhat less severe mortality regime, but Manchester’s experience appears to have been significantly worse than Glasgow’s, while Liverpool’s was apparently very close to Glasgow’s.With Manchester and Birmingham therefore cancelling each other out on either side of the GlasgowLiverpool average, it has been considered most appropriate in Table 6.6 simply to use the Glasgow series as representative of the average experience of its three southern peers during these two decades. By 1841 Bristol, Leeds, and Sheffield had also reached 100,000 inhabitants, doubling the number of cities in the category that now contained about 10 percent of the nation’s population, as Table 6.7 shows. The life expectancy figure for the 1840s has therefore been estimated in a more involved way. By referring to Table 6.1, covering the period where we have reliable information for all these cities, it can be seen that during both the 1850s and 1860s there was a fairly consistent differential between the “administrative city” life expectancy values for each of the four cities for which we do not have information for the 1840s (Birmingham, Leeds, Bristol, and Sheffield) compared with the two for which information exists (Liverpool and Manchester). Life expectancy in Birmingham was approximately 5.5 years higher, in Bristol 7.5 years higher, and in Sheffield and

186

Health and Wealth

Leeds about 4.5 years higher than the average of Manchester and Liverpool in the 1850s. On the assumption that these differentials were similar in the 1840s, they can each be added to the average (“administrative city”) values for Manchester and Liverpool, combined, for the 1840s (27.5 years) so that the following “administrative city” life expectancy estimates can be assigned to each of the other four remaining cities above 100,000 for the 1840s: Birmingham 33 years; Bristol 35 years; Leeds and Sheffield 32 years.These estimated values can then be combined with the empirical figures for Manchester and Liverpool, while weighting appropriately for the different sizes of the different cities in the 1840s, to give a single value for the whole category in the 1840s.As Table 6.6 records, this results in an “administrative city” estimate for the expectation of life at birth of 30 years for cities above 100,000 inhabitants in England and Wales in the 1840s.The figures for this category of city for all the later decades in the nineteenth century are, of course, calculated from the figures in Table 6.2 and in Table 6.8.They therefore represent the averages (weighted by population size of each city) of empirically based “administrative city” calculations, drawn from the relevant registration district data in the Registrar-General’s successive decennial supplements. By the 1891 census there were 24 provincial cities (including two twin cities, Plymouth/Devonport and Newcastle/ Gateshead) in England and Wales containing above 100,000 inhabitants, representing over 25 percent of the national population, as Table 6.7 shows.55 The lower line of figures in Table 6.6 repeats, for comparison, the sequence of estimates published by Woods (1985) for this category of city for each successive census year. A principal substantive conclusion that follows from the new set of figures in the upper line of Table 6.6 is that Woods’s speculative inference drawn from his table of conjectural figures, that increasing urbanism in Britain during the industrial period of the later eighteenth century and the first half of the nineteenth century was not necessarily associated with deteriorating health prospects, seems most implausible.56 Figure 6.1 shows that whereas Woods depicted Britain’s largest industrial cities experiencing a relatively smooth trajectory of decade by decade improvement in expectation of life at birth from a value of 30 years in 1821 to a value of 37 years in 1871, a much more complex pattern is visible (from the upper line of Table 6.6), embracing no fewer than four turning points during that half century: a sharp deterioration when the decade of the 1830s is compared with the 1820s and no significant

Urbanization, Mortality, and the Standard of Living Debate

187

Fig. 6.1 Estimates of Expectation of Life at Birth in Provincial Cities above 100,000 Inhabitants in England and Wales, 1801–1901. 47 45

Life expectation at birth (years)

43 41 39 37 35 33 Szreter/Mooney

31

Woods (1985) England and Wales (national average)

29 27 1801

1811

1821

1831

1841

1851

1861

1871

1881

1891

1901

Date

Source: Table 6.6.

recovery in the 1840s; a substantial recovery in the 1850s but not enough to make good the losses of the previous two decades; no further improvement in the 1860s; finally, a trajectory of sustained improvement from the 1870s through to the 1890s (and beyond, of course).The Woods conjectural series suggests that the two decades of the 1830s and the 1840s were marked by a gathering momentum of improvement for these large cities, that the 1850s represented a relative lull, and that the 1860s brought a resurgence of more rapid improvement in life expectancy.The empirically based estimates in the upper line of Table 6.6 indicate a completely different set of detailed chronological developments. What, then, of the multitude of smaller, growing towns and cities in nineteenth-century England and Wales that never reached a population

188

Health and Wealth

Table 6.6: Estimates of Expectation of Life at Birth in Provincial Cities above 100,000 Inhabitants in England and Wales, 1801–1901

Szreter and Mooney England and Wales (national average)

Woods (1985)

1800s

1810s

1820s

1830s

40

41

35 41

29 41

1811 30

1821 30

1831 31

1841 32

Note: Life expectancy figures for England and Wales are drawn from the new estimates in Wrigley et al. (1997), tab. A9.1, for the period before 1841; and thereafter from the Chester Beatty series: Case et al. (1962). The invaluable advice of Jim Oeppen on these matters is gratefully acknowledged and has been adhered to, in the use of the Chester-Beatty values for the period from the 1840s onwards. Sources: see text.

Table 6.7: Probability Distributions for the Population of England and Wales, 1801–1900 Category of place

1800s

1810s

1820s

1830s

London Over 100,000 10,000–100,000 Rural

0.11120 0.01250 0.12515 0.75115

0.11345 0.03290 0.12805 0.72560

0.1170 0.0540 0.1429 0.6861

0.12075 0.07610 0.16330 0.63985

Source: derived from data originally published in Woods (1985), tab. 2.

size of 100,000 by 1891 but that may have exceeded a size of, say, 10,000? Unfortunately it is not possible to use the methods deployed here in application to the information in the Registrar-General’s decennial supplements to produce a set of “administrative city” estimates for the changing life expectancies in the vast majority of this smaller category of towns containing 10,000–99,999 inhabitants during the nineteenth century.This is because most of these smaller towns are individually contained, throughout the nineteenth century, within an encompassing registration district that also held a substantial rural population and it is therefore not possible to produce life tables for the town population within that

Urbanization, Mortality, and the Standard of Living Debate

189

1840s

1850s

1860s

1870s

1880s

1890s

30 41

34 41

34 41

38 43

40 45

42 46

1851 34

1861 35

1871 37

1881 39

1891 41

1901 44

1840s

1850s

1860s

1870s

1880s

1890s

0.12710 0.10075 0.18385 0.58780

0.13580 0.13225 0.19675 0.53470

0.14220 0.16470 0.20955 0.48355

0.14575 0.19810 0.22520 0.43095

0.14645 0.23155 0.24065 0.38140

0.1427 0.2727 0.2515 0.3331

registration district in isolation.57 We are therefore left with the few pieces of evidence that have been mentioned in the previous section with which to gauge the probable experience of populations in such smaller towns.This evidence certainly suggests that it was apparently also true of many smaller industrial towns, comparable to West Bromwich,Wigan, or Carlisle, that they shared in the trends experienced by the larger cities, and that their increasing urbanization was associated, during the second quarter of the nineteenth century, with sharply deteriorating life chances. But there may well also have been a number of much slower-growing, old, market, county, and cathedral towns, especially in the south, which may have evaded some of the worst health problems of the nineteenth

190

Health and Wealth

century; this is certainly implied by the superior life expectancy figures reported here for most large southern cities. For the latter half of the nineteenth century, at least, there is the new evidence available in Table 6.8, reproducing information similar to that in Table 6.1 for each of the sixteen somewhat smaller largest cities in England and Wales, those that had achieved a size of 100,000 inhabitants by 1891. There is, of course, much interesting variation in the detailed experience of these cities. Once again it is the southern cities, as with Bristol in Table 6.1, that return the highest life expectancies already in the 1850s and that also show the strongest pattern of subsequent improvement. By contrast, the classic northern, inland industrial towns of Salford, Stoke, Blackburn, Bolton, Oldham, and Preston all exhibit high mortality, exactly like their slightly larger peers in Table 6.1, as also does Leicester. The northern coastal cities of Hull, Sunderland, and Birkenhead record a slightly superior experience, while Nottingham is an interesting lone case among the large northern and midlands industrial cities, in that it consistently reduced its mortality in each of the last five decades of the nineteenth century, though it had apparently been in as poor a situation as any of them (except Manchester and Liverpool, of course) in the 1850s. The general conclusions that can be drawn from Table 6.8 therefore largely confirm those that can be drawn from Table 6.1. First, apart from the southern towns, all the other cities exhibit life expectancies substantially below the national average, especially at mid-century. Second, there is little evidence, especially among the northern industrial cities, of a significant improvement until the 1870s or 1880s on the situation prevailing in the 1850s.

4 How, then, does the evidence presented in this chapter for trends in urban life expectancy in nineteenth-century Britain relate to recent developments in the standard of living debate? There have been two major new departures in this literature over the past couple of decades. First, there has been the recovery and analysis of a range of data sources giving information on the height attainments of various selected subsamples of the national population, particularly orphans, military

Urbanization, Mortality, and the Standard of Living Debate

191

Table 6.8: Expectation of Life at Birth in Other Large Cities in England and Wales (Population Below 100,000 in 1851 but above 100,000 by 1891), 1851–1901 Administrative cities

Salford Plymouth/ Devonport Hull Portsmouth Stoke-onTrent Blackburn Bolton Brighton Leicester Nottingham Oldharn Sunderland Birkenhead Cardiff Norwich Preston

1851– 1860

1861– 1870

1871– 1880

1881– 1890

1891– 1900

35 38

35 40

35 41

37 43

37 45

38 40 37

38 42 36

41 44 37

43 45 39

44 46 40

35 36 41 37 35 36 39 [43] [39] 39 34

36 37 41 37 38 36 39 39 41 40 35

37 38 43 39 40 37 39 42 43 42 35

39 41 46 43 41 39 41 44 44 46 37

41 42 47 44 43 40 41 44 45 47 39

Mid-census population of administrative cities (’000) 1851– 1861– 1871– 1881– 1861 1871 1881 1891 Salford Plymouth/ Devonport Hull Portsmouth Stoke-on-Trent Blackburn Bolton Brighton Leicester

1891– 1901

83 102

114 116

151 121

187 131

210 159

92 84 72 55 66 72 65

110 105 90 70 77 84 82

138 121 107 89 94 99 109

177 144 129 110 110 112 149

220 174 180 124 142 120 194

192

Health and Wealth

Table 6.8: (Continued)

Nottingham Oldham Sunderland Birkenhead Cardiff Norwich Preston

1851– 1861

1861– 1871

1871– 1881

1881– 1891

1891– 1901

66 63 72 31 26 72 77

81 78 88 42 37 78 84

137 97 108 65 62 84 91

201 121 124 92 106 95 103

227 134 139 106 147 107 111

Notes: In four cases the administrative city’s population was constituted from two registration districts (R.D.s Plymouth and Devonport; Hull and Sculcoates; Stoke-on-Trent and Wolstanton; Brighton and Steyning), so that the method outlined in note 18 was used to calculate the “administrative city life expectancy.” In six cases the population of the R.D. was consistently somewhat larger than that of the administrative city it contained, probably resulting in a slight overestimate of the city’s life expectancy here (Blackburn, Bolton, Oldham, Sunderland, Birkenhead, Preston). The 1850s figures for both Birkenhead and Cardiff are bracketed because they are not strictly comparable with the values for subsequent decades, due to radical boundary changes at the beginning of the 1860s. In the remaining cases the population of the administrative city and the R.D. corresponded closely throughout. Sources: Registrar-General of England and Wales, Decennial supplements; Mitchell and Dean (1962), 24–7.

recruits, deported convicts, and other criminals.58 Although the populations in question are far from representative random samples, these several independent bodies of evidence, analyzed in a number of different ways, have tended to exhibit some consistent general patterns, at least for the nineteenth century and both for England and Wales and for Scotland. This indicates a marked decline in children’s growth profiles from approximately the birth cohort of the 1820s until that of the 1850s (with gradual improvements thereafter).The pattern is repeated for both sexes where the evidence is available. Furthermore, the deterioration has been consistently found to be most marked among the urban samples of the various bodies of anthropometric evidence that have been adduced.59 Second, there has been a determined attempt, initially by Snell and more recently by Humphries and Horrell, to produce, often from very difficult, partial source materials, some evidence on the scale, general patterns, and trends of female and juvenile participation in employment

Urbanization, Mortality, and the Standard of Living Debate

193

and earnings during the period of the industrial revolution.60 Horrell and Humphries’s most recent research indicates substantial variation in female and juvenile earnings in different regions and industrial sectors. Although the evidence available is still relatively sparse, it does suggest a general pattern of a temporary rise in the importance of female and child earnings as a proportion of the household budget during the quarter century or so after the Napoleonic wars, followed by a gradual decline in their contribution thereafter, from the 1840s or 1850s onwards.61 Horrell and Humphries also conclude that their statistical analysis of the probable causes of these trends is consistent with the research findings of social and political historians.62 This analysis has shown that the later Chartist movement, in the 1840s, was crucial in successfully campaigning for the establishment of the patriarchal concept of the male breadwinner as a dominant idea and political aim among the working classes. It was a concept, furthermore, that elicited a reciprocating response from the male governing class in the form of the accumulative restrictions of the Factories, Mines, and Education Acts, particularly those of the 1840s and 1850s and those of the 1870s, which gradually imposed a range of tightening limitations on female and juvenile participation in the formal, waged labour market.63 The present contribution, focusing on the mortality experience of the most highly urban and industrial section of the working population, would therefore support the general implications of both of these other bodies of recent research, in identifying the second quarter of the nineteenth century as a key period of discontinuities and stresses, from the point of view of general patterns in the proletarian “standard of living.”64 Furthermore, all three forms of evidence confirm that this problematic period lasted, in a gradually attenuating form, throughout most of the subsequent quarter-century as well. Not until the 1870s and 1880s did urban mortality truly begin to recede and children’s heights revive. Most of the work of the previous generation of scholarship on the standard of living debate, from the late 1950s through to the 1980s, was, somewhat unwittingly, methodologically premised upon a patriarchal and economic definition of the problem, through its focus upon the study of adult male real wage rates as the most tractable sources of evidence with which to study the subject.This had produced, by the early 1970s, an “optimistic” consensus, confirmed in the further econometric work in this vein

194

Health and Wealth

in the 1980s: that the standard of living debate was all over by the 1810s, or by the 1820s at the latest.65 This was the date by which it seemed irrefutable that the generality of adult male real wage rates had risen above any previous level, and would never again return to lower levels.66 However, the new anthropometric and household budget evidence, along with the urban life expectancy data produced here, leads to an entirely different conclusion.The thrust of this most recent research is to give measurable aspects of the experience of proletarian women and children their full due, by examining certain social and demographic, as well as economic dimensions of the standard of living.The most general conclusion that appears to be consistently emerging from this range of new work is not so much a simple revival of the “pessimistic” viewpoint but a challenging revision of the chronology.According to this new work the decades of the 1830s and 1840s should not be viewed as the end, but, quite to the contrary, as the beginning of the serious debate over the impact of the industrial revolution on the standard of living of the British working class, as, indeed, was perceived to be the case by the most acute contemporary observers, such as the seventh Earl Shaftesbury, Disraeli, and Engels, and a host of other concerned investigators such as Cleland. The evidence presented here indicates that, notwithstanding probable rises in male real wage rates, during the second quarter of the nineteenth century there was a serious deterioration in the standard of living of the growing proportion of the population recruited into the urban industrial workforce; and furthermore that this trend of deterioration, although halted in the late 1850s and 1860s, was not significantly reversed until as late as the 1870s and 1880s. The reasons for this are dealt with elsewhere.67

Notes 1. The new evidence on life expectancies in British cities presented in this [1998] article employs a method of calculation devised during his doctoral work by Mooney, while the interpretation of the material presented here has been developed by Szreter.This article substantially revises an earlier treatment of the subject, which appeared as Working paper no.67 (1996) of the Demography Program of the Research School of the Social Sciences, Australian National University. Szreter wishes to thank demographers and historians at A.N.U. for their warm hospitality

Urbanization, Mortality, and the Standard of Living Debate

195

during a period spent as Visiting Fellow there during 1996, and the participants at several seminars in Australia for their helpful comments. 2. We follow Taylor’s classic introduction in dating the “modern” debate to the interventions of Hobsbawm (1957) and Hartwell (1961) and the agenda that their two articles set:Taylor (1975). 3. Hobsbawm (1957), 66. 4.Armstrong (1981); Huck (1994). Both of these important studies are considered at length below. 5.Woods (1985). 6. Ibid.Woods developed and modified the earlier work of Law (1967). 7. Schofield (1994), 89–90; also Kearns (1988), 221–23; Wrigley (1988), 88; idem (1993), 39 and note 18; Burnett (1991), 170; Hudson (1992), 148–49; Berg and Hudson (1992), 41; Floud and Harris (1997), 97–99. 8.Woods (1985), 649.These data were originally presented in idem (1984). See esp. Woods (1984), 40–43 for the method of construction of the period abridged life tables for the registration districts, which was essentially similar to the method used here (see below, notes14, 18), but using only three years’ worth of death registration data, instead of the data for the whole decade as has been done here. 9.Woods (1985), 649. 10. Ibid., 649–51; but see below, note 12 on the frailties of Williamson’s work in this respect. 11. The period life table produces a measure of life expectancy on the fictional assumption that all the age-specific rates applying at one point in time will apply to the notional random infant throughout its ensuing lifetime. By contrast, the more involved cohort life table makes no such assumption and applies the appropriate successive age-specific rates for successive dates to measure much more realistically the actual lifetime experience of a notional individual. For the present purposes of deriving measures of the mortality conditions prevailing in different cities at different dates in the nineteenth century, it is the period life table that provides the appropriate technique. 12. Thus Williamson’s work, although apparently containing information on urban mortality patterns in Britain during this period, is vitiated in this respect because of its use of crude death rates only: Williamson (1994), 335; Williamson (1990), 11–14. 13.Woods (1984) published a wealth of valuable, robust life expectancy estimates for registration districts, but only for a single point in time (1861–63). In 1985 Friedlander et al. published a study of mortality change in the period 1851–1911 which rested on their construction of a set of estimates of expectation of life at birth for 479 registration districts of England and Wales. However, they appear to have been unaware of the important age-specific death rate information published in the Registrar-General’s decennial supplements, which forms the essential basis for the method of life table construction used here. (See note 14.) As

196

Health and Wealth

a result they were forced to employ an inferior, indirect method using “implied agespecific death rates” to create an artificial life table for each registration district (because they had no detailed information on the age at which deaths occurred in each district). As a consequence their material could not be used to give a rigorous value for the expectation of life at birth in any specific registration district at any specific date (and they did not attempt to publish such information): Friedlander et al. (1985). 14. Mooney (1994), chap. 4. Although the annual reports of the RegistrarGeneral do not give mortality information classified by age of the deceased for registration districts, the decennial supplements do. They give, for each of the 630 or so registration districts, the decennial totals of deaths in a combination of single year age groups to age 5; five-year groupings to age 25; and thereafter 10-year age groups. These can therefore be divided by 10 to give a yearly total of deaths in each age group for the decade in question. In turn, this can then be divided by the relevant “at risk” population in each age group in the registration district in question, by taking the arithmetic mean of the figures published in the relevant census volumes for each age group at the two censuses at each end of the decade in question.The only important variation on this procedure is that it is necessary to use the total number of births registered across the decade (divided by 10, of course) as the population at risk in the critical “under age 1” group, since the census enumeration can only give a serious underestimate for this particular age group. The resulting life expectancy figure for each registration district notionally relates to the mid-census year of each decade (i.e., 1856, 1866, etc.).These measures of expectation of life are approximate, by the most rigorous of current demographic standards; but by comparison with virtually all other available quantitative historical and economic evidence for the nineteenth century, which has been mobilized in the course of the standard of living debate, they are extremely accurate and comprehensively representative of the imputed populations to which they refer. Since they are constructed by averaging all the deaths in a decade, they also have the particular virtue of being relatively impervious to (though not, of course, in any way failing to take full account of) epidemic fluctuations, of which there were many in the nineteenth century. 15. See Table 6.7. 16. Wrigley and Schofield (1981), Table 7.15, showing e0 below 32 only in the 1550s, the mid-1660s, the 1680s, and the 1730s and early 1740s. 17. See Williams and Mooney (1994), for a demonstration of this point in relation to infant mortality rates. 18.This was done in the following way. For each decade, we can compare the mid-census (i.e., mid-decade) population size of each administrative city (see lower half of Table 6.1) with the mid-census population sizes of each of the two component R.D.s (see lower half of Table 6.2). In each case the administrative city’s population size was larger than that for the R.D. bearing its name. The missing balance in the administrative city’s population must have been located in the second, outer R.D. The figure for the administrative city’s life expectancy in Table 6.1 was therefore

Urbanization, Mortality, and the Standard of Living Debate

197

calculated by weighting the life expectancy values for each of the two component R.D.s, as reproduced in Table 6.2, by the proportion of the administrative city’s total which they represented, a proportion that, of course, shifted at each successive decade. Unfortunately, this method could not be followed in the case of Bradford because, unlike all the other large cities, the R.D. bearing its name was very extensive, in effect covering, from the start of registration in 1837, both the city’s central parishes and a large surrounding area of Pennine villages and countryside. As can be seen from the lower panels of Tables 6.1 and 6.2, the population size of Bradford R.D. is, uniquely among these large provincial cities, actually substantially larger than the administrative city itself. As a result, unlike all the other seven provincial cities, it was not possible in Table 6.1 to calculate an “administrative city” life expectancy for Bradford; and the rather high life expectancy figures displayed there reflect the influence of the non-urban conditions prevailing among the R.D.’s substantial rural population in the area surrounding Bradford. There is no reason to believe that Bradford’s “administrative city” life expectancy would not be very similar to that of Leeds or Sheffield if it could be calculated. 19. Only in the cases of Gateshead and Newcastle and of Hunslet and Leeds was there relatively little difference between the “inner” and the “outer” R.D. This is not difficult to explain since the “inner” and “outer” distinction is much less valid among these two pairs than in the other five cases. Gateshead, sited opposite Newcastle on the southern bank of the Tyne, was a genuine twinned centre rather than a “suburb” of its northern partner.The numerous “out” towns of Hunslet R.D., situated to the south and east of Leeds centre, made up a densely settled and poor, primarily industrial area, failing to include more salubrious agricultural or residential districts, such as Headingley to the north of the city. 20. Dyos and Reeder (1973). 21.The two most important studies of mortality in London, 1850–1900, are Wilkinson (1980), and Mooney (1994). Two major new projects are currently under way: one aimed at elucidating the nineteenth-century epidemiological and public health history of London: Luckin and Mooney (1997); and the other focusing on major provincial cities: Millward and Sheard (1995). 22. Wrigley and Schofield (1981), table 7.15; Wrigley et al. (1997), table A9.l; Case et al. (1962). 23. Apart from Bristol (1825), these figures are taken from the national and sectional life tables based on deaths registered during the first years of registration from 1837 on, after the General Register Office was founded in 1836, relating the deaths to the age structure of the populations enumerated at the 1841 census: 5th ARRG, 23–26, 46–48; 7th ARRG, 330–9 (Manchester); 8th ARRG, 278–93, 320–25 (Northampton). [ARRG: Annual Reporrt of the Registrar-General of England and Wales.] For the derivation of the Bristol figure, see note 26. 24. Glass carefully examined the technical reliability of Farr’s early life tables, taking into account weaknesses of under-registration, especially of deaths, by the early vital registration system. However, he was satisfied that there were no

198

Health and Wealth

major problems with the estimates calculated by Farr and was prepared to cite them himself: Glass (1964). Subsequently Lee and Lam have examined the technical problems associated with the early censuses, particularly questions of the reliability of the reported age structure.While it is clear from their analysis that the data are far from absolutely reliable (no census ever is, of course), the principal significance of the conclusions that they drew from their examination was that there was no need for any important modification to the life table figures calculated by Farr. They found that their own corrected figures for e0 agreed very closely with the independent correction methods used by Wrigley and Schofield, and also with the values resulting from Farr’s original life tables (showing e0 for England in 1841 at 41.16 years): Lee and Lam (1983), esp. 461. 25. This was done simply by assuming that the life expectancy differential between Manchester and Chorlton R.D.s, and between Liverpool and West Derby R.D.s, would have been the same in 1841 as was found for each pair in both the 1850s and the 1860s in Table 6.2.This then allowed the same procedure to be followed as was outlined above in note 18. Thus, the administrative city e0 value for Manchester of 26.56 years ⫽ 0.82(25.3 years) ⫹ 0.18(25.3 ⫹ 7 years), while the administrative e0 value for Liverpool of 28.12 years ⫽ 0.78(25.7 years) ⫹ 0.22(25.7 ⫹ 11 years). 26. The figures for the city of Bristol in 1825 were compiled and calculated by the contemporary actuary, Robert Rankin, and are presented in Vann and Eversley (1992), 237–38. Rankin also drew up the first ever class-differential life tables, providing separate life table estimates for the relatively middle-class Quaker community in Bristol and for “the Poor,” showing the former’s life expectancy at birth at 40.40 years and the latter’s at a mere 20.36 years. Rankin’s data for “the Poor” were based on records for 4,061 individuals held by cemeteries offering cheap burials, and should therefore be treated as an estimate of conditions among a highly selected group of the extremely poor. 27. Unfortunately, many of the bills (usually annual compilations published as a single sheet once a year) for several English, as well as Scottish cities appear not to have survived in any quantity. Furthermore, where, as in Liverpool, a good number of bills for this period have been successfully rediscovered, the problems created by a failing registration system during a period of such rapid urban growth (rescued in Glasgow’s case by Cleland’s reorganization of 1821), make the interpretation of the bills, as reliable measures of mortality levels or even of trends, extremely hazardous, as Paul Laxton, the principal saviour of Liverpool’s bills in this period, has somewhat pessimistically concluded: Laxton, personal communication; Laxton (1986). See also Glass (1973), 16 and note 32. However, the London bills (whose origins date to 1592 although they were kept continuously only from 1603) have been used to great effect by a number of scholars, most recently by Landers (1993). 28. Milne’s correspondence printed on the prefatory pages of Cleland (1832). On Milne and Heysham, see below, note 42.

Urbanization, Mortality, and the Standard of Living Debate

199

29. On Cleland and Glasgow’s vital statistics, see Flinn (1977), 72–77, 83–84, 388. On Glasgow’s history in this period, see Devine and Jackson (1995). 30. Aberdeen’s figure certainly suggests a deficiency in the completeness of its bills of mortality, since the age-specific death rates for infants and children reproduced in Flinn (1977),Table 5.5.4, are unusually low. 31.Tatham (1892). 32. Although the bills were instituted in 1670, survive from 1699, and were reformed in 1783, mortality measures for the city cannot reliably be inferred before 1821, the year in which Cleland reorganized the system. See above, note 29. 33. In some ways the data upon which Table 6.5 is based are of especially high quality. The figures for the life expectancies in the 1820s and in 1831–35 are derived from the contemporary analyses of T. R. Edmonds, the foremost exponent of the life table technique, from whom Farr learned his craft. As a result they are actually based on full quinquennia of deaths and interpolated populations at risk in each age group, with the additional virtue that the life expectancy figures in Table 6.5 have been derived by combining a separate calculation for each sex. However, in one respect they contain a limitation that requires a further modification of our method of abridged life table construction. This is because, with the exception of the data for 1841, the age-specific mortality rates published by Flinn et al. did not distinguish between infant (0–1 years) and child (1–4 years) mortality, a distinction that is essential for life table construction. Fortunately, however, for 1841 at least, the proportion of the single rate for 0–4 that should be attributed to 0–1 could be verified through comparison of the information reproduced in Table 5.5.4 and Table 5.5.2 of Flinn (1977).This confirmed that in 1841 approximately 38.74 percent of the deaths within the age range 0–4 occurred within the first year of life. For the earlier and later dates in Table 6.5, between 1821 and 1861, this ratio has therefore been used in all cases to generate the life expectancy values from the age-specific rates published in Flinn (1977), Tables 5.5.2 and 5.5.3. Given that Glasgow was growing at a relatively constant rate throughout the period in question and that it can be assumed that its birth rate was relatively uniform, no serious statistical distortion should result from this procedure.We thank Gordon Carmichael and Chris Wilson (A.N.U.) for their advice on this matter. 34. See above, note 25. 35. Flinn (1977), 376–79, esp.Table 5.5.2. 36. Cleland (1832), 206, cites Glasgow’s population at 17,034 in 1740 and 28,300 in 1763; see also Wilson (1965), 274, 370. 37. On the history of smallpox, see Razzell (1977); Mercer (1990), esp. chap. 3. 38. Flinn (1977), 388–92, esp.Tables 5.6.2, 5.6.3. 39. It should be noted that there is evidence in the same source (slightly less dependable because of the greater ambiguity of symptoms) to indicate an offsetting rise in mortality in infants, both from measles and from diarrhea, though not on a scale sufficient to compensate for the large fall in smallpox deaths. Flinn (1977), 393–94.

200

Health and Wealth

40. Flinn (1977), 394–95 and tables 5.6.1, 5.5.1. 41. Armstrong was able to use the civil registration data for the larger, encompassing R.D. of Carlisle to produce a set of estimates of age-specific death rates for the town of Carlisle, only, by using census data and other relevant information to enable him to subtract out that portion of population and of deaths in each age group that was not resident within the town itself (in 1851 only about 63 percent of the population of the R.D. of Carlisle lived within the municipal limits of the town). See Armstrong (1981), 99–102, for a full explanation of his methods. 42. Farr in 5th ARRG, xxi, citing Milne (1815), II, Ap tables; Armstrong (1981), Ap 1, section A, 110. The most rigorous demographic assessment of Heysham’s data and Milne’s methods is to be found in Glass (1973), 125–26, esp. notes 36, 39. Glass concludes that if there was any inaccuracy in the estimate it was most likely to have been in the form of a slight under-estimate of life expectancy at birth in the 1780s. 43. Armstrong (1981), 102–4. 44. The life table for Carlisle was constructed from the data in Armstrong (1981), Ap 1, section C, 113. As with the Glasgow data, it has been necessary to make an assumption about the proportion of deaths within the 0–4 age group that should be allocated to 0–1. Two models were tried, one with 38.74 percent of deaths allocated to age 0–1, as in Glasgow in 1841, and one with only 33.74 percent of deaths so allocated. The life expectancy value of 32.907 years for Carlisle, 1838–53, is based on the average of four results, using both models for both sets of data given by Armstrong. In fact, the two models produced very similar results for each dataset (32.1 and 32.4 for 1838–44; 33.5 and 33.6 for 1849–53). 45. Armstrong (1981), 106. 46. Ibid., 104–5. 47. Huck (1995), table 1, also reproduced in Huck (1994), table 2. 48. Note that while levels of infant mortality can be approximately tied to specifiable levels of e0, in an important article Woods has given an empirical demonstration, using nineteenth-century British data, that adult mortality trends have varied somewhat independently of infant mortality levels:Woods (1993), discussed further below. 49. Huck’s results should probably be treated as provisional and indicative, rather than rigorously verified, in view of his limited discussion of the complex range of registration issues originally raised by Krause (1965). In particular, there is the possibility of trended biases in the falling baptism rate of nonconformists leading to an artificial rise in the observed infant mortality rate (because some nonconformists still buried their children in the Anglican burial grounds, though they had been baptized in the nonconformist chapels). Nevertheless, in view of the relatively limited impact of such effects in relation to the size and scale of the trends in Huck’s evidence, it seems quite certain that his work does, indeed, show a genuine phenomenon of substantial rising infant mortality in these townships; but perhaps not quite to the levels he reports.

Urbanization, Mortality, and the Standard of Living Debate

201

50.Woods (1993). 51.Wrigley et al. (1997), 260 and fig. 6.8. 52. Although to a lesser extent, the (quantitatively far less important) mortality rates at ages 5 to 10 and 10 to 15 years also rose in the second quarter of the nineteenth century:Wrigley et al. (1997), 340–53 and figs. 6.34–36.38. 53. Razzell (1977), 69–87, 136–37; and specifically on Manchester and the subsequent resurgence of smallpox, see Pickstone (1985), 34, 89, 131, 158. 54. In both Liverpool and Manchester it was the second rather than the first half of the 1850s that was relatively healthy, contributing to the significantly higher life expectancy values for the decade as a whole, compared with that for 1841. In Liverpool R.D. and Manchester R.D. inspection of the annual death rates published in the decennial supplement to the 25th ARRG shows that in each case there were at least 5 percent fewer deaths recorded for the years 1856–60 than for the years 1851–55. 55. As Tables 6.1 and 6.2 indicate, by 1851, Bradford and Newcastle/ Gateshead had also joined the category of cities above 100,000.The figures in Tables 6.6 and 6.7 reflect the following additions to this category in each subsequent decade: 1860s: Salford, Plymouth/Devonport. 1870s: Hull, Portsmouth; Stokeon-Trent. 1880s: Blackburn; Bolton; Brighton; Leicester; Nottingham; Oldham; Sunderland. 1890s: Birkenhead; Cardiff; Norwich; Preston; Merthyr Tydfil.The life expectancy values were calculated using the “administrative city” method as described above, note 18. 56.Woods (1985), 649. 57. Armstrong was both fortunate and ingenious in being able to circumvent this problem in relation to the town of Carlisle: see above, note 40. 58. The pioneering work in British historical anthropometry was: Floud, Wachter, and Gregory (1990); the major subsequent contributions to the British debate have been Komlos (1993); Nicholas and Oxley (1993); Riggs (1994); Johnson and Nicholas (1995). 59. Floud,Wachter, and Gregory (1990), 205–7, 288–95. 60. Snell (1985), chap. 1; Horrell and Humphries (1995); and see also Horrell and Humphries (1992). 61. Horrell and Humphries (1995). 62. Ibid., 112. 63. Clark (1992); Rose (1992). For a survey of this historiography see Szreter (1996), 484–88; and see Clark’s new general interpretation (1995). 64. There is not room here to summarize the long-standing debate among feminist historians over whether the pattern of increased industrial labour force participation by women during the initial era of industrialization, c.1780–1840, and subsequent decreased participation thereafter represented a net gain or loss for women’s position in society. We concur with Humphries, who has been a longstanding advocate of the view that women’s increased participation occurred on extremely unfavorable terms and was a sign of the weak bargaining position of labor, particularly during the several decades after the Napoleonic wars. In this

202

Health and Wealth

context the political strategy subsequently pursued by the institutions of organized labor to deny employers access to exploit the labor power of women and children was an essential mechanism in defending proletarian living standards over the medium term. However, this interpretation is not inconsistent with the understanding that the consequences of this strategy for the general status of women can clearly be seen to have exacerbated a set of longer-term problems of gender inequality, which have only begun to be redressed over the past few decades. For Humphries’s original statement see Humphries (1977). 65. This was the conclusion of Flinn’s masterly 1974 synthesis of the thenavailable evidence on male real wages: Flinn (1974). The main research efforts of the 1980s confirmed this conclusion, while amplifying our knowledge of important regional and sectoral variations: Lindert and Williamson (1983); Snell (1985), chap. 1; Schwarz (1985); Hunt and Botham (1987). 66. Note, however, that in turning his attention to a revision of the cost of living index in this period, Feinstein has recently argued that the gains shown by the male real wage evidence before the 1840s may have been much more modest than previously believed to have been the case: Feinstein (1995). 67. See this volume, ch.7.

7 ECONOMIC GROWTH, DISRUPTION, DEPRIVATION, DISEASE, AND DEATH On the Importance of the Politics of Public Health for Development*

Over the long term the processes of rapid economic growth seem to be strongly correlated with improvements in the prosperity and health of a society. Hence derives the commonplace notion that economic growth results in development.This essay argues that contrary to this widely held opinion, economic growth entails critical challenges and threats to the health and welfare of the populations involved and does not, therefore, necessarily produce development. Since the 1940s economic and demographic historians, social scientists, and policymakers have broadly accepted that each national

* This chapter is a slightly revised version of the essay that first appeared in Population and Development Review 23, 4 (Dec. 1997).

203

204

Health and Wealth

trajectory of sustained economic growth has always been attended by a “demographic transition,” a process in which a pronounced fall in national mortality levels (and also fertility levels) occurs as a result of the gains to national wealth. In fact the idea of a demographic transition, both as a theory and as a general historical model, has been subjected both to fundamental conceptual criticism and to empirical refutation. Important counter-examples have been uncovered, such as historic France with its fertility decline occurring before either rapid economic growth or mortality decline, and contemporary states, such as Kerala, Costa Rica, Sri Lanka, and China, where mortality has declined in advance of rapid wealth creation.1 Although there has been significant dissent, a glib post-World War II consensus has remained largely unperturbed: that economic growth causes mortality decline, principally through an epidemiological transition—a decline of infectious and communicable diseases.2 The example of Britain’s well-documented economic and epidemiological history during and after the industrial revolution has been repeatedly used as the empirical centerpiece of the most influential postwar models, which have proclaimed that the promotion of rapid economic growth and industrialization is the principal means to enhance the health, welfare, and development of a nation. But an entirely different analysis of the history of the relationship between economic growth and the health of the British population during the nineteenth century is presented here, emphasizing the disruptive consequences of industrialization and the crucial importance of the politics of public health. The argument developed here is that economic growth should be understood as setting in train a socially and politically dangerous, destabilizing, and health-threatening set of forces. These negative consequences of rapid economic growth may be conceptualized as a sequential model: the “four Ds” of disruption, deprivation, disease, and death. The four Ds are always potential outcomes of rapid economic growth, but only the first “D,” disruption, is a universal accompaniment of the process. By disruption, I mean, first, disturbance in the physical and biological environment—the ecological relationship between humans and the habitat. Second, ideological foment involving the cultural negotiation of new values and norms.Third, institutional and administrative destruction and construction. Fourth, political conflict among the competing

Economic Growth, Disruption, Deprivation, Disease, and Death

205

social groups involved, some of them relatively new social formations thrown up as the agents of economic change. It is, of course, possible to point to very many countries’ histories in which substantial economic growth has been achieved over a long secular period without suffering the full rigors of the four Ds. What is less well known, however, is that many of these same successful developed and developing economies also suffered significant setbacks or stagnations in the health and welfare of their populations for substantial periods during their earlier histories of rising economic growth when their polities proved unable to restrain and master the four Ds.This is becoming increasingly clear from recent historical research on body height and mortality rates, not only for the British case, which is explored in some detail below, but also for nineteenth-century Holland, Germany, France, Australia, Canada, the United States, and early-twentieth-century Japan, for instance;3 and in the twentieth century there have been the infamous “growth sacrifices” of the peoples of the Soviet Union in the 1930s and of China in the Great Leap Forward, 1958–61. Furthermore, many developing countries today have vast urban favelas where the full force of the first three Ds is very much in evidence but where, because of the lifemaintaining capacities of relatively cheap and often foreign-aid-subsidized medical technology, the final outrage of the fourth D—premature death—can usually be successfully staved off. Thus the extent to which the sequence of the four Ds unfolds to its final, lethal conclusion in any particular country experiencing economic growth, and which parts of the population suffer most, are contingent on the political, ideological, social, and institutional history of that country. The crucial point is that nothing inherent in the process of economic growth provides protection against its unwanted consequences— the four Ds. In those cases where such growth has proceeded without untoward health and mortality implications, the character of the politically negotiated social and institutional responses to the ever-present multi-dimensional challenges of disruption has enabled these countries to manage their economic growth in such a way as to evade deprivation, disease, and death. Much of the remainder of this essay will describe the course of the relationship between economic growth, the politics of public health, and the state of the nation’s health in nineteenth-century Britain.This follows

206

Health and Wealth

a long line of commentators, analysts, and historians, since the British historical case has always occupied a central place in the literature on economic growth and development. Because Britain was the epicenter of the world’s first industrial revolution, the most influential thinkers who originally addressed and debated the key issues focused their theories and prescriptions upon Britain’s experience. Adam Smith, David Ricardo, and Robert Malthus, Alexander Hamilton (architect of the American Republic’s successful protectionism for its infant industry against British competition), John Stuart Mill, Friedrich Engels, and Karl Marx premised their diverse ideas primarily upon their understanding of the British economy. Moreover, the British state and its provincial upper and middle classes were assiduous students of their own fast-changing economy and society, generating a rich body of literature and comment, but also a mountain of relatively high-quality economic, demographic, and social statistical evidence.4 As a result, three of the most influential postwar empirical social science models of modern economic and social change have been primarily based upon the British nineteenth-century historical evidence: the idea of demographic transition; W. W. Rostow’s theory of “take-off ”; and Thomas McKeown’s thesis on the role of nutritional improvement.5 Each of these three models deployed independent bodies of empirical evidence from the British historical case, drawn from the demographic, the economic, and the epidemiological record, respectively.These are the principal historically based theories that have appeared to support so strongly the conventional notions that economic growth should be seen as a benevolent prime mover that causes improvements in the health of nations and that produces “development.” However, as the reference to Marx and Engels suggests, alternative interpretations have always been offered. Indeed, until the 1820s, leading Enlightenment medical opinion assumed that expansion of trade, increased riches, and greater “luxury” must also bring an increased harvest of death through the “diseases of civilization” (for instance obesity, gout, and venereal diseases); and it was observed that inequality and destitution were afflictions of wealthy, commercial societies, rather than of subsistence communities.6 Malthus gave the latter viewpoint its most apocalyptic rendering in his series of essays, On the Principle of Population, from the 1790s. His views were translated into policy in Britain in the

Economic Growth, Disruption, Deprivation, Disease, and Death

207

year of his death, 1834, with the enactment of the infamous New Poor Law to discourage the poor from reckless overbreeding. Marx and Engels, by contrast, famously pronounced the system of industrial capitalism itself to be dysfunctional beyond repair and viewed the increasing plight of the poor in Britain as the necessary condition for a revolutionary dénouement. But, in addition to the economic apologists for the interests of property and the critical sociological opponents of capital, there was a third, liberal, and social reformist voice that corresponded to the institutional and political position of the public health movement. The public health perspective endorsed neither the proposition that we should place our faith in the invisible hand of economic growth nor the opposed position that economic growth could only lead to the immiseration of the masses and required political revolution as its antidote. Despite important differences in social and etiological theory, the leading practitioners of public health, in France, Germany, and Britain (where there were further significant distinctions between the Scottish school and the English), broadly concurred on an essentially reformist strategy. The increased wealth generated by economic growth held out the possibility of healthy “progress” for the majority in society. But this favorable outcome was in no way inevitable. It had to be devised with the aid of medical science and fought for politically. It could only be achieved if the serious health challenges brought on by economic change, industrial wage labor, and urban living were met with the appropriate political resolution to implement far-reaching preventive health measures, requiring the deployment of substantial social and economic resources to protect and enhance the health of the populace. This view characterized the outlook and efforts of Villermé and Bérard in France,Virchow in Germany,Alison in Scotland, and Chadwick, Duncan, Farr, and Simon in England.7 Within the terms of reference of this centuries-old debate, this essay concurs up to a point with Marx and Engels, in arguing that there is indeed something intrinsically dangerous and socially destabilizing in the wake of economic growth. However, it does not view the relationship between capital and labor as being purely antagonistic nor as being of overwhelming significance in determining the historical outcomes that are possible (though the relationship of “competitive interdependence” between capital and labor is certainly a condition of primary importance in market-oriented economic systems).8 This essay focuses instead on the

208

Health and Wealth

importance of the politics of the public health movement in determining historical outcomes. I argue that Britain’s historical evidence indicates that rapid economic change necessarily brings widespread and pervasive disruption. Of all the dimensions of disruption mentioned above, the most important in influencing possible health outcomes is the scale and nature of political disruption. For it is this that critically determines the capacity of the society, the state, its citizens, and its various associations and administrative units to devise successful strategies to manage the disruptions of economic change without incurring the other three Ds. Hence, the essential importance of the history of the politics of public health in explaining how mere economic growth and its attendant “four Ds” can come to be harnessed into economic and social “development.”

Economic Growth and the Health of the Populace, c. 1750–1870 Our knowledge of the course of economic and demographic change across the entire period of industrialization in Britain is now considered to rest on a relatively firm empirical foundation. Economic growth was occurring throughout the eighteenth century at a steady, gradual, rate of approximately 0.67 percent per annum. In the last two decades of the century the rate of growth doubled to about 1.35 percent and thereafter continued on its upward trend, reaching a plateau of an average of approximately 2.5 percent per annum, more or less sustained across the three decades of the secular boom from 1843 to 1873, before falling back slightly to an average rate of just under 2 percent per annum over the ensuing four decades, 1873–1913.9 On the demographic side, after a period of population stasis and severe mortality during the last half of the seventeenth and first three decades of the eighteenth centuries, England’s population began a sustained rise from 1731, when the total stood at 5.3 million, exactly doubling by 1815, at the end of the Napoleonic Wars; and then doubling again over the subsequent 55 years, to reach 21.5 million by 1871.10 Thereafter the rate of growth slowed only slightly, so that England’s population had reached 35.5 million by 1911.

Economic Growth, Disruption, Deprivation, Disease, and Death

209

The trend and patterns of urbanization are, of course, somewhat more complex. Until 1700 the process of urbanization was almost synonymous with the growth of London, housing at that time 11 percent of the national population and already the largest city in Europe. A century later, although London had almost doubled in size to just under a million inhabitants, even more significant was the fact that rapid urbanization was now occurring in the provinces, too. Whereas in 1700 there had been only six other towns with over 10,000 inhabitants (in fact all of them under 33,000 in size and none of them expanding rapidly), by 1801 there were forty-eight such towns and many of these had been growing fast since the 1740s, so that more of the nation’s population now lived in these forty-eight towns (12.7 per-cent) than in London (10.7 percent).11 However, none of these provincial towns had reached as many as 100,000 inhabitants by 1801, just before the spread of the new mode of production involving the centralization and concentration of work processes made possible by the steam-powered mechanization of industry. Even in the leading sector of cotton manufacture, Boulton and Watt’s rotary steam engine was not first successfully harnessed to a spinning mule until 1795 (by McConnel and Kennedy in Manchester).12 But by 1841 six English provincial cities and one Scottish city (Glasgow) recorded populations over 100,000, with Liverpool, Manchester, and Glasgow each well over 200,000 (Birmingham, Leeds, Bristol, and Sheffield were the others above 100,000). Urbanization continued at such a rate that this new phenomenon of large provincial cities above 100,000 inhabitants accounted for 30 percent of the national total by 1901, over twice as many as then lived in London, although the imperial metropolis was still easily the biggest city in the world at that time.13 The nineteenth century was, therefore, the era of industrializing urbanization in Britain on an unprecedented scale, in a manner that is historically analogous to the economic and urban growth that has since been experienced in so many other countries outside Europe during the twentieth century. What, then, was the relationship between these patterns of economic, demographic, and urban growth and the health and welfare of the populace? On the one hand the many real-wage series that have been constructed, though imperfect, probably offer the best measure of the trends in the economic prosperity (the disposable income) of the majority of workers and families during this period. On the other hand, in

210

Health and Wealth

order to evaluate the health of the populace, measures derived from contemporary death records (parish registers before 1837 and the national civil registration system thereafter) are agreed to provide the most reliable indicators. Insofar as the urban, industrial population was concerned, there seems little doubt among historians that, in general, the real wages received by those adult males born in or migrating to the centers of manufacturing in the eighteenth and nineteenth centuries were consistently higher than those paid to rural workers and that for most workers real wages were tending to rise, albeit spasmodically, throughout the period.14 Undoubtedly there were large groups in the population whose real wages did not exhibit such a strong secular upward trend.These were principally southern agricultural laborers and their families, who formed a large minority of the laboring poor at the start of the period in 1750 but thereafter were a steadily shrinking proportion of the national total as the manufacturing workforces of the northern and midland towns swelled in numbers.15 It is also likely that real wages in the London economy, although high in comparison with all other regions, did not rise much across the eighteenth and early nineteenth centuries and so were, in effect, “caught-up” by the urban workers of the north and midlands.16 On the other hand, this apparently favorable general pattern, which the adult male real-wage evidence indicates, regarding the relationship between economic growth and the prosperity and welfare of the industrial working populace is complicated, if not flatly contradicted, by our other principal category of evidence: mortality trends. Where the health of the nation as a whole is concerned, Wrigley and Schofield’s reconstruction of trends in the national average expectation of life at birth (e0) provides the best summary measure.This shows a sustained improvement across the initial period of gradual economic growth and urbanization: from the 1730s, when national e0 stood in the low 30s, to a point almost a century later in the 1820s, when it had risen to around 40–41 years.17 Although these gains were not subsequently lost, there was no further significant increase in the national average for life expectancy at birth until the 1870s. In other words, the period of most impressive, rising economic growth rates, c.1800 to 1870, resulted in few if any health improvements for the nation as a whole. This mid-nineteenth-century discontinuity in the upward trend in the national series for life expectancy at birth is all the more significant,

Economic Growth, Disruption, Deprivation, Disease, and Death

211

from the point of view of the relationship between economic growth, living standards, and welfare, when the differential experience of urbanizing and rural populations is examined. It is not possible to compare life expectancy at birth for these different environments until the second quarter of the nineteenth century, when a number of vital calculations were made by contemporaries, most importantly the first official life tables compiled by William Farr, based on the relatively solid foundation of the census and vital registration statistics collated by the new General Register Office (GRO) from 1837 on.18 In addition to compiling a national life table based on the census year of 1841 and the deaths registered during the years 1839–42, Farr also published several extremely helpful sectional life tables. These were produced for the cities of London, Liverpool, and Manchester; for a collection of rural parishes in Surrey; and for a selected set of the most healthy districts found in the country, relating to approximately 5 percent of the population in 1851.19 As a result of these contemporary studies, it is possible to form a relatively clear picture of the relationship between industrialization and health during the second quarter of the nineteenth century in England, after approximately a century of economic and demographic growth, rising real wages for the urban workforce, and improving national average life expectancy. This evidence shows that at a time when the national e0 was about 41 years, the population of London, at 37 years’ life expectancy, was very close to the national average. This was especially remarkable considering the appalling levels of mortality that have been documented for London a century earlier; its life expectancy at birth may well have been little above 20 years during the second quarter of the eighteenth century.20 Although Schwarz’s research has confirmed that there had been only modest improvement in the capital’s real wages during the intervening period, the health of its populace had apparently improved beyond recognition, despite continued urban expansion. Second, in the Surrey countryside, Farr found e0 at 45 years and therefore significantly above the national average. This was also notable, considering the difficulties experienced by southern agricultural laborers’ families throughout the previous century of Enclosures—a procession of unemployment, falling incomes, and immiseration that culminated in the wave of “Swing” riots in 1830.21 Third, in the selected group of mainly rural communities composing the nation’s Healthy Districts, e0 in 1851 was

212

Health and Wealth

already as high as 49 years, a figure not reached by the national average until the next century. The story was quite different in the two largest provincial cities, the centers of the nation’s new prosperity and of workers enjoying the most consistently rising real wages. Here Farr found an appalling situation. Average life expectancy at birth for the inhabitants of Liverpool in 1841 was a mere 28 years and in Manchester it was 27 years.22 As Table 7.1 shows, the largest and fastest-growing industrial cities (those above 100,000 inhabitants in each decade) still had life expectancies in the neighborhood of only 34 years during both the 1850s and the 1860s and showed no significant improvement until the 1870s and 1880s.We can add to this official data one other vital piece of high-quality demographic evidence: for the industrial city of Glasgow (along with Manchester and Liverpool, one of the three biggest industrial cities at that time). From this evidence, it seems certain, first, that the problem of life expectancy substantially below the national average in these largest industrial cities was already evident in the 1820s (when the earliest Glasgow data are available showing life expectancy at birth at 35 years) and, second, that the problem became particularly marked during the 1830s and 1840s, as Table 7.1 shows. Additional evidence indicates that the many smaller, but also fast-growing industrial towns of Britain at this time experienced the same pattern of sharply deteriorating mortality conditions across the second quarter of the nineteenth century.23 Other demographic historians have identified a rise in mortality from infectious diseases and sanitation diseases, especially at ages 3–24 months, as most strongly implicated in this pattern of rising urban mortality in the second quarter of the nineteenth century.24 There is, therefore, no doubt as to the basic nature of the relationship between rapid economic growth and the health of the industrial working population in Britain during its classic period of industrialization. For that ever-increasing proportion of the population directly involved in urban and industrial expansion, despite gradually rising disposable income, there appears to have been a marked deterioration in average life expectancy during the second quarter of the nineteenth century and persisting into the third quarter. It is worth noting, incidentally, that this conclusion is supported where studies of trends in other indexes of health, social security, and personal welfare have been constructed, relating to urban crime, illegitimacy, literacy, and children’s height attainments.25

Economic Growth, Disruption, Deprivation, Disease, and Death

213

Table 7.1: Estimates of Expectation of Life at Birth in Provincial Cities (Not London) above 100,000 Inhabitants in England and Wales 1810s–1890s 1810s 1820s 1830s 1840s 1850s 1860s 1870s 1880s 1890s Cities ⬎ 100,000 England 41 and Wales

35

29

30

34

34

38

40

42

41

41

41

41

41

43

45

46

Source: Chapter 6,Table 6.6.

But what caused these problems to manifest themselves so strongly at this point in time, when many of these towns had been growing rapidly and industrializing for three-quarters of a century or so? A number of important dimensions to the evidence rule out some of the more straightforward hypotheses. First, the fact that deterioration is documented during the same two to three decades in towns of widely varying size and growth trajectories, from a Glasgow or a Liverpool to a Carlisle, Wigan, or West Bromwich, militates against any simple notion that deterioration was occurring as a lagged result of earlier expansion or was precipitated by crossing a certain threshold of density, size, or speed of growth. Second, the relative immunity to this deterioration of the colossus of London, and of many of the older and non-industrial market towns, makes it implausible to envisage some kind of epidemiological wave or general climatic factor accounting for the trends. However, there are two important positive clues in the epidemiological evidence. First, the generally increasing importance of sanitation and crowding (infectious) diseases, in particular infant diarrhea and digestive tract problems, along with typhus, typhoid, and cholera; and second, the specific evidence from the city of Glasgow that smallpox mortality actually returned to plague that city in the 1830s and 1840s, after it had almost been eradicated in the 1800s and 1810s following the introduction of Jennerian vaccination.26 Both of these clues suggest the possibility of a political and administrative breakdown in the second quarter of the nineteenth century specific to the fast-growing industrial towns and cities, rather than to

214

Health and Wealth

towns in general. It seems that urban local authorities in industrial centers were failing in the management of their crowded environments at this point.Apparently such towns had been sufficiently well-organized to have delivered an effective preventive health program against smallpox in a city like Glasgow during the first two decades of the nineteenth century, while Britain was engaged in a war with Napoleon’s France. But thereafter things were allowed to slip in Glasgow.There is corroborative evidence for this view, both in terms of the level of effective voluntary action and in terms of “state” provision. For instance, on the voluntary side the second half of the eighteenth century had seen the build-up of sufficient momentum in civic activism so that a large number of voluntary hospitals had been constructed in Britain’s towns.Yet the first half of the nineteenth century saw little further addition to these resources, with serious consequences for the provision of urban medical services.27 Meanwhile the principal state “welfare” institution, the Poor Law, was dramatically reformed in the 1830s in a way that rendered it insensitive to the needs of the growing urban industrial proletariat, whose primary collective cause of insecurity was the trade cycle. But why should there have been a failure of effective urban social and health administration in this particular period; and why was it specific to Britain’s industrial towns and cities? Why were London and Bristol relatively unscathed? In seeking an answer to this problem, I will examine certain critical political, social, and ideological developments. I will argue that these developments provide the true reasons why there was a failure at this point in Britain’s industrial cities to respond to the challenge of the four Ds posed by rapid economic growth, and also why these same cities were subsequently, in the last quarter of the nineteenth century, successfully made into healthier, safer places in which to live.

Economic Growth and Urban Deterioration in Early Nineteenth-Century Britain In the fast-growing, industrial towns of the first half of the nineteenth century, environmental deterioration occurred through a configuration of three socially divisive forces, which were themselves intimately related to—indeed entailed by—Britain’s pattern of economic growth.

Economic Growth, Disruption, Deprivation, Disease, and Death

215

First, inequality of incomes and wealth was growing apace, through capital accumulation, the seizing by a fortunate few of commercial opportunities, and the extraction of rents of various kinds.28 Second, the industrial town was continually receiving rural immigrants, often in great surges during times of depression, and these immigrants tended to fill the least-secure and lowest-paid jobs.29 This reinforced, with an economic basis, quasi-ethnic divisions in self-identity, aspirations, and language between the urbanites and the rural immigrant families (the latter often including a significant proportion of Irish Catholics). Third, in the larger cities there was the process of residential segregation or “suburbanization,” as it has been termed.30 Due to the social and cultural aspirations of the commercial bourgeoisie, the wish to avoid the soot of the smoke-belching factory and the crowding of the city centers, along with the commercial logic of speculative land development, there was a powerful, centrifugal residential movement of the wealthy toward the city’s perimeter, and usually in an upwind, westward direction.While low-cost land on the urban periphery was lavishly developed into fine villas in the new suburbs, to the mutual profit of landowners, builders, attorneys, and surveyors, the older residential buildings in the center were simply rack-rented, predominantly by the same class, to the maximum density for the maximum profit, in return for the minimum outlay on upkeep. There was no point in improving or replacing these buildings because tenants could not be found for higher rents. This situation, as Dyos and Reeder were careful to point out, was a logical and functional entailment of a profit-maximizing, capital-accumulating, wage-minimizing economy: the availability of low-rent housing in central locations for low-paid workers was an essential condition for the perpetuation of this form of economic growth.31 These inner-city slums festered until they were demolished for a railway, a widened arterial roadway, more commercial premises, or, eventually in the last quarter of the century, for reasons of public health and municipal reconstruction.32 These, then, were the three principal forces of urban socioeconomic differentiation accompanying industrializing economic growth and urbanization, as they occurred in nineteenth-century Britain. During this period of its genteel abandonment, from 1830 to 1860, the image of the industrial city center increasingly assumes its dark, brutalizing, frightening, and unknown aspect in the imagination of the propertied

216

Health and Wealth

and educated class, as reflected in the novels of Charles Dickens starting in the late 1830s and Mary Gaskell’s in the 1840s.The educated, literate elite no longer dared or cared to know its own cities firsthand, by living in their centers and walking their streets.The urban police force was created at this time, deputed to maintain law and order in place of the community’s absent social leaders.33 However, these dynamic forces of economic and cultural differentiation were not, alone, responsible for the deprivation, disease, and death that occurred in Britain’s industrializing cities. It is necessary to ask why there was no effective political and administrative response at the national or local government level to the environmental and welfare problems occurring at this time. The reason for this failure of political response leads us back to the first “D,” disruption. Rapid economic growth entails the disruption of established social relations, ideologies, and structures of authority. This created a political and administrative paralysis in British cities during most of the second and third quarters of the nineteenth century. Britain’s urban political history during the first half of the nineteenth century shows how such paralysis occurred. To appreciate fully the novelty of urban social and political disruption at this particular point during the second quarter of the nineteenth century, one needs to understand that many industrial towns had grown just as fast, in proportional terms, during the second half of the eighteenth century as during the first half of the nineteenth, while nevertheless retaining considerable social integrity, political unity, and, according to the only reliable evidence that is available (for the town of Carlisle), reasonable salubrity.34 Indeed, in many of the prospering eighteenth-century and early-nineteenth-century towns there had gradually coalesced, across the property divide, an increasingly coherent and unifying antiaristocratic, anti-rentier urban politics of reform. A plebeian radical tradition had joined hands with the bourgeois liberal cause of nonconformist Dissent (from the established Anglican church), uniting the ranks of the self-styled “productive classes” (urban employers, small master artisans, and their employees, the workers) against the rural, landed Ancien Regime of “unproductive,” idle, nepotistic aristocrats—“Old Corruption,” as it was called by the reforming radicals. Most manufacturing and commercial employers in the 1810s and 1820s were still relatively small-scale: working and living cheek by jowl with their workmen

Economic Growth, Disruption, Deprivation, Disease, and Death

217

even in the largest towns, in this era before the residential move to the suburbs and the rapid expansion of the factory. With burgeoning commercial and industrial wealth as well as increasing proletarian numbers on their side, such a cross-class reform movement was, by the 1820s, becoming far too powerful to be ignored or resisted by the ruling class, the landed gentry. Accordingly the incumbent elite now conceded various constitutional reforms: the Test and Corporation Acts, which had disabled religious dissenters from political service, were repealed in 1828; Catholics were emancipated in 1829; the commercial bourgeoisie was electorally enfranchised by the Great Reform Act of 1832; the 1834 New Poor Law overhauled the nation’s social security system in the interests of “economy” and against the practices of traditionalist paternalists; and the 1835 Municipal Reform Act created representative local government in the towns with an electorate of small-scale property-holders. Nevertheless, these substantial successes for the reform movement resulted in the disintegration of the political alliance of urban employers and proletarian employees, especially as the incumbent, aristocratic, governing class had ensured that the reforms politically enfranchised only the employers and the propertied class while excluding the propertyless proletarians, thereby successfully driving a wedge between the two. These new political divisions between urban employer and wage laborer had many popular manifestations: above all, the Chartist movement, which unsuccessfully campaigned for working-class suffrage, 1837–48; but also the Factory movement, the Ten Hours movement, the anti-Poor Law and anti-policing campaigns. Political alignments became so fragmented that in the last two of these campaigns the phenomenon of Tory Radicalism was seen in parts of the country, representing a political alliance of the still-influential, paternalist landed class with the manufacturing artisans and workers against their erstwhile allies, the local businessmen and industrialists.Yet at the same time, the Anti-Corn Law League was campaigning in full force, representing a continuation of the battle between urban food-consumer interests and the landed agricultural producers. Consequently, although the constitutional and electoral reforms granted by the landed class conceded significant powers to the urban, nonconformist, liberal, and commercial interests, from the mid1830s through to the late 1860s, local politics in the provincial, industrial towns was in fact predominantly characterized by debilitating

218

Health and Wealth

internal divisions, cross-cutting interests, shifting alliances, and stymied initiatives.As a result stalemate ensued, in terms of the capacities of cities and their governments to respond to the environmental and health problems that they faced as their populations grew rapidly. Furthermore, with the mid-century consolidation in the industrial towns of newly reformed self-governing, usually Liberal corporations, supported by a predominantly petty bourgeois electorate, a new political force emerged in most towns, which became the major source of obstruction to municipal improvements over the ensuing two, mid-Victorian decades of relative prosperity: the petty capitalist class, with their ratepayers’ associations and obsessive concerns for “economy”.35 The petty bourgeois ratepayers, who had the majority of the votes in the reformed municipalities after 1835, predominantly represented those who lived among the crowded poor in the industrial and commercial districts of the town’s center.Though better-off than most of their neighbors, they were unable to afford the suburban villas that would have offered them and their families partial protection from high urban mortality. Nevertheless, they could not be induced to vote for, still less campaign for the expensive municipal measures that might have saved their own lives. By the late 1840s, this was certainly not out of simple ignorance concerning the health threats they faced: the alarming death rates of different cities were well known and increasingly well publicized in the local press, with the annual and quarterly reports issuing from the GRO.36 The notion of a strong connection between cleanliness, both of streets and of person, and freedom from disease was a common-place of educated opinion by the beginning of the nineteenth century.The problem was that the benefits to be gained from extremely expensive urban improvements to clean up the environment were too abstract, remote, and speculative to carry conviction for this class of practical men, whose principal attention was consumed with week-to-week survival in trade and the avoidance of bankruptcy.A dramatically increased demand for local rates out of their pockets, to pay for an improved local environment, was an all-too-tangible and painful call on their limited balances. Whereas in the eighteenth century a patrician oligarchy of local gentry and urban merchants had been able to implement without great objection their class’s preferences for collective spending on town improvements and services, such that some historians refer to this period

Economic Growth, Disruption, Deprivation, Disease, and Death

219

as one of an “urban renaissance,” the disruptive forces of rapid economic growth had now thrown up new forms of wealth and property, challenging and, by the late 1830s, toppling the patrician ascendancy.The problem now was that the new men represented such a wide diversity of interests, in terms of wealth levels, income sources, religious creeds, and social origins, that there was no obvious consensus among them regarding the town’s priorities; and no one section could easily assert its authority over any of the others. This resulted in grave difficulties in mobilizing agreement on the thorny issue of self-taxation and on questions of how to proceed with the large collective enterprises required to maintain the hard-pressed urban environment. It was much easier to agree to disagree, and for each to get on with minding his own business, in accordance with the liberal and libertarian precepts of the age. Ideological conflict and its historical momentum certainly played an important role in accounting for the prolonged period of municipal inactivism from the 1830s until the 1870s. In this heyday of mid-Victorian prosperity and global trading expansion, the commercial classes were now ideologically confident and committed to their class’s radical and liberal virtues: individualism, nonintervention in the workings of the urban and industrial economy, and low levels of taxation (including low municipal and low Poor Law rates). In 1834 the New Poor Law dramatically cut the nation’s expenditure on “welfare” payments to the sick, old, and poor from 2 percent of national product (probably the highest proportion in Europe at that time) to only 1 percent.37 The principal way in which this momentum of ideological and political commitment manifested itself across the three mid-century decades was in the vigor with which the “retrenchment” and “economy” campaigns of radicalism-liberalism were pursued, at both national and local government levels, respectively, by William Gladstone and by the ratepayers’ associations.38 That it would have been administratively, financially, logistically, and technically within the capabilities of mid-century municipalities to have engineered the kind of comprehensive sanitary facilities only subsequently provided during the last quarter of the century is demonstrated, first, by the fact that during the 1840s and 1850s town councils proved quite able to think big and act big where rail communications were concerned. City centers were refashioned on a grand scale as land-hungry rail lines, stations, and marshaling yards were driven through the centers

220

Health and Wealth

of all large towns.39 Unlike comprehensive watering and sewerage, the commercial advantages of rail connection were unanimously held to be incontrovertible. The railway was considered to be an absolute imperative for a town’s prosperity in a nation of shopkeepers that had, by now, so thoroughly embraced the ethos of trade. Individual town councillors and factions of local elites were eager to be seen as the ones responsible for bringing the railway to their town. Second, as to this society’s capacity for understanding the importance of observing rigorous standards of hygiene, diet, and collective cleanliness, especially in crowded conditions, the research of Philip Curtin on European troop mortality, of Shlomowitz, Haines, and Brennan on maritime sanitary practices during this period, and of S. Ryan Johansson on the medical advice taken by the unusually long-lived upper classes during the late eighteenth century all show that there was no deficit of effective knowledge or practices at this time.40 Although the germ theory of disease had not yet been developed, this society had adequate knowledge and practical capacity to protect itself against the worst hazards of dense and crowded urban living.Thus, the following brief examination of the relevant aspect of the history of water supply and sanitation in the growing industrial cities of nineteenth-century England shows that, while the appropriate technology for water provision and for arterial sewering was well understood by the 1840s at the latest, it was the debilitating sociopolitical divisions, and their eventual resolution from the 1870s onward, that critically influenced the delay in provision of this vital public health resource.

Water, Health, and the Politics and Economics of Public Health in British Cities Comprehensive water supply and sanitation for the urban poor is a classic problem in the economics of the provision of public goods.41 The scale and dispersed nature of demand for clean water created by rapid urbanization are so great that the investment costs involved are beyond the financial logic of any commercial operation, so long as the majority of customers remain too poor to pay more than a token amount for their water. It therefore requires political will and collective organization to cope with

Economic Growth, Disruption, Deprivation, Disease, and Death

221

the challenge of supplying the less-wealthy majority to ensure the health of all. That cities such as Manchester and Birmingham could have grown in size to the hundreds of thousands of inhabitants by 1861 and still not have secured a comprehensive water supply, let alone an integrated mains sewering system, seems scarcely credible. But, of course, many barriada slum populations in the world’s largest cities today face similar problems. The manner in which British cities initially did not, and then, in due course, did successfully supply themselves with adequate water and comprehensive sewering provides an accurate mirror of the changing nature and the importance of the sociopolitical relationships that governed the way in which the forces of economic growth initially were, and eventually were not allowed to wreak the havoc of the “four Ds” on the expanding British urban population. The first half of the nineteenth century witnessed a rapid increase in the number of private companies supplying water to those who could pay in the fast-growing towns: businesses and wealthier homes.42 However, during the 1840s the alarming urban death rates publicized by the GRO prompted official inquiries into the state of Britain’s industrial towns, which resulted in passage of the nation’s first general Public Health Act in 1848. This included provisions to enable local authorities to borrow sufficient funds (subsidized loans from the central government Exchequer, which still had to be paid back out of the town’s rates) to provide their populations with adequate water and sewerage facilities. A pattern of subsequent municipalization of the urban water supply did indeed occur, including buyouts of private companies in many cases. But this was not quite the sanitary revolution it might appear to have been. As noted above, the mid-Victorian towns were in thrall to the economizing interests of the “shopocracy”—the petty bourgeoisie enfranchised by the 1835 Municipal Reform Act. In the name of local self-government, a virtual rebellion among this class of ratepayers took place against those clauses of the 1848 Public Health Act that threatened to force towns to spend on improving their water supply. As a result these clauses were rarely invoked and subsequently rescinded by an Act of 1858.The municipalization of water that occurred after 1848 was pursued primarily for other than health-promotion purposes. J. A. Hassan has emphasized that the significance of water as an industrial raw material was often the primary consideration, with commercial demand

222

Health and Wealth

consuming in many cases half of the extra urban water supply capacity created after 1848.43 In other words, because of the particular disposition of powerful local political interests, the state in Britain at this time was unable to enforce sanitary improvement on the principal voting constituency of reluctant urban citizens; often it was only when key local businessmen could see a commercial advantage that an initiative was taken. The telltale sign of the industrial and commercial, rather than health-promoting, motivational forces behind the municipal expansion of water supply from the late 1840s until the 1870s lies in the partial manner in which Edwin Chadwick’s “Sanitary Idea,” the inspiration behind the 1848 Public Health Act, was being acted upon during that period. Chadwick had envisaged every urban house connected both to a clean water supply and to a water-borne mains sewerage system. However, increased volume of water supply was forthcoming during subsequent decades, but sewering was not. Hassan shows that the volume of constantpressure water supplied rose substantially in most towns; but there was remarkably little effort or expenditure devoted to the other half of the engineering blueprint laid down by Chadwick as the means to attain healthy cities. Plenty of new mains water supply pipes were laid under dug-up streets from the 1840s onward, but the Royal Sanitary Commission found as late as 1871 that most provincial cities were only just then beginning to build the integrated sewerage systems necessary to avoid contamination from wastes.This was despite the fact that in the epidemic of 1854 E. C. Snow had conclusively demonstrated the role of waste-contaminated water supplies (the Broad Street pump in London) in transmitting that most dreaded affliction of the Victorian age, cholera. Furthermore, except where the wealthier residents paid for it in their suburban villas, before the last quarter of the nineteenth century little effort was devoted to connecting-up, en masse, individual homes to the enhanced urban water supplies, a development that would inevitably have also led to the need to link such homes to an arterial sewering system. From the late 1860s onward, however, the dawn of a more genuinely effective public health movement began to stir in Britain’s industrial cities, leading over the next four decades to an accumulating momentum of substantial investments in domestic water supply and in sewerage.44 From the late 1860s there was the beginning of a widening appreciation of public health aims as a high priority among the rising

Economic Growth, Disruption, Deprivation, Disease, and Death

223

generation of politicians, town officials, and the political, voting class of the largest industrial cities. This was part of a new, religiously inflected civic consciousness and pride, a social movement in the town halls of Britain’s new industrial cities that has been appropriately termed “the civic gospel,” a call to undertake public good works first preached in Birmingham by a number of charismatic Nonconformist ministers.45 As a sense of pride began to grip the imaginations of the wealthier inhabitants of these great cities, explicit parallels began to be drawn by the confident city fathers with the cultural achievements of the city-states of classical Greece and Renaissance Italy, as models for the corporate conversion of mere industrial prosperity into positive human progress, civilization, art, and learning.46 From the 1870s positions of public leadership in Britain’s provincial cities were increasingly sought by practical men of substance and vision as valued positions of honor.47 The status of the activities involved in municipal services and administration was commensurately enhanced during this period, with the proper selforganization and professionalization of many of this growing range of public service officials. For instance, the key post of Medical Officer of Health now became a salaried statutory office in every local authority; vocational training in specialist courses became mandatory (Dublin and Cambridge Universities being among the first to offer the new Diploma in Public Health), and a national professional journal for Medical Officers of Health, Public Health, was founded.48 The civic gospel was part of a wider “optimistic” intellectual movement sweeping Britain’s upper and middle classes in the 1860s and 1870s. This can, perhaps, best be summarized as the flowering of the mid-Victorian faith in the possibility of social progress and the relinquishing of the profound misgivings and fears that had accompanied the first three-quarters of a century of bewildering, rapid change.49 A more optimistic assessment of the “improvable” character of the laboring classes prevailed among an influential section of the elite, including Prime Ministers Disraeli and Gladstone.50 Consequently an electoral constituency potentially much more responsive to the ambitious patrician plans in Britain’s industrial cities was now created. The hold of ratepayer “economy” over municipal politics was broken in the late 1860s and 1870s when the voting power of the petty bourgeoisie, in command since the 1830s, was submerged in the new, wider

224

Health and Wealth

national and local franchises following the Second Reform Act of 1867 and the collateral Municipal Franchise Act and Assessed Rates Act, both passed in 1869.51 In consequence, the electorate approximately quadrupled in size at urban local government elections, bringing an influx of working men, comprising about 60 percent of all proletarian males, the class that had been left out in the cold in the 1830s.52 Furthermore, many of these new voters, being wage-laborers and tenants rather than homeowners, did not pay local rates directly (they were termed “compounders” as it was deemed that they paid local rates indirectly, compounded into the rents that they paid their landlords). The results of these electoral reforms increasingly brought into the calculations of urban politicians, both in local and national elections, questions of how best to cultivate the interests of these, the respectable and more prosperous, but non-ratepaying segments of the manual working classes. Joseph Chamberlain, Mayor of Birmingham for three consecutive years, 1873–76, was the first major political figure to exploit this by constructing a coherent program of practical policies to satisfy this workingclass constituency with his “gas and water” “municipal socialism.”53 His was a political program whose democratic novelty lay in its appeal to the urban consumer, not the producer or retailer interests. Chamberlain rhetorically undercut the traditional cry for economy by arguing that failure to spend on the town’s environment was false economy, causing untold costs to the health and working efficiency of the town’s populace; true economy required municipal investments, whose value should be assessed over the longer term. Such views commanded respect when they came from one of the city’s most successful businessmen. Their chances of political success were, of course, assisted by the fact that they were addressed to an electorate many of whom were not faced with direct bills for the increased rates required. Following Chamberlain’s lead, sustained efforts to improve the living conditions and the amenities of the urban working class came to be seen as potentially paying high political dividends. In this era of the civic gospel, a rivalry developed between the town halls of many of Britain’s great “city states” during the last quarter of the century, as they competed with one another for salubrity, provision of public services, and the lowest death rates. Once this cross-class alliance between the urban patriciate and the urban plebeians had again taken hold (having been in abeyance since the

Economic Growth, Disruption, Deprivation, Disease, and Death

225

1820s) the political will could be committed to investment in the urban environment.The nature of the transformation in the quality and scale of municipal activity from around 1870 onward can be grasped immediately, in summary form, by noting that the amount requested by local authorities in subsidized (low-interest) loans for sanitary activities from the central Exchequer increased eightfold, from £11 million during the period 1848–70 to £84 million during 1871–97.54 But this massive increase in the use of such loans was only one of three principal methods that urban councils used to free their ambitious plans from exclusive and direct dependence on the local rates levy on fixed property.There was an active search during the 1870s and 1880s for new fiscal mechanisms to achieve the electoral promises of urban improvements for the minimum current costs in rates, so as to avoid unduly provoking the ratepayers’ associations, the still-feared pressure groups of the petty bourgeoisie. Apart from Exchequer loans, the two other techniques evolved were, first, taking out large, long-term, low-interest loans on the commercial money markets of the City of London (thereby deferring costs for current improvement onto future generations and avoiding immediate, dramatic hikes in the rates) and, second, indirect taxation on the urban populace through “municipal trading”—running local monopoly services, such as gas, electricity, and trams, at a profit in order to create revenue for the city to fund improvements.55 Millward and his colleagues have shown that by 1913 £190 million in municipal loans had been raised in stock issues in this way, representing a quarter of all local authority debt at that time.56 They also found that by the opening years of the twentieth century, a sample of twenty-five borough towns were showing, between them, net profits on their municipal trading activities equal to their entire annual labor, maintenance, and capital costs for all public health and police activities.57 Following the earlier and mid-nineteenth-century trend of deterioration and uncertain recovery in the mortality experience of Britain’s largest cities,Table 7.1 indicates the positive impact that these new political developments and associated investments in facilities and services were having on urban health and welfare during the last three decades of the Victorian era. The historical epidemiological evidence for England and Wales has been the empirical centerpiece of the highly influential McKeown thesis, which argued that municipal improvements could

226

Health and Wealth

be assigned only a minor role in accounting for mortality decline in nineteenth-century Britain and that nutritional improvements delivered by rising real wages should be seen as performing the principal role.58 However, McKeown’s thesis was always under challenge when comparative evidence from other countries was considered.59 As we have seen in chapter 4, it is now clear that McKeown seriously misconstrued his own analysis of this valuable body of evidence and that in fact the research results he published support the opposite conclusions to those he himself drew.While improvements in quality and quantity of urban food supply and rising average real wages were no doubt important contributors, detailed reinterpretation of McKeown’s analysis of the historical British epidemiological evidence shows that in fact it was primarily improvement in mortality caused by diseases affected by sanitation and by specific public health measures (typhus, typhoid, cholera, and infant diarrhea, in the former category; smallpox in the latter category) that most unequivocally made the primary contribution to mortality decline during the period before the Great War. As with the timing of urban health trends, therefore, this evidence strongly implicates the importance of the politics of public health and of municipal preventive health measures as having played the most significant role in improving the health fortunes of the British population from the 1870s on.60 In a recent contribution to this debate, Constance Nathanson compared the histories of public health measures related to maternal and infant care and to tobacco control in the United States and France to develop a framework for conceptualizing the principal factors involved in the politics of public health.61 From this comparison of one country with a strong political culture of the unitary central state (France) and one with a particularly strong culture of individual liberty from the central state (the United States), Nathanson showed that in each case the rhetorical and social construction of a significant public health risk, and the nature of the response to it, were consonant with these pronounced national differences in political system and ideology. For instance, in France the perception by central state officials and the national political leadership of a military threat to the nation’s survival resulted in the creation of a national set of maternal- and infant-care measures following France’s defeat in the Franco-Prussian war of 1870–71. Whereas in the United States, under the nation’s fragmented state system, the initiative

Economic Growth, Disruption, Deprivation, Disease, and Death

227

for such services instead had to come from a protracted grassroots movement of women reformers and married women themselves, concerned about their own health prospects. Furthermore, their legislative successes were far from total because their schemes were opposed by another association of interested citizens, the mainly male members of the American Medical Association. Nathanson’s analysis demonstrated that the highly variable character of the history of public and preventive health measures is intimately related to the varying powers and character of the state, lodged in its distinctive political culture. Both in France and in the United States it was this which constrained, first, the manner in which perception of a significant health risk could be institutionally constructed as being of sufficient importance to require action; and, second, how it could then be acted upon with effective organizational resources. Christopher Hamlin has documented this in the British case with respect to the science of water purity during the second half of the nineteenth century.62 Hamlin shows that with the British central state declining to take an authoritative position, there was enormous cultural, institutional, and legal space for decades of debate both in official and professional journals and in the courts of law between different water analysts and engineering specialists to dispute questions of water purity and the implications for the relative merits and costs of alternative sanitary engineering proposals advanced by their competing clients, the private water companies and the municipal authorities. Hamlin’s research details the protracted, highly negotiated nature of the scientific debate over defining and measuring acceptable standards of water purity and the complex implications this could have for investment in the appropriate “lumpy” and expensive technology. Hamlin demonstrates the impossibility of holding to any straightforward scientific or technological determinist viewpoint that would attribute the dramatic increase in water and sanitary investment to a particular scientific breakthrough (the most obvious candidate being the germ theory of disease, although William Bynum long ago showed the dilatory nature of the acceptance of even this theory by the medical profession itself).63 The wrangling over the science of water technology went on into the 1880s and 1890s.The conclusions to be drawn from Hamlin’s account emphasize the highly political, ideological, and commercially involved nature of the public health policy debate. While it is always a powerful

228

Health and Wealth

rhetorical move to claim scientific authority for the implementation of any public health measure, those opposed to it can prove themselves equally adept at creating scientific uncertainty over the precise practical implications, as Nathanson’s account also shows. Thus, while strong scientific evidence and arguments are in no sense unimportant in the history of the politics of public health, they are more realistically viewed as the necessary, rather than the sufficient, sources of public health activism on any issue. Science and technology are only parts of the complex political alliance of social and ideological elements that is necessary to drive such a large-scale phenomenon as the public health movement. In terms of this essay’s focus, therefore, Nathanson provides us with a framework for understanding the politically contingent range of factors involved in determining the capacities of different societies to respond to the health challenges—generated by economic growth—of the four Ds. The case study of Britain presented here emphasizes the likely salience and significance of one or two additional considerations that can be incorporated into the framework Nathanson proposes. It suggests that in countries which are not so extreme as either France or the United States in their respective veneration of or aversion to the central state, a range of intermediary civil institutions and sociopolitical forces, which fall somewhere between the central state and the social movement, may also be important determinants of the politics and practice of public health. Nathanson clearly recognized that in some circumstances the politics of local government might be critical to public health, and this seems to have been the case in Britain (see this volume, ch.9 on local expertise).64 Indeed, a nuanced, variable, and perhaps even decentralized conception of the state may be required. Michael Mann’s conception of the intrinsically variable “polymorphous” state may be helpfully developed in this connection.65 This formulation recognizes that the “presence” of agencies of the central state in the provinces, and the state’s capacity to enlist the services of genuine brokers to be its eyes and ears as well as its arms and legs, crucially affect the strength of the state, in terms of its reach into society and its capacity to transmit the drive of its engine.66 Mann’s notion of the state can embrace much of what is more often termed “civil society” and, perhaps misleadingly, thought of as separate from the state: especially local government agencies, aspects of the voluntary sector, and the public service professions. The professions, like local government structures,

Economic Growth, Disruption, Deprivation, Disease, and Death

229

can be of particular significance because of their relative permanence and capacity for institutionalizing specific aims and interests, which may or may not correspond with those of the central state. (This can also, of course, be true of certain long-lived voluntary or philanthropic associations, as well as commercial corporations, as Nathanson’s tobacco example and Britain’s nineteenth-century private water companies illustrate). In the British case, the Victorian and Edwardian public health movement would certainly count as a social movement in Nathanson’s terms, but it was an unusually long-lived one, and one that had, from early on, colonized certain important institutional resources within the structures of the polymorphous state.This was principally by virtue of its early “capture” (1837–41) of the nation’s primary social and economic intelligence system (the General Register Office, the office of state responsible for taking the decennial census), which it promptly used to launch a continuous flow of influential propagandist public health publications.67 Also important was the creation of a public health medical department within the central government (from 1848) and the statutory establishment of a trained cadre of Medical Officers of Health in every local authority around the country (from 1875). In developing countries today the role of the World Bank and the World Health Organization, international aid agencies, and nongovernmental organizations would evidently all need to be acknowledged as additional institutional and political forces influencing the relationship between state and society. Indeed, it may well be that the political and institutional presence of these nonindigenous agencies, rather than their technical or financial inputs and advice, have sometimes had the greatest impact on the development of public and preventive health measures in such countries.

Conclusions: The Importance of Politics, the State, and Social Capital The British historical evidence indicates that rapid economic growth can directly cause critical social insecurities and health problems. Such growth necessarily brings, as its immediate corollaries, not security and prosperity but disruption and deprivation, resulting—unless mediated by effective social and political responses—in disease and death.

230

Health and Wealth

This essay has examined a well-documented, long-term historical example of rapid economic growth pursued according to the principles of economic liberalism, with minimal intervention from the central state: the case of nineteenth-century Britain, the first industrial nation. Even in a society that was well endowed with voluntary institutions (friendly and other self-help provident societies as well as philanthropic and medical charities) and a relatively effective welfare net (the Poor Law), which had functioned throughout the early modern era to protect the poor from the worst rigors of indigence and misfortune, serious and alarming health problems rapidly ensued within a single generation.The processes of economic growth and the blind laws of profit-taking unleashed in Britain’s industrial towns and cities generated the problems of disruption and deprivation.The evidence presented in this essay shows that economic growth, in and of itself, in no way guarantees a nation’s health and welfare, but, if given free rein, may lead directly to and cause the four Ds. The clear perception of the disruptive entailments of rapid economic growth ought to prompt a thoroughgoing reappraisal among social scientists and policymakers of the value of such growth. It is not an unalloyed good. It is highly questionable whether it is wise for a government’s policies to be aimed simply at the promotion of rapid growth as its top priority. Policies favoring more modest and well-diffused increases in prosperity, as a goal both for the nation and for individuals therein, may well provide a healthier and more viable, deliverable, and stable agenda than the rhetoric of maximizing growth. Of course, the “sustainable growth” school of thought also advocates the approach recommended here on the separate, but no less important grounds that it is necessary for long-term environmental viability. Governments would be well advised to pay as much attention and concern to monitoring trends in their nations’ income distribution and in the health of vulnerable sections of the population (backward regions, migrant workers, and women, for instance) as to their GNP figures. The governments of vast developing societies, such as those of China and other South and East Asian countries, are responsible for the future wellbeing of colossal numbers of individuals. They are nations currently experiencing rapid economic growth and seeking to transform that growth into genuine development in the next century. It is imperative that these governments

Economic Growth, Disruption, Deprivation, Disease, and Death

231

realize that the recurring lesson of history, from nineteenth-century Britain to Eastern Europe in the 1990s, is that nothing needs such careful planning and continual management as a “free market” economy, if the four Ds are to be avoided.68 There is, however, a chronic problem in the way of establishing this awareness as a permanent priority in the public mind, a problem that seems to result from an iron law of public health history, such that each generation has to relearn the lesson.This problem lies in the unintended consequences of the public and preventive health movement’s own historic successes, whereby electorates habituate to successful and effective preventive health measures, many of which have become so normal and routinized in advanced societies that they have become politically invisible.Who, for instance, would now consider that the historical origins of hard-surface urban streets of a certain minimum width lay principally in public health, rather than efficient transit considerations? Another salient example has been the recent fate of the welfare states in some Western liberal democracies.These were the proud creation of a previous generation (some of whom are still alive thanks to its provisions!), valued for its unifying social security and health services open to all citizens, regardless of wealth. By the late 1970s, however, all this had come to be so taken for granted by a sufficient proportion of the electorate in both the United States and Great Britain that their citizens voted throughout the 1980s for governments promising the Fools’ Gold of lower personal taxes in return for dramatic reductions in the provision of such public services. The ensuing retrenchments were premised on the stigmatizing argument that such public services were wasteful and parasitic (on the “productive” economy) and on the further presumption that no important negative consequences would flow from the contraction of these services and their selective targeting.69 Both electorates eventually voted out these governments, finding that the incipient dismantling of the social security and preventive health systems has in fact resulted in unpalatable social and health problems, such as home-less teenagers on the streets, rising proportions of children living below the official poverty line, rising class sizes in state schools, and the BSE and other food scares in Great Britain. Of course, it cannot be expected that the four Ds will manifest themselves in exactly the same manner in the contemporary developing

232

Health and Wealth

countries as in historical Britain. In particular, the sections of the population bearing the highest health costs in the developing economies of the late twentieth century may well be found either in the countryside and in remote regions rather than in the cities, or among prime working-age males rather than among women and children—both of which appear to be the case in China, for instance.70 It may be that it is often deprivation, rather than disease or death, that is now the principal price such populations pay. Even so, this does not negate the validity of the four Ds approach, which does not predict that the negative consequences must be experienced in the cities or among any particular section of the population or that the full sequence of all four Ds is inevitable. In this conclusion, therefore, I suggest that Britain’s nineteenthcentury history of the relationship between economic growth, the politics of public health, and “development” exhibits at least four specific aspects that may have more general relevance and that may apply to the late twentieth century. First, given that rapid economic growth necessarily involves disruption of extant sources of authority as new forms of wealth and sources of power emerge, it seems likely that the intra-elite conflicts and cross-cutting clashes of interests among holders of different grades and types of property, along with ethnic or denominational rivalries of the sort found in the British historical case, will typically characterize such rapid economic growth in most societies.This competitive sociopolitical situation can cause serious and prolonged health problems for deprived sections of the population (whether urban or rural) if, as occurred in Britain, political and administrative paralysis ensues. The necessity of politically negotiated bargaining to promote expensive environmental and social improvements can all too easily become bogged down for decades by sectional conflicts and defensive political standoffs. This point can be related to the perspective developed by Drèze and Sen.71 They invoke the concept of “cooperative conflicts” to characterize the social relations of communities under pressure, where negotiation is required to finesse the Prisoner’s Dilemma predicament they face: that all could benefit from mutual cooperation but this will not arise from pursuit of sectional self-interests. British political and urban history in the second quarter of the nineteenth century shows that the severe disruption entailed by rapid economic growth was reducing the capacity

Economic Growth, Disruption, Deprivation, Disease, and Death

233

of this society to resolve its many cooperative conflicts. Mutual suspicions and misunderstandings were instead too much the rule, as the different sections of the community pursued their diverse economic interests and separate denominational codes of loyalty and association. Second, the British case indicates the great importance of constitutional arrangements and of political organization, particularly the extent to which the poorer sections of the community have an effective political voice. This is not, however, simply a matter of working-class votes, though they can be critically important in the right circumstances, as the period from the 1870s onward shows in Britain. Equally important at that point was an imaginative, neopatrician political leadership provided by a section of the urban propertied elite among the business class, effectively focusing the energies of the working-class voters on backing a practical program for alleviating their health and environmental problems. In Marxian or Weberian terms this was a cross-class political alliance. This shows that there is no simple relationship between the acquisition of voting power by the poor and their effective political representation, because this class is, almost by definition, relatively deficient in autonomous political resources. It is therefore their relationship with elements of other, more privileged social groups and the latter’s ideologies that may be more critical in determining the consequences of their voting power. Third, there is the complex issue of popular ideas and conceptions of property rights, property interests, and legitimate forms of local and central state taxation and appropriation.72 This is intimately connected to the issues that Amartya Sen has emphasized with his concepts of entitlements and capabilities, in that these popular perceptions, and the ideologies behind them, govern the legitimacy in different societies of varying balances between the acceptability of private appropriations and the public redistribution of the wealth that is generated by economic growth.73 As the political history of late-twentieth-century Britain has shown, as clearly as that of the mid-nineteenth century, the libertarian British, like U.S. citizens, can be peculiarly sensitive to central and local governments’ direct appropriations in taxes and rates from their current income, which they resent as a compulsory forfeit of what they believe they have personally earned.Yet they can remain supine in the face of even quite sharp rises in indirect taxation (value-added taxes) on their consumption

234

Health and Wealth

activities, because they view the latter as essentially voluntary and elective.Although different cultures vary in their attitudes in this respect, the generalizable implication is that, given the enormous costs of maintaining the health and environment of the populace during rapid economic growth, politically successful solutions will probably depend on treating property rights and associated fiscal sensitivities with great respect. Furthermore, the particular types and forms of taxes adopted can themselves have a range of positive or negative redistributional implications, not always immediately apparent to the electorate or even to the specialists devising them (if, for instance, too narrow or undiscriminating a framework for analyzing their impacts on different kinds of family or household is adopted). Fourth, the British historical case indicates the importance of the state and politics in determining the character of the response to the four Ds and, therefore, in determining the changing relationship between economic growth and the health of the population. Once it is accepted that political choices and social and cultural institutions are critical in determining this relationship, it becomes incumbent on demographic and epidemiological social scientists to turn their attentions to the politics of public health, as has been recently advocated by Constance Nathanson. It is also necessary to adopt a much wider and more flexible understanding of the “state” as embracing a range of devolved agencies, mediating institutions, and ideological influences. For instance, in the British historical case local government, the public service professions, and a section of the urban big business class each played crucial roles. To conclude, the argument here is not a Luddite one, of simply being against economic growth. Rather, the thesis is that the causal relationship between economic growth, enhanced human welfare, and development is dialectical and therefore can appear to be paradoxical. Rapid economic growth must be viewed, in the long run, as a necessary condition for improvements in human health and welfare, through its provision of the material resources for this possible outcome. But in the shorter run, the direct consequences of the more unrestrained forms of economic growth have often been inimical to the health and welfare of the individuals living in a society subjected to these processes. As noted above, recent research is uncovering a number of examples in the European, North American, and Japanese historical record that bear the

Economic Growth, Disruption, Deprivation, Disease, and Death

235

same demographic footprint of the four Ds as in the British case: where the initial phase of rapid economic growth was accompanied by an interruption in a longer-term trend of improving conditions of health.74 The crucial further point is that the punitive short term does not automatically turn into the more beneficial longer term simply through the passing of time: such is the pernicious myth of the invisible hand or trickle-down, metaphors that enable growth apologists to ignore, or treat as trivial, the key political and institutional questions involved in development. Robert Dorfman recently noted that “both Rostow and I use the terms economic growth and economic development interchangably,” asserting that “economic growth and development are so closely linked . . . [that] distinguishing between the two concepts does not seem worthwhile.”75 The thrust of the present essay is to argue, on the contrary, that this semantic conflation is profoundly misleading. Economic growth becomes sustained economic development only through the mediation of the social and institutional forces promoted by the politics of public health. Development is really a much broader concept than economic growth. While it may be true that development cannot occur without growth, it is equally true that economic growth cannot persist without development. The problem perhaps lies partly in language. The biological metaphors used here invite us to think of development as the product of growth, insidiously implanting the idea that growth is the prior, causal force, and development is its consequential outcome. But this is highly misleading. For instance, the social development of an expanding and diversifying education system producing a more literate and numerate population is both a product of the fruits of increasing national wealth (though high levels of education can also be delivered in nonindustrialized countries) and simultaneously a vital condition for that society’s achievement of continuing economic growth. This is equally true of the relationship between economic growth and the health and welfare of the population. Given that it is the quality of the human working parts and their institutional relationships that determine the productivity of any economy, it is an unhelpful fiction to view growth of the economy as being prior to or independent of the accompanying changes in social institutions. Like the two strands of DNA’s double helix twisting around each other, they are mutually dependent for their perpetuation.

236

Health and Wealth

Development therefore comprises a range of institutional changes that vary considerably in their manifestation in different countries, depending on each society’s political and ideological inheritance and its familial and social structures. The importance of this fact is increasingly being recognized by growth and development economists and sociologists, among whom Cold War notions of economic and social convergence toward a single kind of modern political economy have fallen out of favor, as instead they have begun to envisage the salience of distinct models of market-oriented societies, such as “American,” “European Social Market,” “British,” and “Japanese.”76 At the same time the 1990s have seen a growing acceptance of “new growth theory” among economists, who recognize that there are serious limitations in the dominant, neoclassical “growth accounting” model of economic growth, dating from the 1950s, and that the very different performances even of advanced economies since World War II indicate that social and cultural institutions play a much more formative role in economic affairs than has previously been acknowledged.77 The recent conceptual elaboration and empirical critique and application of the concept of social capital (as distinct from both financial capital and human capital) appears to offer a highly promising way forward for those exploring the relationships among economic change, social institutions, the state, the politics of public health, and health outcomes.78 The set of concepts related to social capital provides a methodology for specifying and studying the changing economic and political implications of social and cultural institutions influencing relationships of trust, honor, friendship, social equality, and civic participation. Empirical research is beginning to explore the way in which social capital is vital both for good communications and the efficient functioning of economic organizations and for the promotion of positive health across societies.79 The idea of social capital, along with other, related conceptual work on the embeddedness (in society and polity) of economic exchange relations, radically undermines the distinction, sacrosanct in the approach of neoclassical economics, between the state and the market (or, even more misleadingly, between the state and civil society).80 Hence recent, comparative empirical work, critically developing the idea of social capital, has produced evidence of the importance of “co-production” across the “public-private divide,” involving detailed negotiation and cooperation between state, voluntary, and market

Economic Growth, Disruption, Deprivation, Disease, and Death

237

agencies, in bringing about positive economic developments in Taiwan, Kerala, Brazil, and China, while also explaining the difficulties encountered in Nigeria, Mexico, and Russia.81 This work looks rather similar to the account offered here. In Britain’s nineteenth-century industrial cities, an initial period of disruption and breakdown was followed by the rebuilding of social capital and of mechanisms for “co-production.” The sequence of the four Ds was redressed and economic growth translated into positive economic and social development only when the relations of social capital in Britain’s industrial communities were sufficiently strong that the politics of public health could direct collective resources toward the good of the community as a whole.

Notes 1.The theory’s most influential progenitor, Frank Notestein, was aware of its empirical limitations by the early 1950s: Hodgson (1983), 12, citing Notestein (1953). For a conceptual critique, see Szreter (1993); and Szreter (1996), chap. 1 and chap. 10. On contemporary mortality declines in poor countries, see Halstead, Walsh and Warren (1985). 2. Omran (1971). 3. On Japan see Johansson and Mosk (1987). On the United States see Steckel (1995), 1920; and Haines (1998). On the Netherlands see Horlings and Smit (1998). On Germany see Twarog (1997), esp. 297–99 and 306–7. On France see Weir (1997), esp. figs. 5.8 and 5.10. On Australia see Whitwell, de Souza and Nicholas (1997). On Canada see Pelletier, Legare and Bourbeau (1997), esp. table 2 and 99–100. 4. Cullen (1975). 5. Rostow (1960); McKeown (1976); on the dependence of the original formulation of demographic transition theory on the British historical evidence, see Szreter (1996), 9–21. 6. Ackerknecht (1948), 140; Ackerknecht (1967), 156; Coleman (1974); Polanyi (1957), 103. 7. On France see Coleman (1982) and La Berge (1992). On Germany see Ackerknecht (1953) and Tesh (1988). On Britain see Flinn (1965); Lambert (1963); Eyler (1979); and Hamlin (1997). 8. For the concept of the competitive interdependence of labor and capital, see Burawoy (1979) and Burawoy (1985). 9. Figures (rounded) from Crafts and Harley (1992), 715; and Feinstein (1972). Of course, these average annual rates of growth are toward the lower end

238

Health and Wealth

of what economists would categorize as rapid economic growth in the late twentieth century. Indeed, this modern perspective partly lies behind the currency of the historiographical notion of “slow growth” as characterizing Britain’s early eighteenth-century stages of industrialization, following Harley’s celebrated revisionist article: Harley (1982). The key historical point, of course, is that sustained economic growth at rates substantially above 1 percent per annum for any length of time, let alone a period running into decades on end, was unprecedented in world history. If an economy today began to experience growth rates of about 15–20 percent per annum, decade after decade, this would be a reasonable historical analogy to the revolutionary speed of sustained growth achieved by the British economy from c.1800 onward. 10.Wrigley and Schofield (1981), table A3.1.These figures more or less represent England and Wales: in 1871 the population of Wales was about 1.3 million and in 1911 it was about 2 million. 11. Corfield (1982), tables I and II. In 1801, 70 percent of the population still lived in an essentially rural environment (defined as a settlement of fewer than 2,500 persons). 12. Chapman (1987), 21. Of course, the factory method of workforce organization had already been pioneered before the application of the rotary steam engine, particularly from 1771 by Richard Arkwright at his water-powered cotton mills at Cromford, Derbyshire. 13. See above chapter 6, table 6.7. Outside England and Wales, the other major cities in Great Britain with over 100,000 inhabitants in 1871 were Edinburgh, Glasgow, Dundee, Dublin, and Belfast. 14. Flinn (1974); Hunt (1981), chap. 3; Lindert (1994), 368–72. The most recent research has revised downward to extremely modest rates the scale of likely real wage and real household income rises experienced before the 1840s by the population in general: Feinstein (1995); Horrell and Humphries (1995). However, it remains the case that urban, industrial workers and their families are believed to have been the main beneficiaries of the real wage and income rises that occurred throughout the period (see next note). 15. Snell (1987), esp. chap. 1. 16. Schwarz (1985); Hunt (1986); Hunt and Botham (1987); Schwarz (1990). 17.Wrigley and Schofield (1981), table A3.1;Wrigley, Davies, Oeppen and Schofield (1997), table A9.1. 18. Glass carefully examined the technical reliability of Farr’s early life tables, taking into account weaknesses of under-registration, especially of deaths, by the early vital registration system. He was nevertheless satisfied that there were no major problems with Farr’s estimates and was prepared to cite them himself. Subsequently Lee and Lam have noted minor technical problems with some of the early censuses but, again, their research would not indicate a need for any significant change in the figures calculated by Farr. Glass (1964); Lee and Lam (1983).

Economic Growth, Disruption, Deprivation, Disease, and Death

239

19.The national and sectional life tables based on the 1841 census were published in 1843 and 1845 in the 5th and 7th Annual Reports of the RegistrarGeneral, while the Healthy Districts table, based on the 1851 census, was published in Farr (1859). 20. Laxton and Williams (1989); Landers (1990). 21. Snell (1987), chap. 1 and Appendix, on southern agricultural incomes; Hobsbawm and Rudé (1969). 22. Farr in fact produced figures that indicated values of 25.7 years for Liverpool and 25.3 years for Manchester.The slightly higher values cited in the text were calculated by Szreter and Mooney (chap. 6, this volume) in order to reflect the full population of each city in 1841, including the 20–30 percent of inhabitants resident in the somewhat healthier outer suburbs, a section excluded from Farr’s original calculations: see above, chapter 6, table 6.3 and note 25. 23. Armstrong (1981); see chap. 6, this volume; also Huck (1995), table 1, examining infant mortality trends in West Bromwich, Sedgely, and Walsall in the South Staffordshire Black Country and in Wigan and Ashton-under-Lyne in Lancashire. 24.Woods (1993);Wrigley et al. (1997), 260 and figure 6.8. 25. On crime see Gatrell (1980). On illegitimacy see Laslett and Oostereven (1973). On industrial urban literacy see Schofield (1973). And on heights see Floud,Wachter, and Gregory (1990); and Johnson and Nicholas (1997). 26. Flinn (1977), 388–95. 27. Cherry (1980). 28. Perkin (1969), 135–36, 419; Phelps Brown (1988), chaps. 11.1, 14.3–14.4. 29.Anderson (1971), esp. 157 and table 43; Pooley and D’Cruze (1994); see also King (1997). 30. Dyos and Reeder (1978), 369. 31. Ibid., 361. 32. Kellett (1993). 33. Storch (1993). 34. See above, chapter 6: expectation of life at birth in Carlisle in the 1780s can be estimated at 38.7 years, which was actually above the national average of 36–37 years at that time. 35. Hennock (1963); Fraser (1976). 36. See chap. 8, this volume, 245–49. 37. Lindert (1994), 385–86. 38. Biagini (1992); Prest (1990); Hennock (1963). 39. Kellett (1993). 40. Curtin (1989); Shlomowitz (1996); Haines, Shlomowitz and Brennan (1996); Johansson (1997). 41. Pigou (1920). 42. Hassan (1985), esp. 535–36. 43. Ibid.

240

Health and Wealth

44. Chap. 4, this volume, 121–31. 45. The most detailed and illuminating account of the origins and influence of the civic gospel is found in Hennock (1973), which examines its provenance among the dissenting congregations of the Birmingham social elite and its influence in the city of Leeds. 46. Briggs (1968), 206. 47. This is a principal thesis of Hennock (1973). See also Briggs (1968), 219–20. 48. See chap. 9, this volume, 284–90; and Ch.4, 123, 128. 49. Boyd Hilton has dubbed the earlier era “the age of atonement,” distinguishing it from the subsequent period of much more confident, incarnational religion and missionary zeal on the part of the upper and middle classes, earnestly endeavoring to bring the light of “civilization” to the poor and ignorant, both at home and abroad. Hilton (1988). 50. Harvie (1976); Cashdollar (1989). 51.The history of change both in formal municipal voting qualifications and in the actual practices found in different towns is extraordinarily complex throughout the nineteenth century. A standard introductory text is Keith-Lucas (1952), chap. 3. I believe that Hennock’s otherwise excellent, pioneering research in this area tended to discount too much the significance of change in the municipal electorate during the late 1860s and 1870s and placed too much emphasis, instead, on expansion of the municipal electorate in the 1850s: Hennock (1963), esp. 221, 224.The most recent research has concluded that the sequence of developments between 1867 and 1883 renders this the key period in the expansion of the urban municipal electorate to incorporate a dominant section of the working class: Davis and Tanner (1996). 52.Waller (1983), 297–98; Read (1994), 266–67. 53. Fraser (1993). 54. Chap. 4, this volume, 124–25. During a period of minimal inflation these figures represent a real sevenfold increase in expenditure. 55. Millward and Sheard (1995). 56.Wilson, Sheard and Millward (1993), 6–8. 57. Millward and Sheard (1993), 9. These are trading profits after subtraction of loan charges, which can be calculated for these years, 1903–5. 58. McKeown (1976). 59.The principal comparative evidence in favor of public health expenditure and measures was assembled in Preston (1976). 60. The revisionist reworking of McKeown’s historical epidemiological data for nineteenth-century Britain is reproduced in chap. 4 in this volume; see also Guha (1994); chap. 5, this volume; and Johansson (1994). 61. Nathanson (1996). 62. Hamlin (1988/89); Hamlin (1990). 63. Bynum (1983). 64. Nathanson (1996), 631, note 2.

Economic Growth, Disruption, Deprivation, Disease, and Death

241

65. Mann (1993), chap. 3. 66. On the concept of brokers see Wolf (1971). 67.On the GRO’s public health role, see this volume, chapter 8. 68. Powles and Day (1995). See also the papers by Shkolnikov, Mesle and Hertrich, Rychtarikova, Shapiro, Kingkade and Vasin (1997), and Szreter (1999). 69. On the importance of the principle of universality in social security and welfare entitlements in promoting social inclusionism, avoiding social deprivations, and enhancing citizenship, see Titmuss (1968). 70. Chen, Campbell, Li and Peto (1990), 102–3. See also the papers by Weimin and Li, Banister and Peng (1997). 71. Drèze and Sen (1989), 11–12. 72. On these issues in Britain, see for instance Offer (1981); and Crowther and White (1988). 73. For the original work on entitlements, see Sen (1981); and for a summary of entitlements and capabilities, see Drèze and Sen (1989), 9–19. 74. See references cited in note 3. 75. Dorfman (1991), 573. 76. Hutton (1995), chap. 10. 77. Crafts (1995), 434. For reviews of new growth theory, see the special issues of two journals devoted to this subject: Oxford Review of Economic Policy 8, no. 4 (1992) and Journal of Economic Perspectives 8, no. 1 (1994). More generally, see Abramovitz (1989). 78. Coleman (1990), chap. 12. Social capital should not be confused with Pierre Bourdieu’s notion of cultural capital (more or less corresponding to an individual’s success in the educational system), though it is certainly related to it; see Bourdieu (1973). Social capital is the property of a social group and its institutions, not of an individual. Coleman distinguishes social capital from the related concepts of economic capital (productive plant and finance) and human capital (which is not dissimilar to Bourdieu’s cultural capital, being the aptitudes, skills, and training possessed by an individual worker). Social capital is lodged neither in individuals, as their capacities, nor in the physical implements of production. It inheres in the pattern of relationships between persons: how they are able to communicate with each other. It is therefore constituted in the institutions, associations, and communities of society and the economy. 79. On social capital and both civic participation and economic performance, see in particular Putnam (1994). On social capital and health, see Wilkinson (1997); and Wilkinson (1996). 80. Granovetter (1985); Evans (1995). 81. See the excellent special section of World Development (1996), introduced with a helpful review of other relevant work by Peter Evans. This presents five empirical studies contributed by Lam (Taiwan), Heller (Kerala), Ostrom (Brazil and Nigeria), Fox (Mexico), and Burawoy (Russia and China).

8 THE G.R.O. AND THE PUBLIC HEALTH MOVEMENT IN BRITAIN, 1837–1914*

From its earliest years the General-Register Office (GRO) developed a twin-pronged publication strategy to maximize both its political and scientific impact in promoting the environmentalist policies of the public health movement. Through its weekly and quarterly bulletins of comparative death-rates the GRO fought a relentless campaign to heighten local awareness of the extent of preventable death. The government’s chief medical officer also used this information to investigate negligent local authorities. A parallel series of annual and decennial reports offered a more rigorous and scientific analysis of the incidence of the nation’s fatal diseases. A relative decline in the GRO’s leading position in the public health movement after the retirement of William Farr in 1880 has been

* The chapter is slightly revised from its original version in Social History of Medicine 4, 3 (Dec. 1991): 465–94.

242

The G.R.O. and the Public Health Movement in Britain

243

misinterpreted as the end of its commitment. But this was only a temporary lull, primarily due to developments beyond its control: the rise of germ theory and also the increasing powers and professional organization of the Medical Officers of Health.The GRO had to adapt to a less glamorous supporting role supplying the country’s MOHs with the epidemiological information they required. In the Edwardian period, however, the GRO was to be found once more in the center of the most significant scientific and political conflict, successfully defending an environmentalist and increasingly state-sponsored public health and welfare policy against the attacks of hereditarian eugenicists.

The GRO’s Powers of Influence How did the GRO perform an effective role promoting public health in the nineteenth century? First among its contributions in this respect was the attempt to provide authoritative factual information on districts’ overall death-rates. It is easy to overlook the importance of this simple and obvious service. But this was, after all, the essential basis for informed local action. There was nothing more likely to prevent a local authority from taking a decision to implement what was always perceived by their voting ratepayers to be grievously expensive preventive health measures than a debilitating uncertainty as to the basic facts of their situation.1 Provision of regular bulletins on the changing state of health in many localities was an entirely self-appointed role.2 That the GRO did voluntarily assume such responsibilities was all the more important in the midVictorian period, since the Local Government Act Office (LGAO), which formally presided over the nation’s sanitary affairs for thirteen years after the Local Government Act of 1858, did not itself collate any such local statistics; nor did it encourage the Local Clerks under its tutelage to undertake this task, despite its supposed remit to do so.3 Ignorance and confusion over the basic facts of life and death were, indeed, the rule before the GRO began its publications. For instance, in 1843 Farr published pioneering comparative life-tables that used the combination of vital registration and census data to measure rigorously the true level of mortality in the industrial city of Liverpool. Here it was apparently surprising to find that mortality was absolutely atrocious,

244

Health and Wealth

with almost half of all persons born in the city dying before their sixth birthday. By comparison, for the nation as a whole at this time such a rate of attrition was not achieved until a generation had passed its 45th birthday. One would have thought that a difference of this magnitude would have been obvious. Not so, however. In commenting on this finding George Graham (then Registrar-General) ruefully reminded his readers that even within the last few years, “some of the best informed people in the land had believed Liverpool to be one of the healthiest spots in England.”4 Graham noted that this had even included the late John Rickman (1771–1840), who was possibly the best-informed person of all before vital registration began, since while employed as a clerk in the House of Commons, he was also the appointed Commissioner in charge of the first three national censuses, 1801–31! Rickman had even inserted the following note in the Population Abstracts of the 1831 Census: The great increase in the town of Liverpool is attributed to the salubrity of the air, and the progressive improvement in trade, commerce, steam, navigation and railroads.

Graham whimsically commented: I am not aware that the increase of population in any other localities was ascribed to their noted “salubrity.”5

In the case of Liverpool, the publication of Farr’s results was quickly followed by the scandalized city’s authorities taking their own private Public Health Act through Parliament in 1846—a relatively expensive procedure—rather than wait for the national legislation that eventually came to fruition in 1848.6 Apart from the provision of this essential mortality information, the second contribution of the GRO to the public health movement was in the creative use that it made of such statistics, informally waging what amounted to a major propaganda campaign. Given that remedial health improvements were left largely in the hands of the ratepayers and their elected representatives in Victorian Britain, probably the most important single achievement of the GRO was in its deliberate creation of a lively local public interest in, and demand for the mortality information that it

The G.R.O. and the Public Health Movement in Britain

245

published. Over the course of the century, most parts of the country exhibiting seriously excessive mortality were at some time subjected to treatment akin to that dealt out to Liverpool in 1843. The GRO went well beyond mere information provision, engaging its energies in the much more difficult and historically significant matter of actively striving to create a market for its products, ingeniously turning the Victorians’ vigorous defense of the virtues of local autonomy and pride in local selfgovernment into a powerful propaganda weapon to promote public health activism. The GRO blatantly and successfully set out to foster an atmosphere of competition and rivalry between local authorities with respect to their widely varying levels of mortality and thereby to create a national forum of informed public opinion and urgent debate on disease and mortality and the need for preventive public health measures. The GRO seems to have evolved a two-tier strategy to fight its information war. First was the need to process the death records as rapidly as possible to “show, soon after the events have occurred, all the principal movements of the population of which knowledge is required for immediate administrative purposes.”7 Second, given that the causes of most diseases were still a matter of scientific dispute, in which it was hoped that careful analysis of their comparative geographical incidence might provide some of the answers, the GRO was simultaneously involved in a parallel project of more thorough and time-consuming analysis of the same death records: “determination of the law of mortality requires an extensive area of observation both in space and time, to eliminate accidental perturbations.”8 The first prong, the political leading-edge of the attack, resulted in various series of weekly and quarterly reports, compiled into “Annual Summaries” (rarely used now by medical and demographic historians because of their technical limitations). These are not to be confused with the series of much more substantial Annual Reports, published up to three, and occasionally four years later, which contain more comprehensive forms of analysis. Even these, however, were only the lightweight version of the GRO’s scientific enterprise, whose flagship operation centered around the massive decennial exercise of the national census. Combining population census information on numbers at risk with concurrent vital registration data on numbers dying enabled national life-tables to be compiled, as well as the presentation of information in sufficient detail to enable those interested

246

Health and Wealth

to calculate age-specific and cause-specific mortality rates for every registration district in the country.9 The delayed results of these more patient labors, requiring enormous clerical and computational efforts, were inevitably of less immediate political impact or administrative use to Farr’s contemporaries in the public health movement. (But, on the other hand, it is these figures that have been of most use to medical and demographic historians: they are considered to comprise the best quality historical dataset available for the study of pre-twentieth-century national mortality patterns).10 As experience accumulated in rapid processing of the vast body of inflowing data (hundreds of thousands of events each year), the GRO can be seen successively adopting more and more effective tactics for pursuit of the first prong of its propaganda strategy. Already, by the time that the second annual report was published in 1840 the GRO had begun to collect cause of death information from Metropolitan Registrars on a weekly basis and publish an abstract of the information.11 Once metropolitan Medical Officers of Health (MOH) began to be appointed (starting with John Simon’s appointment by the City of London in October 1848), they began to request—and received—this information from the GRO as soon as it was available each week.12 From 1842 on, quarterly reports on the general mortality rate in the 114 most populous districts of the country began to appear within a month of each quarter’s end. As George Graham commented upon this innovation: The Quarterly Tables will give immediate warning of any great increase in the mortality, and they have the further advantage of directing frequent attention to the particular districts, agricultural or manufacturing, in which the mortality is above the average.13

A new series of such quarterly returns began from 1849, aiming at comprehensive coverage for all 623 registration districts.14 From the mid-1850s on, these quarterly returns were ranked to produce a competitive league table, according to the districts’ prevailing general mortality rate.15 And from the mid-1860s on, weekly reports similar to those for the metropolis were instituted for ten large provincial cities, a number that had grown to twenty by 1877 and to thirty-two by the end of the century. Finally, beginning in 1870, at the behest of the nation’s chief

The G.R.O. and the Public Health Movement in Britain

247

executive medical officer, Sir John Simon, the GRO’s rapidly published quarterly returns for all districts in the country were upgraded to include detailed cause of death information.16 The earliest obvious historical marker of the public success of the GRO’s information war was the incorporation into section 8 of the Public Health Act of 1848 of the provision that local authorities would be compelled to establish health boards to implement local sanitary reforms if their annual mortality rates were found to be above 23 per thousand, the national average figure at that time as measured by the GRO. Never content, however, merely to let the propaganda battle rest on its laurels and lose momentum, Farr then went on to develop during the 1850s the concept of the Healthy Districts mortality experience as being the desirable national standard, to which all responsible local authorities should aspire. This was originally based on a set of sixty-three registration districts, exactly one tenth of the national total, whose crude death rate was below 17 per thousand.17 Over the ensuing decades there then followed periodic reminders by way of withering calculations of the tens of thousands of preventable deaths in various cities around the country that would never have occurred if only the sanitary conditions in these towns approximated those of the Healthy Districts. To the competitive and practical-minded Victorians this was a most effective goad: the Healthy District was not some pie-in-the-sky ideal but, in many cases, a galling reality that existed in a closely adjacent area. The notion of the Healthy Districts was an ingenious rhetorical invention. It referred not only to an indisputably realistic target, but also to one that was insidiously dynamic. Rather than merely measuring dispersion from the national average, this strategy established the more exclusive and therefore inherently more progressive standard of the optimal as the norm for emulation. The great majority of the nation’s local authorities would always be indicated as deficient according to this standard. Furthermore, provided at least some parts of the country could continue to achieve improvements, this small minority could then be relied upon continually to raise the level of performance by which all the others were judged. Thus, when repeating the exercise using data for the decade of the 1880s, John Tatham, Farr’s second successor, was subsequently able to institute a much more stringent definition of salubrity, including as Healthy Districts only those recording a corrected death-rate of under 15 per thousand. He was

248

Health and Wealth

also able to illustrate the extent of the improvements that had occurred in many districts in the intervening period since Farr’s original exercise by pointing out that no less than 263 registration districts could now conform to this even-more stringent standard.18 Whereas Farr’s original sixty-three Healthy Districts had contained less than 6 per cent of the nation’s total population in 1851, over 16 per cent of the total now lived in these 263 districts; and fully 25 per cent of the nation lived in districts where the crude death rate in the 1880s was below Farr’s original “Healthy” standard of 17 per thousand.19 Compounding local with national rivalries was perhaps the ultimate ploy. In the town-hall building age of the civic gospel of municipal progress ushered in by Joseph Chamberlain’s go-ahead Mayorship of Birmingham 1873–76, the cruelest cut of all the swipes dealt out by the GRO was to be worsted not just by another municipality but by a foreign or Scottish one! For instance, the GRO compared the infant mortality rate in Glasgow at 160 per thousand as against Liverpool at 216 per thousand during the years 1873–76, and regularly published international comparisons of death-rates for major European cities.20 Thus, the GRO’s realistic and in any case inevitable acceptance of the framework of local government as the appropriate administrative agency for the pursuit of public health was nevertheless combined with a fundamental commitment to the orchestrated promotion of the nation’s positive health improvement through a variety of effective propagandist techniques. The following example taken from the 1872 Annual Summary shows something of the style of the GRO propaganda machine at the height of its powers and in full spate, exhibiting many of the above-mentioned techniques in combination. A rank-ordered list of the “20 great cities and towns of the Kingdom arranged in the order of mortality” was displayed as the prelude for admonitory exhortation: The authorities of the 20 great cities deserve applause for what they have done or attempted; but they are far from having attained the stage of the traveler who can rest and be thankful.The deaths in 1872 were in excess by 53,886—more than 1,000 a week—of the healthy standard; . . . and so long as the wail of thousands of children, of the young cut off in the bloom of life . . . are heard, mayors and town councilors should give themselves no rest until they have done their utmost by sanitary precautions to save life, and to render the respective populations under their rule vigorous.They are on their trial.They will be questioned at the bar of public opinion.21

The G.R.O. and the Public Health Movement in Britain

249

An illustration of the wide-ranging, if diffuse, effects of the GRO’s deliberate campaign to foster an atmosphere of proactive public health interest at the local level can be gauged from the surprising conclusion that emerged from Royston Lambert’s careful study of the sanitary activities of the noninterventionist LGAO of 1858–71: “By a supreme irony . . . it was the localities that found the ministrations of the central authority could not be dispensed with, and it was the localities that had to induce the centre continually to extend its responsibilities.”22 A specific example of the kind of stimulus that Farr’s creeping barrage of statistics could have upon initiatives in the provinces is provided in the local research reported by Fred Lewes. He reports a copy-book example in Exeter in 1868 of the local press stimulated to put pressure for sanitary activism on the local council as a result of their discomfort at the Registrar-General’s comparative mortality statistics, showing-up Exeter in an unfavorable light (Lewes 1991). Apart from the GRO’s strategy aimed at stimulating local moves to improve the environment, its work also had an important role in facilitating the other main source of initiative to promote local sanitary measures during this period. This came as a result of special investigations undertaken by the staff of the central Medical Department of the Privy Council under Sir John Simon. As Simon himself acknowledged, the intelligence flow from the GRO provided “a basis which had not before existed for regular and comparatively prompt enquiry as to sufficiency of local administration.”23 This practice was further improved after 1870, with communication between the GRO and Simon’s Medical Department facilitated by their location within the same department of state, the new Local Government Board (LGB). Simon was able to arrange for the GRO to deliver a new series of highly detailed cause-specific quarterly returns of death-rates for all districts of the country, alongside the already existing weekly ones for the metropolis, to be passed over directly after processing at the GRO to Simon’s Assistant Medical Officer, Dr George Buchanan, for immediate scrutiny.24 “The Medical Department [of the LGB] closely examined the Registrar-General’s quarterly returns, making them both a ground for correspondence with the local authorities, and in extreme cases, for inspection.”25 Between 1871–88, for instance, of a total of 546 special inquiries undertaken by the LGB’s Medical Department, “Nearly half of these were set on foot by returns from or information received from the Registrar-General.”26

250

Health and Wealth

Thus, although the GRO’s mode of operation was necessarily indirect, through the medium of “influence,” there is plenty of evidence to show that it played this role with remarkable resourcefulness and to great effect. As well as cooperating with the small executive staff of the central government—the Medical Department of the Privy Council and its successor at the LGB—the GRO successfully sustained the immediacy of public health and sanitary issues on the public agenda in the numerous local forums of debate throughout the country.And that was where it really mattered in this period, both because that was where discretionary power to act continued to lie and because that was, of course, the milieu in which virtually all of the nation’s medical professionals were actively involved.27 The “sanitary revival” of the mid-1860s was particularly a phenomenon driven by the members of the medical profession itself, which had only at the end of the previous decade seen the successful conclusion of a long campaign for professional self-organization that had been pushed forward from below and from the provinces.28 As W. J. Reader has pointed out, in the era before the statutory MOH it was energetic local medical notables who, “applied themselves particularly . . . to cleaning up the filth of towns and the science of public health, which is generally associated with names like Chadwick, Southwood Smith, and Sir John Simon, owes a great deal to them.”29 It was, then, in particular this constituency of opinion that the GRO’s publications nourished from the late 1830s onwards, and whose demands, once organized as a profession, issued in the pressure politics of the “sanitary revival” and the consequent public health legislation of the 1870s. (Incidentally, given the importance of this provincial input, the perpetuation of local powers in the public health legislation of the 1870s seems all the more understandable). A flavor of the diffuse but pervasive manner in which the GRO’s campaign operated on the parochial public consciousness, facilitating and informing such local medical men’s efforts, is recorded in Henry Acland’s address to the National Association for the Promotion of Social Science at their meeting in Plymouth and Devonport in 1872: Through the labor of the Registrar-general’s office, and the untiring energy of Dr. Farr, we are enabled to see every week on our breakfasttable the barometer of Comparative National Health, in respect, not only within Great Britain of our great towns, but of Turin, Berlin, Vienna, St Petersburg, New York, Calcutta, Bombay.30

The G.R.O. and the Public Health Movement in Britain

251

The unity of purpose that existed between the GRO and other progressive and reforming elements within the leadership of the newly consolidated medical profession is most compellingly demonstrated in the lobbying that went into securing these reforms of the nation’s public health administration in the 1870s.31 Farr was one of the key actors in helping to bring about the appointment of the Royal Commission on the Sanitary Laws. It was Farr and W. H. Rumsey who, at the Dublin meeting of the British Medical Association in August 1867, proposed that the Joint Committee on State Medicine be formed in combination with the politically highly influential National Association for the Promotion of Social Science (NAPSS), of which Farr had been a founder-member since 1856.32 It was this deputation that finally achieved the sanitarians’ wishes, in the appointment of the Royal Commission of 1869–71.33 Hence, according to contemporary testimony, Farr and the senior secretary at the GRO, William Clode, were among the six most significant individuals whose efforts were vital to the securing of the commission’s appointment.34 There was, therefore, a close solidarity of interests between the GRO and the leading medical figures of the public health movement during this critical period.

The GRO’s Public Health Program The aim of identifying “preventable” diseases was the consistent, central aim of the GRO’s data analysis from 1837 to 1914. In the first-ever annual report of the Registrar-General for 1837 (in fact covering only the second half of the year’s vital statistics, as registration did not begin until the first of July) we find Farr writing in his “Letter to the R-G”: The deaths, and causes of death, are scientific facts that admit of numerical analysis; and science has nothing to offer more inviting than the laws of vitality, . . . the influence of civilization, occupation, locality, seasons and other physical agencies, either in generating disease, or in improving the public health. . . .35 . . . .Diseases are more easily prevented than cured, and the first step to their prevention is the discovery of their exciting causes.The registry [of vital events] will show the agency of these causes by numerical facts, and measure the intensity of their influence.36

252

Health and Wealth

From the start, then, it was the identification of preventable disease that was to be the main objective of the Office’s analytical efforts and it was this aim, among many possible alternatives, that informed Farr’s famous pioneering work in nosology. Farr was perfectly well aware that “Classification is another name for generalisation.” Therefore, “the superiority of a classification could only be established by the number of facts that it generalized, or the practical results to which it led.”37 It followed that “more arrangements of the facts than one may be useful, but . . . the main object in view should regulate its principle.”38 Farr recognized that the valuable mortality data collected by the GRO could be classified by any one of several possible methods for medical purposes: for instance, according to anatomical, functional, diagnostic, or pathological considerations. It was his clear conviction, nevertheless, that the primary value of this enormous statefunded exercise of vital registration must remain the opportunity that it afforded for the promotion of the nation’s health in the most practical manner. Therefore, the primary divisions of a “Statistical Nosology” should evidently be founded upon the mode in which diseases affect the “population.”39 This was so as to assist the design of and monitoring of preventive measures. Hence in Farr’s nosology, The first class will embrace all diseases . . . that prevail endemically or epidemically, together with . . . such maladies as are communicated by inoculation.This great class of maladies is the index of salubrity; it is this class that varies to the greatest extent . . . and almost always admit [sic] of prevention or mitigation. Of the utility of keeping this class of diseases distinct in a practical sanatory [sic] report there can be no question.40

Thus, Farr was quite clear from the start that the classificatory principles informing the analysis of the nation’s state-collected mortality data must be directed to the statistical, “practical sanatory” goal of disease prevention, with the potentially conflicting interests of forensic or other scientific interests occupying an ancillary, rather than primary role. Of course, Farr’s “prevention” was premised on a particular understanding of disease causation. This stressed the importance of general environmental hygiene and sanitation and therefore led him to lump together most forms of communicable disease into his “first class,” the

The G.R.O. and the Public Health Movement in Britain

253

so-called “zymotics.”41 With the subsequent triumph of the germ theory and a primarily contagionist aetiology in the 1870s, the GRO needed to revise its original nosology to recognize the importance of differential aetiologies within Farr’s category of “zymotics.” This was duly done following Farr’s retirement in 1880 and the GRO’s nosology was thereby brought into somewhat closer harmony with the Nomenclature of Diseases of the Royal College of Physicians, first published in February 1869. The College was itself undertaking the first major revision of its nomenclature at that time, with Dr William Ogle (Farr’s successor) on the revising committee.42 However, note that the primary commitment to publicizing preventable disease remained a constant aim throughout this process of adjustment to a new aetiological paradigm.There was to be no abandonment at the GRO of Farr’s founding precepts, as can be seen, in the careful distinction of purposes made by the new Registrar-General, Brydges P. Henniker (who held the post from 1880 to 1900), in the course of introducing the office’s new classification of causes of death: [T]he objects aimed at by the College of Physicians and by the GRO in their classifications are not precisely the same. The classification of the college is, in the main, pathological, but the classification of the Registry Office, intended as it mainly is for the use of those engaged in devising methods of prevention, should, so far as possible, be aetiological.43

Commitment to classify and publish the information in a form most useful for the prevention of mortality therefore remained the major goal. This continued to be the case also with Ogle’s own successor, Dr. J. F. W. Tatham. Hence, the following enunciation of aims, quite explicitly seeking to locate himself within the Farr tradition or “school” of thought.Tatham was here introducing his own first major official publication, the decennial report on mortality for the period 1881–90 (published in two parts, 1895 and 1897): It is . . . clearly incumbent on the officer who is responsible for the classification and analysis of the national mortality records to take care that every detail shall be utilized which may serve to increase our knowledge of the intimate nature of preventable diseases. . .. I have striven to develop to the utmost the practical value of these volumes as a work of reference for students of Preventive Medicine; for I feel assured that to

254

Health and Wealth have succeeded in this endeavour would constitute the highest tribute I could offer to the memory of Dr William Farr. . . .44

The final methodological consummation of this focus on diseaseprevention occurred right at the end of our period, with the development by Dr.T. H. C. Stevenson, in turn Tatham’s successor, of a scheme for social classification of the nation by grouping male occupations into a hierarchy of five grades, a system that has remained in use down to the 1991 census. It was immediately deployed by Stevenson in 1913 in an analysis of infant mortality, once again powerfully to drive home the public health message regarding the preventability of death and disease. Much may be learnt from this table as to the extent to which infant mortality can be regarded as preventable. . . .The excess of mortality in class 5 over that in class 1 is 41 per cent in the first month, 92 per cent at 1–3 months, 142 per cent at 3–6 months, 165 per cent at 6–9 months and 183 per cent at 9–12 months.These astonishing figures not only show what can be done, but clearly point to the plan of campaign, viz., an attack upon the causes of mortality in the latter months of the first year of life.The same lesson is taught by comparison of the mortality of county boroughs and rural districts. . . . [T]here again the difference in mortality increases steadily with the age of the infants, indicating that the later deaths are most susceptible of diminution by improvement in environment.45

Thus, the history of the GRO’s nosological developments and its methods for assessing disease incidence constitute further illustrations of the argument made by Higgs (1991) in his exposition of the epidemiological principles lying behind the GRO’s occupational census. Neither the consistency, nor the logic nor the point of these two grand taxonomic schemes, the nosology and the occupational classification, which between them structured the bulk of the GRO’s vast statistical output, can be understood without appreciation of the integral part they played in the office’s fundamental politico-medical concern to promote the public’s health through exposing preventable deaths. This constitutes the most consistent and general theme throughout the Registrar-General’s publications, informing the various developments of classificatory techniques right across this period.

The G.R.O. and the Public Health Movement in Britain

255

There is a key pair of paragraphs written by Farr towards the end of the enormous 5th Annual Report of the Registrar-General of England and Wales (ARRG), published in 1843, that contain the distilled essence of the original, libertarian, environmentalist, yet simultaneously collectivist and interventionist rationale behind this concern to publicize preventable death. Farr began by refuting Dr Southwood Smith’s “dangerous” suggestion that the poorest and most deprived elements in society might be incapable of rehabilitation because “physical wretchedness annihilates the mental faculties.” Farr’s answer to this was a powerfully written assertion of the common human dignity of all individuals, drawing on his own personal experiences of the destitute: Once, on walking down the “lane,” in which a fish-market is held, between Hounsditch and Whitechapel,—amidst the most degraded population in the metropolis, . . . a man walked hurriedly past, shaking a box; no one stopped or scarcely looked, but pence and halfpence dropped in on all sides. Upon enquiring what this meant, the Registrar, who accompanied me, said, “That is the charity-box, to which these people all contribute, and thus raise a fund for the relief of the sick and old amongst them; they are very charitable to each other and will do anything or give anything rather than see their friends sent to the workhouse.” It was a ray of light in the darkest place. Here were the people who, to a superficial observation, appeared to have lost the vestiges of humanity, not only with self-dependence, but social affection and charity in their hearts—ready to divide their few pence with the sick and afflicted—with those a little more miserable than themselves—as freely as if they were fathers, sisters, or brothers. God had left them charity; and if circumstances had obscured, they had neither paralyzed the intellect nor the heart.Who will venture then to despair—to pronounce these most miserable men inaccessible to the influence of enlightenment and humanity? If you talk to them of their interests, they can understand you; if you approach them to save their families from sickness and death, with a kind and generous liberality, bringing into their wretched courts and habitations what they may not now purchase—the necessaries and blessings of health—they can be grateful, for they also have succored their fellows.46

Farr outlined a clear strategy for a long-term national program for raising the standard of health and quality of life of the population,

256

Health and Wealth

premised on the egalitarian argument that the poor had an equal right, alongside any other citizen, to enjoy the benefits of personal health: “Health is as dear to the poor as to the rich.The most abject part of the population . . . can understand its value; and as we know are capable of making sacrifices for the good of others.”47 Nevertheless, Farr argued that “because the causes of insalubrity are not palpable, cannot be seen, and are only discovered by extended observation, calculation, and abstract reasoning” therefore, “The movement for the sanatory improvement of towns must originate with and be carried out in great measure by the educated and more intelligent classes,—by the Statesman.”48 However, Farr was clear that, “care must be taken to discriminate between what can be done by legislation for the people and what can only be accomplished by themselves individually, and swayed by the slow progress of public opinion.”49 Farr recognized that people had to learn actively for themselves—and could not simply be forcibly “taught”—the practices and habits of healthy living in their new urban environments: To leave many things to the people themselves will be to proceed slowly, because knowledge and new principles on such subjects can only be communicated slowly, but it will be to proceed surely—and the improvement will not die away or be superficial, for it will be the act of the mind, penetrate the inmost recesses of the home, and be imparted to future generations.50

But note that the list of what was first to be done for the poor by the rich and the educated was hardly an invitation to evasion of financial responsibility on behalf of the property-owning class: Over the supply of water—the sewerage—the burial places—the width of streets—the removal of public nuisances—the poor can have no command . . . and it is precisely upon those points that the Government can interfere with most advantage.The Legislature may enact the removal of known sources of disease, and, if necessary, trench upon the liberty of the subject and the privileges of property, upon the same principle that it arrests and removes murderers, who, if left unmolested, would probably only destroy lives by hundreds, while the physical causes, which have been adverted to in this paper, destroy thousands—hundreds of thousands of lives.51

The G.R.O. and the Public Health Movement in Britain

257

In its founding incarnation the GRO conceived of itself as occupying a position of central scientific authority at the apex of a necessarily informal national network of information diffusion on matters affecting the public’s health. It was argued that only from the unique vantage point of its oversight of the statistical experience of the whole nation could certain crucial insights into the nation’s health patterns emerge. For all their valuable experience, precisely because individual medical practitioners tended to see only that part of the nation selected for sickness, especially if they worked in hospitals, their views on general health patterns were probably least accurate of all.52 The radiating network of communication to carry the public health message out from the GRO evidently included medical practitioners themselves and Medical Officers of Health (MOH). But, equally, communication should reach nurses and midwives—indeed, every individual and especially every mother in the land, as well as local councillors, landlords, ratepayers, and others who might have no special knowledge of, nor sympathy for, the expensive preventive health measures and services required, but who nevertheless had to be persuaded.53 As a result, therefore, of holding to a radically “democratic,” or libertarian ideology, all citizens were considered to be relevant executive authorities, each having charge of a part of the nation’s health, however small a charge. All eventually had to be reached and influenced by the public health message if it was to succeed.54 The Office under Farr and Graham was therefore keenly aware that the potential of the messages it sent out to effect real change depended not simply on the scientific rigor of its approach, which was necessary to impress and hold the loyalty of the relevant part of the medical profession. Even more it depended on its communicative abilities in handling and presenting the information at its disposal as effectively as possible, so as to gain maximum effect upon a wider and more varied audience. Hence the dual-pronged approach evident in the two parallel sets of publications, the populist and the scientific. Of course, the very concept of “preventability”—with respect to mortality—entails implied claims, regarding first the presumed efficacy of available remedial measures, and, second, the existence of a responsible executive agency, willing to undertake such preventive measures.The rhetorical effectiveness of the GRO’s exposure of “preventable death” rested therefore on its audience’s tacit acknowledgment of and response

258

Health and Wealth

to the validity of those implied claims. The claims, in turn, depended on the prevailing understanding of the science of disease causation and of the politics of permissible government intervention, both of which were subject to change in the course of the nineteenth century.As a result the consensus notion of “the preventable” was itself mutable.55 Indeed, different kinds of potential audience—public health professionals as against the general ratepaying public, for instance—could subscribe to somewhat different understandings of “the preventable” at the same point in time.To be effective, the GRO had to divine correctly its key audience—the one that carried the greatest political leverage—and then tailor its publicization of the “preventable” appropriately to their prevailing political and scientific assumptions. Grounded in a libertarian and “democratic” philosophy of social reform and change, it was a political calculation of this sort that informed the predominantly populist strategy endorsed by Farr and Graham.This, then, was an integral part of a comprehensive, optimistic philosophy of social transformation, characteristic of the generation that came to maturity in the reform decade of the 1830s.56 In his definitive study of Farr’s ideas and methods J. M. Eyler has identified its three component elements as “political liberalism, an environmental approach to the understanding of human misery, and a belief that social progress would follow the construction of a positive science of statecraft.”57 Farr himself broadly adhered to this throughout his career and held the fort for this perspective at the GRO so long as he remained in post. However, with his retirement, a positive response to certain changes that had in fact long been underway in the science, politics, and institutional organization of the public health movement began to become manifest in the approach of the GRO. The most obvious such change, in the accepted scientific explanation of disease causation, which led to Ogle’s nosological revision, has already been mentioned. Eyler has commented on this process of generational succession primarily in terms of medical paradigms, with the eventual passing during the 1860s and 1870s of the miasmatist “sanitarians” and their replacement in the 1880s by a younger cohort of medical professionals advocating more disease-specific preventive measures derived from the new insights of germ theory.58 But in some ways almost the more significant change was an associated, more gradual and insidious one: the quiet, almost

The G.R.O. and the Public Health Movement in Britain

259

imperceptible relinquishing of the radically democratic libertarianism entailed by Farr’s political liberalism in favor of a more exclusively technocratic and professional perspective. Slowly but surely, after Farr’s retirement, GRO publications were increasingly aimed at the needs and requirements of the cadre of trained public health professionals, rather than at a general lay public. The GRO under Farr and Graham actively resisted such incipient changes over the last two decades of their “reign.” This can be seen most clearly in the simmering disagreement, dating from the late 1850s, between the GRO and some of the early public health medical professionals over the Office’s regular practice of publicizing ranked leagues of towns and cities and metropolitan districts, according to their crude, general mortality rates, uncorrected for age-composition and other known sources of bias.The public controversy that existed intermittently between the staff of the GRO and certain other public health figures might at first glance be considered to support the impression fostered by Royston Lambert: that Farr and the GRO were unhelpful to the public health movement.59 But, as argued, at the end of the previous section, this would be a grave misrepresentation. It was, for instance, the case that two of Farr’s most percipient and able critics on the issue of comparative death-rates,A. Ransome and H.W. Rumsey, were at this time joining forces with Farr to co-operate in promoting an important scheme for improving death registration, the system for the comprehensive certification of all deaths by medically qualified personnel that eventually became law with the 1874 Registration Act.60 A man like Rumsey was under no illusions, then, that whatever his differences with Farr, these were merely fraternal disagreements between allies who were in strong agreement on larger matters.61 Hence, we find that Rumsey was certainly someone who fully appreciated the value of the parallel stream of scientific output from the GRO, pointing out that its annual and decennial reports were absolutely essential reading for all serious students of public health.62 This was a view that was also formally endorsed in the syllabus of the Cambridge University Diploma of Public Health course, which began in 1875 and soon became the principal source of qualified MOHs in England.63 While most dimensions of this simmering disagreement have been ably covered in J. M. Eyler’s account of it, Eyler does not emphasize the point that this was seen by the GRO very much as a disagreement over

260

Health and Wealth

correct political strategy.64 When most hard pushed in the mid-1870s, the GRO defended its practice on the grounds of political expedience, rather than technical virtuosity. This occurred when Henry Letheby, in his capacity as president of the Society of Medical Officers of Health, chose to devote a substantial part of his inaugural address on 17 October 1874 to the proposition that the GRO’s tables of comparative general death-rates were not an authentic indicator of the sanitary conditions in a locality and so were not an aid or guide to public health officers in their attempted remedial work.65 The GRO’s swift response came in a paper delivered by Farr’s able deputy, Noel A. Humphreys, to the Statistical Society of London on 15 December 1874 at a meeting presided over by William Guy, with both William Farr and Letheby himself in attendance and participating in discussion afterwards. The arguments put forward by Humphreys were entirely in terms of the pragmatic necessity and political wisdom of the two-tier strategy of presentation. Humphreys—quite correctly—pointed out that there was nothing novel in Letheby’s or in anybody else’s technical criticisms of the RegistrarGeneral’s figures; they raised nothing that had not been already recognized long ago by Farr himself and also dealt with by him in the scientifically rigorous decennial publications of the GRO.66 However, it was explained that the statistically correct and rigorous procedures were quite impractical for “statist” purposes and for “popularization,” both of which were of the utmost importance.This required instead the production of indices that were quickly calculated from the raw data and obvious—easily interpretable.67 For all its detailed technical flaws, it was demonstrated by Humphreys, through the careful working-through of various hypothetical test-examples, that the crude general death-rate was sufficiently robust not to be fundamentally misleading in virtually all practical cases, while possessing the essential virtues for “statist” purposes, of rapid computation and comprehension.68 In his contribution to the annual report of the following year, the Registrar-General himself took up this theme, to reinforce the points made by Humphreys and to reiterate the overall rationale for the two-pronged strategy that the GRO had consistently pursued under his command. The history of death-rates in the various towns and districts of England has been recorded in my annual reports for a period extending over 36 years, and from time to time it has been pointed out that the variations from such

The G.R.O. and the Public Health Movement in Britain

261

disturbing causes as sex and age are confined within comparatively narrow limits—especially the element of sex—and do not affect the general mortality of persons at all ages to such an extent as to interfere with its value as a sure indicator of the prevalence of conditions prejudicial to life; and recent investigations have confirmed this, and shown that the ratio of deaths to population at all ages may be taken as a fair indication of the sanitary condition of the population.Wherever the general mortality is high, agencies are to be found at work unfavourable to health and the town or district requires the attention of the medical officer of health, but statisticians have long considered the general death-rate as only a preliminary test, to be followed up by further research relating to the mortality of children and adults at different ages and by different diseases.69

There is an important sense in which this dispute can be seen as an inevitable consequence of the tensions created by the GRO’s continuing insistence on holding to its founding generation’s “democratic” philosophy of change, premised on the need for “popularization,” in the face of a rising tide of professionalization of the public health field, represented by an increasingly articulate body of MOHs. It is interesting to note the first signs of an explicit acknowledgement of this in Humphrey’s response to Letheby: The want of confidence that would be engendered among health officers were the adverse criticisms on the death-rates and other figures of the Registrar-General to remain unanswered, would materially impede sanitary progress.70

Here we can see the adumbration of the gradually dawning perception at the GRO that the growing cadre of trained local MOHs were the future of the public health campaign in Britain. It was a relatively small logical step from this insight to the conclusion that to promote public health most effectively in a political sense, there should be a change of publication strategy by the Office. It would eventually cease to regard its primary target audience as the amorphous, rate-paying constituency of untutored provincial public opinion that voted-in and -out local authorities; and instead it would increasingly seek to satisfy the requirements of the trained executive public health professionals themselves. This, of course, entailed an implied technocratic, rather than “democratic,” conception of the mechanisms of social change to promote the

262

Health and Wealth

public’s health; but it was also one that was pragmatically premised on the real existence, or not, of a national network of effective trained public health medical officers. That was something that had not even existed in theory before the 1872 Public Health Act, which for the first time stipulated that every health authority in the country had to appoint an MOH; and even then it took most of the remainder of the century for this subprofession to consolidate its status and powers.71 As such this was essentially a post-Farr development. Farr’s formative experiences of how best to fight the battle for public health improvements had been gained in a world in which such officers generally did not exist and only rarely possessed adequate powers to intervene effectively, even if they had had the knowledge correctly to interpret such detailed cause-specific and agespecific epidemiological data, as was being requested by the technically most precocious among them. Farr’s strategy was principally aimed at “converting” an ill-informed general public. The fact that it does not seem to have been realized by most of those complaining at the GRO’s crude mortality rates in the 1860s and 1870s that all of their technical reservations had in fact been already dealt with by Farr in his decennial publications, tends to confirm that there was still, even into the early 1870s, a surprising degree of ignorance and neglect of the more technical publications of the GRO even among these early MOHs themselves.This in turn tends to suggest that Farr’s policy of keeping things as simple as possible was probably realistic and politically correct, at least until the latter half of the 1870s, when the average level of expertise in vital statistics among the cadre of MOHs was, at last, probably improving quite rapidly, with the instigation of professional training courses—the Diploma of Public Health.72 The GRO’s positive response to this development was in fact first signaled soon after Farr’s retirement when, in the Annual Summary for 1883,William Ogle began the practice of publishing district correction factors for age and sex alongside the crude mortality statistics for each district, thereby meeting the MOHs’ main objections to the crude, general mortality rates.73 Professionalization and the rise of the MOHs was undoubtedly an extremely important development in the public health movement, something to which the GRO eventually had to respond—ultimately altering forever its relationship with its “public.” In this sense, the World War I era seems more or less to demarcate the formal end of a unified founding period, hence the terminal date indicated in the

The G.R.O. and the Public Health Movement in Britain

263

title of this essay. By the end of World War I the GRO had ceased altogether to reflect in the style of its publications the “democratic” and libertarian values that were the central core of its operational philosophy in the founding era of Farr and Graham.The adoption of an entirely anonymous format in its publications from 1920 succinctly conveys this more purely bureaucratic and authoritarian ethos.74 Ironically, then, commitment to a “democratic” style of public health propaganda finally ceased almost exactly at the date when the formal conditions for political democracy, for males at least, had at last become a constitutional reality, with the Representation of the People Act, 1918. Historians of other departments of central government have also remarked on the turning inwards upon itself of the civil service at this point in time.75 This was the date at which the professional career civil servant had finally arrived in Whitehall as the exclusive method of recruitment.76 In the case of the GRO, at least, the evidence presented here appears to show that this was less a novel consequence of unusual wartime circumstances or subsequent reactions to those developments, and more the final consequence of a long drawn-out process whereby the Office had slowly become assimilated with the interests and aims of the relevant organized professionals within its field of expertise and competence. Led by the Society of Medical Officers of Health this was a group lying outside central government and yet, of course, by no means synonymous with the populace at large. Perhaps, then, these findings and those of other historians, too, may be reflecting the fact that the process of professional self-organization that was coming to maturity for many public service occupations in British society at this time may have been a most important force affecting the characteristic discourse and relations that developed between the “state” and its perceived “public” or clientage during this formative period, when central government was explicitly involving itself in the administration of social policies for the first time.

Continuity and Change in the Role of the GRO 1837–1914 There seem to be three distinct phases visible in the intensity of activity at the GRO and in the characteristics of its publications during the period

264

Health and Wealth

1837–1914. In the first phase, predominantly the Farr and Graham partnership of 1842–80, there was a generally high volume of output and many innovative forms of analysis were presented across a wide range of epidemiological, social, and economic subjects. Thereafter, throughout most of the twenty-year reign of Brydges P. Henniker, Graham’s successor as Registrar-General, the office’s published investigations related to a smaller range of relatively uncontroversial subjects; analytical efforts were confined more to the technical improvement of established measures and indices, notably in relation to occupational mortality. From the beginning of the twentieth century onwards, however, there was once again a much more politically engaged attitude evident in the presentation of the statistical evidence and the “editorial” content of the annual reports.The disappearance in 1880 and subsequent reappearance in 1902 of the Statistical Superintendent’s interpretive and often politically topical “Letter to the Registrar-General” as a regular feature of these annual reports more or less demarcates these phases.77 At first sight, this broad pattern appears to correspond to the obvious changes at the top in the incumbents of the two senior posts.When Graham and Farr retired in 1880 a new style appeared in the annual reports with the new Registrar-General, B. P. Henniker, now taking formal responsibility for all of the text, and leaving only the decennial supplement (associated with the Census and requiring actuarial proficiency) in the hands of the new Statistical Superintendent,William Ogle.When Henniker eventually retired, his first replacement only stayed a year before moving on to the Scottish Office. It was no doubt partly as a result of the opportunity presented by this rapid turnover in the senior administrative post that the Statistical Superintendent, J. F.W.Tatham, who had by then been in post for eight years since replacing Ogle, was able to revive the device of the “Letter to the Registrar-General,” once again affording the opportunity for extended commentary by the medically trained chief statistician.These changes in the format of the main annual publication appear, then, to have been at least precipitated by the circumstances of succession, reflecting the differing personal styles of the successive Registrar-Generals and their Statistical Superintendents. However, this is by no means the whole story: these alternating phases of relative activism are also indicative of a considerably more significant set of historical forces acting upon the GRO, some of which have

The G.R.O. and the Public Health Movement in Britain

265

already been mentioned, when referring to change in contextual political and scientific factors. Changes in personnel at the top were merely triggers for the expression of these underlying forces of change. The most obvious and directly impinging of these “external” factors, as we know from the work of Professor MacLeod, was the Treasury’s imposition of tight budgetary restrictions on the Local Government Board (LGB).78 It would appear that initially in the 1870s there was a brief honeymoon period for the new LGB, both with respect to public opinion and the Treasury, as its activities were seen to expand by the former and had been expected to do so by the latter.79 MacLeod’s work shows that the era of most severe difficulties for the LGB, as for several other ministries, was heralded with a Treasury minute of 1886, inaugurating a regime of inflexibility and refusal to countenance expansion in staff costs or improvements in pay.80 As a result, the net cost to the Exchequer of the LGB was actually cut slightly from 1884–85 to 1896–97, an almost unbelievable upshot in a period of such massive local government expansion, reflected in a roughly 50 per cent increase in its workload at this time, as measured by indices such as volume of registered correspondence.81 Such economies, however, were achieved by cutbacks in highergrade officers and were bought at the cost of staff demoralization, decline in quality of output and increasing delays in response to the localities. Half-chances to make improvements were lost in 1897 and again in 1905, with the result that the LGB came to retain a thoroughly negative reputation with its clients, the expansionary local authorities themselves, which ensured that it was not seriously considered as a suitable administrative home for any of the welfare innovations of the Progressive Liberal era after 1906.82 Decreased activism at the GRO during this period should, therefore, be assessed properly in this context and relative to what was possible at that time, not what had been possible for Farr. Apart from such financial constraints, there were also two separate intellectual developments in biological and social science during the last third of the nineteenth century, both of which conspired to render more difficult the GRO’s self-appointed role as a scientific investigator. First, the bacteriological revolution broadly downgraded the scientific status of the GRO’s principal methods of investigation. Previously the methodology of comparative statistical inference, utilizing the epidemiological evidence collected by the GRO, had represented one of the

266

Health and Wealth

leading scientific techniques promising insights and theoretical advance. But with the spreading acceptance of the germ theory of disease during the second half of the 1870s and the 1880s, the superior power of the new techniques of scientific investigation provided by microscopy were becoming fully evident.83 Once the leading edge of aetiological debate had moved on into the field of bacteriology, the techniques of medical epidemiology were temporarily eclipsed, and the GRO was inevitably left high and dry as a scientific institution. Of course, it had no remit to pursue basic scientific research and could hardly propose entering this new field, which would have entailed the setting-up of its own laboratories and so on. (Farr went about as far down this road as was possible, after his conversion to the waterborne cholera theory in 1866, by providing a publicity platform from 1868 onwards in the Annual Summaries of the GRO for Dr. Edward Frankland’s water sample analyses, aimed at imposing stricter standards of water purity on London’s water companies). Inevitably, therefore, as a consequence of medical science leaving epidemiology behind during the 1880s, Farr’s successor, William Ogle, though very much Farr’s equal as a man of letters—possessing an independent reputation as an eminent Aristotle scholar and translator— could never build a reputation as a leading contributor to scientific debate in the way that Farr had.84 Nor could he expect to command automatic support from his superior for such a wide range of epidemiological analyses as had Farr, since this method no longer held the high promise for scientific advances across a wide front that had seemed to be the case throughout most of Farr’s era. It is thus no surprise to find the GRO taking a much lower scientific profile over the last quarter of the nineteenth century. Of course, the methods of comparative statistical observation still remained administratively highly relevant in identifying sections of the nation most exposed to unacceptable levels of preventable disease. Hence, Ogle devoted most of his analytical energies in the 1880s to refining these kind of measures. Where Farr had concentrated principally on publicizing as effectively as possible the uneven geographical incidence of generally high mortality, Ogle emphasized greater precision of measurement.Agedivisions became a regular feature of publications and this further emphasized the significance of the fact that it was extraordinarily high mortality over the first five years of life that was the main source of

The G.R.O. and the Public Health Movement in Britain

267

differences between unhealthy communities and the rest.85 Also, closer attention was paid to occupation-specific hazards, with a cross-classification of male occupational mortality according to specific causes of death.86 This was something to which Ogle gave particular attention since at least here the comparative epidemiological method survived in its role as a most valuable scientific investigative technique. It promised to reveal occupational differentials in disease incidence, whose direct causes were most likely to lie in the characteristic conditions of the occupational environment and its working materials. The second development in the last third of the century to complicate Ogle’s efforts to maintain the GRO’s established policy of promoting public health was the appearance and impact in the social sciences of Darwinian evolutionary theory. During the late 1870s and 1880s, social Darwinism swept through English bourgeois society and conquered, at least temporarily, many of its most influential social commentators, social scientists, and important figures in the biomedical sciences.There were, of course, strong conceptual affinities between Darwinist biological theory and liberal economic theory: survival of the fittest supposedly took place in a state of nature bearing close resemblance to that of the perfect and open competition ideally envisaged in Smithian political economy. Gareth Stedman-Jones in his classic Outcast London has shown how by the 1880s, in addition to the convinced evolutionists such as Herbert Spencer and Francis Galton who first took up this form of analysis in the late 1860s, even mainstream liberal social scientists of a conservative disposition, of the stature of Alfred Marshall, Charles Booth and H. Llewellyn Smith, as well as respected medical men such as G. B. Longstaff and James Cantlie, were all publicizing views on the causes and remedies of urban poverty that were strongly influenced by crudely Darwinized social theory.87 A simplistically socialized Darwinism, with its maxim of survival of the fittest, could undermine the rationale for a public health policy by implying that resources invested in public health measures were a misguided waste, merely prolonging the lives of nature’s weaklings. It could be argued that measures to reduce the infant and child mortality of the “residuum” (the chilling term for the poor and destitute in the terminology of the Darwinian so-called theory of “urban degeneration”) would merely be cancelled out in greater morbidity and mortality rates at higher ages, as these

268

Health and Wealth

unviable individuals hopelessly struggled to survive, clogging up the nation’s labor market with enfeebled and inefficient “stocks.” William Ogle at the GRO stands out in all this illustrious company for his clear-headed skepticism about such claims. His careful examination of the issue was presented in the only major publication of the Office under his formal authorship, the report in the decennial supplement covering the years 1871–80, composed and published in 1885 at the height of the populist storm over “urban degeneration.” His analysis kept faithfully to the Office’s tried and tested actuarial methods for the rigorous evaluation of such problems and led to a resounding conclusion in favor of public health, couched in such terms as would not lose an opportunity of appealing to the economists, businessmen, and ratepayers in his audience, while simultaneously deflating the claims of the degenerationists.88 Comparing the full life experience of those born into the conditions prevailing 1871–80 with those of 1835–54, Ogle was able to show that there had been no rise in mortality at higher ages because of increased survivorship in infancy. The changes in the death-rates therefore have given to the country an annual addition of 1,800,047 years of life shared among its members; and allowing that the changes in death-rates are the direct consequences of sanitary interference, we must regard this addition of nearly two million years of life as an annual income derived from the money invested in sanitation.89

After this period of difficulties, the third phase, c. 1902–20, was characterized by the GRO once again taking a more active leading role in the public health campaign.This dated from the beginning of the Edwardian period, in the reactions of John Tatham and his superior, W. C. Dunbar (RegistrarGeneral 1902–9), to the post-Boer War hereditarian claims of the Eugenics movement, regarding the nation’s supposed physical deterioration. In an entirely unintended way the hereditarian eugenicists restored the scientific and political significance of the GRO because their methodology once more returned issues surrounding the interpretation of demographic and epidemiological statistics to center-stage. The statistical methodology developed by the Galtonian school of “biometrics” for the study of evolutionary questions was applied by them to various social

The G.R.O. and the Public Health Movement in Britain

269

and demographic data to provide supposedly “scientific” evidence that the prolific, teeming poor were composed of inherently feeble and unfit stock. Such views were diametrically opposed to those of public health environmental ameliorationism for exactly the same reasons that they had been in the 1880s. In these circumstances, the GRO’s traditional expertise in statistical inference and as official custodian of the nation’s demographic record once more returned the Office into the political limelight, as it provided the public health movement with its most effective intellectual resources for a refutation of the eugenicists’ views—in their own “scientific” and statistical terms. The GRO therefore played a vital part in mounting a highly effective counterattack against the assertions being advanced by the resurgent eugenics movement. The latter were inspired by the views of Sir Francis Galton and sustained by the “scientific” analyses of vital statistics produced by his disciples working in the Galton Laboratory, which he endowed in 1904 at University College London, under the supervision of Karl Pearson (endowed as Professor of Eugenics on Galton’s death in 1911). In the public outcry for scapegoats to account for the ignominious performance of the British Army in the Boer War, revelations as to the defective physical state of high proportions of the urban working class volunteerrecruits had been popularly seized upon. With great initial success, the eugenicists had sought to revive and republicize an hereditarian, evolutionist interpretation of such reports. These supposedly scientific assertions therefore invested the available demographic statistics on fertility and mortality—in particular infant and child mortality—with an acute political importance. The defenders of public preventive health services found themselves faced with an urgent political need to contest these apparently authoritative hereditarian interpretations of the nation’s vital statistics in order to demonstrate the speculative nature of the social Darwinists’ views, the implications of which entailed the dismembering of the nascent welfare services provided by local authorities. It has often been blithely remarked by historians how little impact upon social policy the Edwardian eugenics movement actually had for all its bluster, without sufficient indication of where, specifically, the successful resistance to such views came from. Because the core of the intellectual debate hinged on interpretation of infant and child mortality statistics, in fact it was the GRO, alongside Arthur Newsholme as Chief Medical Officer at the LGB,

270

Health and Wealth

that was in the front-line of the campaign of intellectual defense and, indeed, successful counterattack. Jane Lewis has given a lively account of the way in which this battle for the louder say in influencing public policies on infant and maternal health care developed, revolving around the causal interpretation of the statistics of infant and child mortality.Was it defective heredity or bad environment that was to blame for the high mortality of the underweight infants of the poor?90 If there ever was a genuine polarized “Nature versus Nurture” scientific debate in the social sciences in Britain, it was fought out during these years, c.1903–13, between the biometric eugenicists and the public health medical epidemiologists. While Lewis’s account gives Sir Arthur Newsholme at the LGB his full due as the leading proponent of the public health viewpoint in this episode, it does not give sufficient credit to the GRO for its earlier and also continuing role in this intellectual contest. Newsholme depended on Stevenson at the GRO for much of his best data in the battle against Pearson, some of it already analyzed by the GRO in the appropriate form for his use.91 Furthermore, virtually all Newsholme’s most telling statistical arguments made against Pearson in the 1910s were reiterations of the points originally made by Tatham in his special study presented in 1904 to the famous Interdepartmental Committee of Inquiry into Physical Deterioration. Newsholme’s subsequent role was essentially that of a holding operation, preventing the hereditarian arguments from breaking out of the tight pen into which they had been corralled in 1904. Tatham’s authoritative evidence had been an important part of the successful case made at that time against the popular hereditarian assertions of racial degeneration.92 The opposed, environmentalist case had been presented so successfully by the witnesses to the Inquiry that the committee actually recommended significant extensions in child welfare and health services, such as the provision of free school meals for the needy, to the horror of the hereditarian eugenicists. Indeed in almost each successive annual report by the GRO over the next few years after 1904, there followed a series of ever-more-searching forms of measurement of infant and child mortality, all part of the momentum of a coherent and sustained attack on the eugenicist position, started by Tatham and W. C. Dunbar, and then continued by Stevenson after 1909. The ultimate intellectual step in this public health counterattack against hereditarian views came directly from the GRO itself, with Stevenson’s

The G.R.O. and the Public Health Movement in Britain

271

development of the official social classification system.This was immediately deployed in the 74th ARRG (published 1913) to support the argument that the excessive infant mortality exhibited in the lowest social classes was entirely preventable.This was in effect throwing the phenomenon of social inequality back in the faces of the eugenicists but with an environmentalist, socioeconomic, and cultural explanation for its existence—something that therefore justified demands for the further extension of publicly funded welfare and health services to the poor. By the close of the Edwardian period an analysis of the nation’s infant mortality drawing attention to the nationwide class disadvantage that existed now at last made sense in terms of the life-saving “practical” and “sanatory” aims, which, it has been argued, provided the consistent rationale behind all the analytical work done throughout this period, 1837–1914, at the GRO.The poor families of the unskilled and casually employed manual working class were a social group spread right across the country suffering inadequate living conditions under many different local authorities. But the analysis of “preventability” no longer had to be aimed exclusively only at specific local and municipal authorities in the attempt to shame them into action.With the progressive Liberal government of Asquith and Lloyd George trying to fend off the rise of a party of Labour, there was at last a central government administration prepared to take the deeper causes of the nation’s social ills seriously and to contemplate central, state-funded and nationally organized action to alleviate the plight of entire sections of the population regardless of geographical location. Such problems as sectoral unemployment and the need for old-age pensions had been effectively shown to be genuinely national social problems, not easily remediable at the local level.93 Hence, the GRO’s newfound willingness to present demographic data in this way, once it was appreciated that it could serve some “practical, sanatory” purpose in activating the energies of an identifiable executive authority, as was now the case with the public acknowledgment of the central state’s responsibility for certain aspects of its citizens’ welfare. After 1908, with Newsholme installed as the government’s chief medical officer at the LGB and his former junior colleague and collaborator, Stevenson, occupying the position of Superintendent of Statistics at the GRO, cooperation between the executive and intelligence-providing branches of the public health movement was so effective that at long last

272

Health and Wealth

a general solution was even found to the perennial, vexing problem of incompatibility between the territorial definitions of registration (Poor Law) districts and sanitary (administrative) districts. This problem had meant that mortality data was collected and published for areas (registration districts and sub-districts) that often did not properly correspond to the exact territorial extents covered by the jurisdiction of the relevant local sanitary authorities. However, it should be noted that this problem had at least been dealt with for the metropolitan boroughs and for the largest city boroughs in the land—the gradually growing number that received weekly returns from the 1860s onwards. For these, the most significant concentrations of population, the great effort was already being made at the GRO to adjust the incoming data from the local registrars so as to make available accurate death returns relating to the exact geographical boundaries of each borough’s sanitary authority.94 (The most enterprising MOHs were also, of course, enabled to acquire and plot a weekly cause-specific return of the exact locations of all deaths in their jurisdiction, receiving the information directly from the local registrar before it had even been sent up to London.95 A general solution for the whole country only finally became feasible with the arrival at the GRO in the first decade of the twentieth century of the Hollerith mechanical tabulating machine, first used in the U.S. at the 1890 census.96 Its punch-card system dramatically reduced the clerical effort and expense involved in such a continual exercise of resorting and tabulation as was required in order to publish vital statistics for the nation’s 1,885 sanitary and administrative areas from data that was originally collected according to the overlaid set of 634 Poor Law-based registration districts.97 At this point the GRO also agreed to adapt its nomenclature of causes of death to achieve compliance with the extant practice of Medical Officers of Health, who used the International List of Causes of Death in their reports to the LGB on local mortality patterns (an entirely parallel system of annual reporting, distinct from the older, vital registration system).98

Conclusion Thus, while the GRO’s commitment to the promotion of public health remains a constant throughout this period, the effects upon it of the

The G.R.O. and the Public Health Movement in Britain

273

changing administrative, scientific, and professional context in which it consistently pursued this aim produced an observable pattern of variation in its apparent degree of activism and in the characteristics of its output. It would be misleading to attribute such variation simply to the changing personalities or quality of the Office’s senior staff. Perhaps the most significant of these “external” forces was in fact the strengthening professional organization of the public health branch of the medical profession. During the last quarter of the nineteenth century, the balance of power within the broad church of the public health movement was continually shifting towards the expanding network of increasingly professionalized MOHs, who by the turn of the century had become the senior, qualified executive figures within the nation’s locally devolved health system, supervising an expanding range of staff and services in most localities. The most unequivocal proof of this growing identity of interests between the GRO and the increasingly professional and organized vocation of MOH lies in the recruitment pattern of the chief statisticians at the GRO. Ogle was the first of three successors to Farr, each of whom served his apprenticeship as vital statistician while employed in the office of provincial Medical Officers of Health. (Even Farr had briefly flirted with the idea of becoming the first MOH for the City of London in 1848).99 During the Edwardian era, such was the prestige of the position and the recognition among public health specialists of its potential for positive influence that no less a figure than Sir Arthur Newsholme, a former president of the Society of MOHs who was about to become the last Chief Medical Officer of the LGB (from 1908 until the creation of the Ministry of Health in 1919), confided in his memoirs that when John Burns, the Liberal president of the LGB, had first approached him in 1907 with a view to an appointment among the medical staff at the LGB in Whitehall, “I answered that the only appointment under the Government which I desired was that now held by Dr Tatham as medical statistician at the GRO, although my interest in statistics was almost exclusively as a means of advancing health administration”.100 Note that this testimony, from probably the most able and farsighted man at that time in the public health movement, who rose to the very top of the profession, sits most uneasily with the notion either that the GRO played only a passive and minor role in the public health movement or that it had ceased to be a dynamic or important office after the retirements of Farr and Graham.

274

Health and Wealth

Thus, the GRO was quite intentionally a highly directed agency of social and political change in modern Britain, operating somewhere very near the center of the public health movement throughout the entire period 1837–1914. The GRO was sending out a ceaseless flow of compelling, exhortatory publications: bombarding and cajoling public opinion, singling out local “blackspots” for no doubt unwanted attentions, and standing firm against the analyses of the problems of poverty and disease put forward by a sciolistic social Darwinism.

Notes 1. For examples of the kind of debilitating effects that such uncertainty and lack of consensus could have upon local sanitary activism, see Hamlin (1988). 2. See Szreter (1991a), note 27 and accompanying text. 3. Lambert (1962–63), 133. 4. 5th ARRG, 33. (ARRG: Annual Report of the Registrar-General of England and Wales). 5. 5th ARRG, 34. 6. Frazer (1947). 7. Supplement to 25th ARRG (PP, 1865, XII), iii. 8. Ibid. 9.The first such exercise in national life-table construction, based around the 1841 census, was presented in the 5th ARRG (PP, 1843, XXI, xii–xxxv and 161–78). Further national life-tables then followed at regular decennial intervals (except for a longer gap between 1864 and 1884) as well as a number of other lifetables for selected sections of the nation, such as the “Healthy Districts.” For fuller details, see Eyler (1979), chap. 4. The series of decennial Supplements, tabulating detailed information for every registration district, began with the Supplement to the 25th ARRG, relating to the year of 1862, published in 1864, and to be found in Parliamentary Papers for the 1865 session (PP 1865 XII Cmd 3542). Thereafter, such decennial supplements appeared with every tenth ARRG. For helpful further details, see Woods and Hinde (1987), esp. 30–37. 10.The “McKeown thesis,” for instance, was based on a secondary analysis of precisely this body of data: McKeown (1976). Recently, Professor R. I.Woods and associates have been subjecting such GRO data to further fruitful analysis: Woods and Hinde (1987); Woods, Watterson and Woodward (1988); Woods, Watterson and Woodward (1989). 11. 2nd ARRG, 18. 12. Lambert (1963), 114, 246. 13. 5th ARRG, 48.

The G.R.O. and the Public Health Movement in Britain

275

14. 12th ARRG, Appendix, I. 15. Eyler (1976), 342. 16. Lambert (1963), 419. 17. In fact, Farr’s original group of healthy districts was based on data from the 1851 census and associated deaths occurring 1849–53 for sixty-two districts where the crude death rate was under 17.50 per thousand (i.e., 17 to the nearest whole number) plus the sixty-third lowest, included to make up the numbers to a tenth of the total: Farr (1859). 18. 55th ARRG, Supplement, Part II (PP 1897, Cmd. 8503), cii–dii. 19. Ibid. 20. 39th ARRG, 257. 21. Reprinted in the annual report for the year of 1872: 35th ARRG, lv. 22. Lambert (1962–63), 150. 23. Simon (1890), 318, cited in Brand (1965), 245. 24. Brand (1965), 26, 70. 25.Young (1964), 241, 242. 26. Ibid. 27. As Anne Hardy has pointed out, only a tiny handful of doctors were ever employed by the central state throughout this period, whereas local government presented many expanding opportunities: Hardy (1988), 129. 28. MacLeod (1968b), 213. The political motor driving the medical practitioners towards fully fledged professionalization during the first half of the nineteenth century was conspicuously not provided by the neoaristocratic, London-based Fellowships of the established Royal Colleges of Physicians and Surgeons. Instead, the general practitioners of the British Medical Association (renamed as such in 1855, and formed from the Provincial Medical and Surgical Association founded in Worcester in 1832), was the body that successfully campaigned for the Medical Act of 1858, effectively creating the modern medical profession ruled over by its General Medical Council. Reader (1966), 62–64. Waddington (1984), chaps. 4–6. 29. Reader (1966), 63. Several of those who are mentioned in the course of the present article would provide examples:Arthur Ransome (1834–1922) was the son and grandson of Manchester surgeons, who himself became a physician after studies that included a spell in Paris. He had been responsible for initiating a scheme for the weekly notification of certain diseases in Manchester and Salford in 1860 and took a leading role in the Manchester and Salford Sanitary Association. He retired in 1895 as Professor of Public Health at Victoria University (Manchester). E. H. Greenhow’s (1814–1922) early commitment to public health was signaled in his training at Edinburgh and Montpelier. Before his move to London and work for John Simon, he had served as the chairman of the Tynemouth Board of Health during eighteen years in his father’s (and grandfather’s) practice at North Shields. H.W. Rumsey (1809–76) also, like Greenhow and Ransome, hailed from a medical dynasty stretching back to his grandfather. His early public health work among the

276

Health and Wealth

poor had enabled him to submit a mass of evidence to Lord Ashley’s 1844 Select Committee on Medical Poor Relief, while he was also Honorary Secretary to the Sick Poor Committee of the Provincial Medical and Surgical Association. At his death in 1876, his advanced ideas on state medicine had been recognized in his honorary membership of the Metropolitan Association of MOHs (Sources: Munk’s Roll; Plarr’s Lives). 30. Cited in Eyler (1976), 342.Acland was the Regius Professor of Medicine at Oxford. 31. This was, of course, by no means Farr’s only substantial political contribution to the public health movement during this period. For instance, he was instrumental alongside Chadwick, B.W. Richardson and Lord Shaftesbury in founding the Sanitary Institute in London in 1876, which was to act as the examining body for posts as Surveyors and Inspectors of Nuisances in local government. Dowling (1963), 193. 32. See Szreter (1991a), note 20. 33. MacLeod (1968b), 212–15. 34. Flinn (1969), 22. The four others were: H. W. Rumsey, A. P. Stewart, W. H. Michael, and H. Acland. 35. 1st ARRG, 86. 36. Ibid., 88. 37. Ibid., 93. 38. 2nd ARRG, 69. 39. 1st ARRG, 93. 40. Ibid. 41. Farr’s aetiology was in fact based on a synthesis of miasmatist (anticontagionist) and contagionist ideas. Farr held that although each “zymotic” disease (his “first class” of diseases that vary to the greatest extent) might be caused by a different specific poison, they all entered the body in the same way and caused damage in the same way: by “pythogenesis,” or fermentation. The specific poisons of each disease were given off in the airborne miasma, odors, or exhalations of decomposing animal and vegetable products or of sufferers, which then entered the human body and propagated in the blood stream in a manner similar to fermentation, the process then recently described by the German chemist, Jutus von Leibig. It therefore followed that for a policy-prescription Farr was strongly inclined to back general environmentalist measures to promote urban sanitation and domestic hygiene, since this should successfully prevent the communication of most forms of disease according to his “pythogenic” thesis. See Eyler (1979), chap. 5. More generally, see Pelling (1978).An example of Farr’s relatively open state of mind in this debate is his careful, though ultimately skeptical assessment of the contagionist work of Henle of Berlin as early as 1840, where he noted that,“Henle has proved the existence of this cause and the truth of the theory in every way but one: he has never seen the epidemic infusoria.” 2nd ARRG, 95. This was far from an isolated moment of interest: three years later Farr published a long discussion of the causes of puerperal fever, derived from the newly

The G.R.O. and the Public Health Movement in Britain

277

available work of the American, O.W. Holmes, and the Doncaster surgeon, Mr Robert Storrs, coming out in favor of a more contagionist emphasis in this case: 5th ARRG, 384–95. As Eyler has shown, it was as a result of his scientific participation in a series of studies of cholera incidence in each of the three successive epidemics of 1848–49, 1853–54, and 1866–67, that Farr finally became persuaded in favor of Snow’s theory of its waterborne contagion, though not entirely abandoning a belief in the role of chemical decomposition: Eyler (1979), 114–18. 42. Robb-Smith (1969). 43. 44th ARRG, xviii–xix. 44. 55th ARRG, Supplement Pt. I, iii. 45. 74th ARRG, xli–xlii; for a fuller exposition of the environmentalist, preventive intentions of Stevenson, see Szreter (1984b), 527–31 and (1996), ch. 4. 46. 5th ARRG, 434. 47. Ibid., 435. 48. Ibid. 49. Ibid. 50. Ibid. This is something that has had in a sense to be relearned recently, with the discovery that the socially deprived sections of the population have not enjoyed equal access to the benefits and facilities theoretically equally available to them in the NHS, because of economically induced cultural disadvantages in their capacity to articulate their needs:Townsend and Davidson (1982), chap. 4. 51. 5th ARRG, 435. 52. 3rd ARRG, 97. In this Farr exactly anticipated the form of the more general argument that J. S. Mill was later to make famous in his essay of 1859 on Representative Government, when he argued that by virtue of its superior intelligencegathering and information-processing capacities, there was a distinct role for the central state in a liberal society over and above both local and individual claims to autonomy: and it was the specific example of public health matters that Mill was to use to illustrate and support his arguments. Hennock (1982) pointed this out in his extremely stimulating survey.The reference is to be found in Mill (1912), 377. 53. 5th ARRG, 381–83. 54. Ibid., 433. 55. For instance, for a most thought-provoking treatment of the changing relationship in the nineteenth century between the concept of private property itself, rights to health, and the mediation of an interventionist medical profession, see Crowther and White (1988). 56. Graham and Farr were themselves members of this rising generation of professedly liberal reformers. As the son of a Shropshire farm laborer, enabled to study medicine in Paris by a bequest from the employer to whom he had been apprenticed as a youth, Farr’s own steep professional trajectory was a prime example of an individual benefiting from the relative freeing-up of opportunities for suitably educated “talent” to rise, regardless of its social origins. Of course access to high office was only relatively freed-up. To his chagrin, Farr was never offered the

278

Health and Wealth

post of Registrar-General itself, serving under three men each of whom was a brother-in-law to a member of the Cabinet at the time they were appointed. Eyler (1979), 1, 46–47, 190. 57. Ibid., 200. 58. Ibid., 187. 59. See Szreter (1991a), passim. 60. MacLeod (1968b), 212–13, and see n. 34 above. 61. See Eyler (1979), 217 (note 142) on the unbroken family friendship between the Farrs and the Rumseys. 62. Eyler (1976), 351, note 54. 63. MacLeod (1968b), 223. 64. Eyler’s account of the nature of the various technical disagreements, and of the motivations involved, is in Eyler (1976), 346–55. 65. Letheby’s own summary of his argument, as recorded in Humphreys (1874) 472–73. 66. Humphreys (1874), 438. 67. Ibid., 437–38. 68. Ibid., 438–64. 69. 36th ARRG, xiii–xiv. 70. Humphreys (1874), 465. 71. For two complementary accounts of the process of professionalization of the Medical Officers of Health, see Wilkinson (now A. Hardy) (1980); Watkins (now D. Porter) (1984). 72. MacLeod (1968b), 220–23. 73. The change is referred to in the Registrar-General’s Annual Summary for 1890 (Eyre and Spottiswoode 1891), iii. 74. See below, note 77. 75. Harris (1988), 239–40. 76. Ibid.; and Turner (1988), 222. 77. In the intervening period the “Letter to the Registrar-General” from the Statistical Superintendent appeared only in the enlarged publications associated with the two census years of 1881 and 1891.With the succession in 1909 of Mallet and Stevenson to the posts of Registrar-General and Statistical Superintendent, respectively, the format remained the same initially. But then, from the second year of their partnership (72nd ARRG onwards), the format once more changed significantly with the annual publication becoming almost exclusively a vehicle for the Statistical Superintendent, alone. A small prefatory report by Mallet was followed by the bulk of the analysis, presented as a “Review by Dr Stevenson of the Vital Statistics of the Year.” The subsequent change after the Great War, from reporting to the president of the LGB to the new Minister of Health (81st ARRG) was at first associated with no significant alteration in the compilation of the report.This continued until the 83rd ARRG (relating to the year 1920), when a format of complete anonymity was adopted. This broadly coincided with the retirement in 1920 of

The G.R.O. and the Public Health Movement in Britain

279

Mallet as Registrar-General, though Stevenson was to continue to serve under the new Registrar-General, S.Vivian, until 1931. 78. MacLeod (1967); MacLeod (1968a). 79. MacLeod (1968a), 12–14. 80. Ibid., 25. 81. Ibid., 34–35. 82. Ibid., 43–50. 83. Eyler (1979), 107, dates Farr’s own recognition of the validity, in principle, of germ theory to 1873, following microscopial proof. However, the full absorption of germ theory into British medical theory and practice was in fact a most complicated and protracted process. As W. F. Bynum has pointed out, the immediate effect of the promulgation of the germ theory in the late 1870s and early 1880s was actually the opposite of its longer-term consequence, whereby the concept of disease-specificity and the closely associated aetiological principle of contagionism were both reinforced: Bynum (1983), 49–51. 84. Ogle’s authoritative translation of De Partibus Animalium was published in 1882. He was a personal friend of Charles Darwin, Edwin Ray Lankester, and J. D. Hooker. 85. 54th ARRG, x–xvi. 86. 45th ARRG, Supplement, xxi–lxiv. 87. Stedman Jones (1971), chaps. 16–18. 88. 45th ARRG, Supplement, iv–vi, x–xi. 89. Ibid., xi. 90. Lewis (1980), 28–33. 91.This paragraph is a brief summary of the account to be found in chap. 9, this volume. 92. Interdepartmental Committee on Physical Deterioration (1904), Appendix Va, 130–37. 93. Harris (1972), chaps. 4–6. Booth (1894); Booth (1899). 94.This practice was apparently instigated directly in response to the request for such information made by William Lucas Sargant in his paper to the Statistical Society of London, delivered in January 1865: Sargant (1865).Although virtually all of Sargant’s other criticisms were rebuffed in the reply given just a month later by Farr himself, this one request was deemed by Farr “so perfectly reasonable that the Registrar-General has taken it into account in his recent weekly publication of the births and deaths in ten of the principal cities and boroughs of the U.K.”: Farr (1865), 138. See also Report of the committee appointed by the Treasury (1890), Evidence Q. 1291–94, where the mechanical adjustment is described. Furthermore, it was precisely because these returns were used so much that there were throughout the last three decades of the nineteenth century repeated (but unsuccessful) calls by those interested in promoting local initiatives in public health, such as the Society of MOHs and the Royal Statistical Society, for Treasury sanction for a quinquennial census.The principal argument in favor was that when more than four or five years had

280

Health and Wealth

elapsed since the last accurate census, there was too great and unpredictable a change in the population size (the denominator of a death-rate) of cities and their sub-districts for reliable current death-rates to be calculated from the death registration data (the numerator of a death-rate). This was one of the main issues discussed at the 1890 Treasury-instigated committee of inquiry. 95. Report of the committee appointed by the Treasury (1890) Evidence Q. 1192; 1305–10, referring to the work of B. A.Whitelegge when MOH for Manchester at the time of the Treasury inquiry. 96. It is not clear why it should have taken so long for this extremely useful invention to have been adopted at the GRO, especially given the acute shortages of skilled staff that were a frequent source of grievance, always exacerbated by the periodic burden of the census: see Higgs (1988), 83–84. One possibility is the extremely inflexible attitude of the Treasury to any form of additional expenditure by the LGB almost regardless of any arguments for the longer-term savings and efficiencies that might result.As has been noted, this was particularly constraining during the relevant period, 1886–96, according to MacLeod (1968b), 25–34, esp. 25. As Alain Desrosières (1991) points out, the SGF in France had already capitalized on the U.S. invention in time for their 1896 census. 97. 74th ARRG, vii–viii. This represented the universal extension to vital registration data of a practice already periodically undertaken without the benefit of mechanization for the population census.The most onerous single task facing the GRO at each decennial census had always been that of dealing with the problem of the overlapping and intersecting boundaries that demarcated the different juridical categories of territorial extents for which population counts were required. By 1890 ecclesiastical parishes, registration districts, and their sub-districts, the units of local government that comprised sanitary authorities and, finally, parliamentary constituencies made up four different types of noncongruent geographical area, for each of which census returns were worked out for all the divisions in the country. Furthermore, each of these could and did change considerably between each census. Detailed knowledge of these boundaries, of necessity, resided entirely in the locality with the reporting agents: the 2,300 registrars and their 40,000 appointed census enumerators. Reports of the committee appointed by the Treasury (1890), Evidence Q. 209–34; 1318; 5. The problem was less severe in Scotland and non-existent in Ireland. Ibid., Q. 1964–71; 373, 420. 98. Ibid. 99. Lambert (1963), 104. 100. Newsholme (1936), 28.

9 THE SILENT REVOLUTION IN NINETEENTH-CENTURY GOVERNMENT The Rise of Local Government Expertise*

The National Efficiency Crisis By the beginning of the twentieth century Fabian socialists had been advocating collectivist social legislation for well over a decade, on grounds of functional efficiency, national defense and, increasingly, congruence with the lessons of evolutionary science. In this respect their

* This chapter is an abbreviated version of “The Emergence of a Social Explanation of Class Inequalities among Environmentalists, 1901–1904,” chapter 4 in Simon Szreter, Fertility, Class and Gender in Britain 1860–1940 (Cambridge 1996).

281

282

Health and Wealth

analysis and aims coincided to a considerable extent with those of the eugenicist and biometrician Karl Pearson. Both shared a nationalist interpretation of evolutionary theory: “social Darwinism” as it has come to be termed. The specific form of social Darwinism espoused by the Fabians and by the biometricians would be more accurately termed “nationalist Darwinism,” since there were so many other social Darwinisms.1 Sidney Webb and Karl Pearson had both come to the conclusion quite separately that, among humans, national populations were the fundamental unit of evolution, to whom the unavoidable laws of survival of the fittest applied in all their rigor. The collective protection—or even positive enhancement—of the health of the domestic, national population was therefore deemed to be an appropriate task for the state to take upon itself. Evolutionary logic dictated that the goal of national physical efficiency was the prerequisite for national survival against the competition represented by other nations. Such responsibilities required the state to undertake a prudential policy of rational and scientific regulation of the economic system’s motor force of capitalism in order to prevent its individualistic, internally competitive forces from outrunning their overall national, social utility.2 Pearson and Webb shared a belief in the rational perfectibility of human society, a reverence for the efficacy of scientific empiricism, an acceptance that the state could and should direct its citizens in the means to improve themselves, and a meritocracy as the ultimate goal.3 Until the opportunity created by the public outcry over the army’s poor performance in the Boer War, however, these two precocious apologists for the scientific state had been largely preaching in the wilderness. Their unremitting collectivizing and regulating prescriptions were unable to find an appreciative national audience in a society that still cherished its liberal and libertarian myths. Albion’s self-image was still that of the home of the radical, independent free-born Englishman, who may not have the vote but knew—or thought that he knew—that he lived free of the continental blight of “despotism”: the anonymous and capricious interference of the inherently corrupt and costly hand of central government. This mythic libertarian national identity, first fully and powerfully articulated by the propaganda machine that helped to mobilize the nation into arms to defeat the Napoleonic dictator, had of course—even for a myth—become extraordinarily divorced from reality by the end of the nineteenth century.4 It was true that central government had grown only

The Silent Revolution in Nineteenth-Century Government

283

relatively slowly since its explosive expansion in the second quarter of the nineteenth century. But, compensatingly, local government functions and expenditure had mushroomed in the second half of the Victorian era, while administration of the Empire had, of course, become a global “despotism” for many of those on its receiving end. At the commencement of the new century, therefore, the individualist libertarian myth was overripe for its fall. Public opinion was more than ready for a rapid conversion to more collectivist norms, reflecting ideas long propounded by a variety of political theorists and policies already long practiced in an ad hoc manner as good municipal government. With the much-heralded public scandal over the deplorable physical condition of so many of the urban recruits offering themselves for service in the South African Wars, the full force of the National Efficiency analysis and the apparent logic of their radical collectivist policies came flooding into the public mind, within and without Parliament.The maverick journalist of popular jingoism and ressentiment, Arnold White, seems to have played a prominent role in linking “degenerationist” notions with the recruitment fears. He first drew attention to the recruitment rejection rates in October 1899 and from May to December 1900 White followed up with a series of thirty-three articles in the Weekly Sun.5 Other influential figures thereafter took up the hue and cry, among whom General Sir (John) Frederick Maurice seems to have been responsible for two of the most influential articles.6 Ultimately, public anxiety was stirred up sufficiently to make it inevitable that the government be seen to do something, leading to Prime Minister Balfour’s reluctant appointment of the famous inquiry of the Interdepartmental Committee on Physical Deterioration.7 There was, however, a wide and fundamental divergence of scientific interpretation between Sidney Webb’s Fabian socialism and Karl Pearson’s eugenic socialism. They were in fact representative of the two most opposed political extremes, for all that they had shared a pioneering preoccupation with promoting “national efficiency.” Once serious discussion of remedial policies began, this difference was bound to become manifest. As MacKenzie has pointed out, Fabians were in favor of extending the franchise; Pearson was not.8 The Fabian advocates of scientific administration and avoidance of “human waste” believed that the agencies of local government, public health, hygiene, and all the official powers of regulatory enforcement should be expanded, infused with

284

Health and Wealth

scientific principles, and so made more effective as the means to improve the “quality” of the nation’s human material.The selectionist hereditarian eugenicists, while sharing the same ultimate aims, believed that such efforts to improve the poor were mistaken, since the poor corresponded more or less to the inherently unfit.The population’s quality could only be scientifically raised through policies to encourage reproduction of the fit, or to discourage it in the unfit.

The Silent Revolution in the Public Service Professions and Local Government Apart from the somewhat speculative and grandiose analyses of Fabian and eugenicist intellectuals, there were other significant constituencies of informed opinion that had developed powerful convictions regarding the nature, causes, and remedies of the urban poverty that the Boer War recruiting statistics had so dramatically implicated in the early years of the new century. Prominent among these other voices were those who had dedicated their professional careers to the task of improving the conditions of life in towns and communities all over the land—the largely local authority-employed public service professionals. These included sanitary engineers, surveyors, food and drugs analysts, sanitary inspectors, and—above all—the Medical Officers of Health (MOHs) and the Town Clerks, who were the executive élite among these trained cadres of officials. Others whose professional activities entailed a direct interest in urban poverty and the domestic conditions of the working classes included such local and central government officials as school attendance officers, building inspectors, HM Inspectors of Factories and of Schools, school managers, and the newly regulated profession of midwife. Finally, of course, there were the swelling ranks of teachers in the nation’s recently consolidated universal elementary school system, a large occupational group perhaps more directly and fully in contact with the lives of the poor than any other. In the course of the last three decades of the nineteenth century this proliferating mass of salaried posts for suitably trained officials had emerged and promptly professionalized itself with examining bodies, subscriptions to national associations, annual conferences and journals.9

The Silent Revolution in Nineteenth-Century Government

285

To this must be added a second major category of practical worker in the poverty industry, the self-appointed ranks of volunteer philanthropists and social workers throughout the country, such as the Settlement House residents, Salvation Army and Temperance League workers, the National Society for the Prevention of Cruelty to Children (NSPCC), and Dr Barnardo’s and the Lady Health Visitors, many of long pedigree and increasingly professional in their self-organization and training under the auspices of such institutions as the COS.10 At one remove from these official and voluntary social workers in the front line, but still close enough to have personal experience of these communities of the poor, were those investigative philanthropists who were anxious to define for themselves the true nature and extent of urban poverty. Charles Booth and Seebohm Rowntree were, of course, the outstanding examples of such social investigators at this time, hoping both to promote deeper understanding of the perplexing problems, and simultaneously thereby to contribute to more effective legislation and social action.11 Most of those giving evidence to the Interdepartmental Committee on Physical Deterioration were practical students of the problem of poverty, drawn from one of these various constituencies.12 In the numerous studies that have appeared of social policy in the Edwardian period, local government employees and related officials and educationists, have rarely been given the attention they deserve as an empowering and progressive agency. In these studies they have usually ceded pride of place to New Liberal intellectuals and other thinkers, and to politicians and Fabian civil servants,13 or else to the various categories of philanthropists.14 Nevertheless, it was precisely these local officials, teachers and school managers—often working in cooperation with local voluntary bodies—whose collectivist initiatives and schemes were so to impress Sir Frederick Maurice when he first began to campaign for greater attention to the nation’s health in the aftermath of the Boer War.15 Maurice was to confess himself quite overwhelmed by the response from these quarters when he raised the issue of the nation’s health in 1903: “[I]t was the accidental circumstance of my happening to touch, without knowing it, upon a subject about which all who had really been studying it were red hot, that has made me appear to have more to do with it than I have had. . . .”16 The temporary resonance between the beliefs and practices of these increasingly powerful and prestigious

286

Health and Wealth

personnel, proliferating in local and central government positions of social responsibility, the programmatic diagnosis of Britain’s ills offered by the various nationalist Darwinists, and the loud alarum sounded by national figures such as Maurice, ultimately swept into the forum of national politics a novel collectivist, interventionist language for addressing the nation’s social problems, an ideology and practice of social reform.17 Local welfare administrators and executive agents, and their various provincial political allies on local councils, had been steadily growing in numbers and powers for many decades.The stereotype image of local councillors and ratepayers as a uniformly myopic “shopocracy” preoccupied only with economizing on the rates needs to be informed by a more realistic acknowledgment of the diversity of opinion in such a body, and also by a recognition of the historical importance of the growing participation of women in local politics, as well as working men (deemed to have the local vote by virtue of their votes being “compounded” within the rents they paid to their absentee landlords), after they were both admitted to the municipal franchise in 1869. These were two new constituencies both of whom could be more favorably disposed towards health and welfare measures and services, and increasingly were after 1869 (see chapter 7). A system of localized self-government and social responsibility had been asserted in the Local Government Act of 1858, consolidated by the major Public Health Act of 1875 and finally made universal with the Local Government Acts of 1888 (defining County Councils) and 1894 (defining district and parish authorities). As well as acting as full council members, locally elected political representatives could serve on Poor Law boards of guardians, where women were also eligible and were increasingly elected alter 1875. Additionally both women and working-class men could serve on local school boards, established with a householder franchise in 1870.18 The increasing activism and dynamism of local authorities during the last decades of the Victorian era provides something of a contrast with the activities of the main corresponding central government department. Roy MacLeod long ago exposed the many and varied stratagems by which the Treasury deliberately sought to stymie initiative and expansion in the Local Government Board (LGB), especially its medical activities, during the last two decades of the nineteenth century.19 This was

The Silent Revolution in Nineteenth-Century Government

287

the era of “Lingenism,” when the preeminence of the generalist over the technical specialist was being established throughout the civil service.20 A Gladstonian policy of retrenchment and control over central expenditure was prosecuted in pursuit of the laissez-faire virtues of minimal taxation and minimal central state interference, appealing to a widespread and ingrained radical ethos in favor of local self-government.21 But it has been insufficiently appreciated by historians that precisely because this Treasury-implemented strategy of devolution in social policy—casting off executive and financial responsibilities onto the provinces—was so successful, the last quarter of the century witnessed an unprecedented expansion of administrative and organizational initiatives at the local authority level. Not surprisingly there was a corresponding growth in the numbers and strength of the public service professional groups involved in this activity. In other words, the inevitable and actual corollary of the success of central government retrenchment and the refusal to be drawn into executive responsibility for all the collectively funded facilities and services required to avoid the urban public squalor against which late Victorians recoiled was a compensating growth in government and policy initiatives at the local authority level. Central government provided concessionary grants-in-aid and technical advice if requested, but it was primarily local government that initiated, staffed, sometimes devised and mostly funded the enormous expansion in urban infrastructure and social services that occurred throughout the period, 1858–1914.22 As H. J. Hanham has observed: “In retrospect the extent of local selfgovernment during the nineteenth century appears stupefying. As a matter of principle Whitehall thrust every type of administration on to elected local bodies.”23 This is unequivocally borne out by the basic quantitative evidence: the expenditure of local government as a share of all government expenditure (itself a continually increasing figure) rose dramatically from 1870, when it stood at just under 30 percent, to 1905 when it peaked at over 50 percent (see this volume,Table 10.1).24 It was only at this juncture that the political desirability of a shift in the fiscal burdens and formal responsibilities for social policies back towards the central state and direct taxation became sufficiently pressing and widely acknowledged that such a policy program was adopted by a national party—the New Liberals.25

288

Health and Wealth

Not surprisingly all this produced considerable fiscal strains for local authorities.They attempted to manage this in various ways, notably through the innovations of “municipal trading” and deficit financing— borrowing on the money-markets.26 As ever, under the illogical yet compelling pressures from ratepayers to deliver the services and improvements to their environment that they wanted while not adding a penny to the local rates bills, town councils had increasingly found it expedient to supplement the funds for local services collected in from the rate base with income generated by running municipal services such as tramways and gas supply. This phenomenon, and the innovations in local revenue generation devised to fund it, was broadly referred to by its contemporary, anti-collectivist detractors as “gas and water socialism” and “municipal trading.”27 The peculiar invisibility of the massive local government-based preventive health achievement during the period 1870–1914, and of the degree of its informal integration with an associated penumbra of both proletarian and genteel institutions of voluntary support and philanthropic assistance seems to be due to a set of compounding historiographical factors.28 First, as Sidney Webb’s celebrated and oft-repeated fictional anecdote suggested, the invisibility started with contemporaries’ perceptions. The preventive and regulatory public health apparatus grew with the collusive protection of a kind of Victorian ideological blind spot: “The individualist town councillor will walk along the municipal pavement, lit by municipal gas and cleansed by municipal brooms with municipal water [while declaring, many “municipals” later,] ‘Selfhelp, Sir, individual self-help, that’s what made our city what it is.’ ”29 This creed was also manifested on the stage of national politics by the strict adherence throughout the century to the ritual formula of local selfgovernment.30 In such expensive matters as preventive public health measures, central government merely enabled and advised, leaving local ratepaying property-holders to decide. But decide they did, slowly and reluctantly responding over the course of several decades to consciencepricking statistics of poverty and scenes of offensive public squalor. Second, and probably of most importance in the historiographical vanishing act of local government has been the long-lasting effect of the two most influential studies of the history of local government that were both produced in this period, by A. V. Dicey and by the Webbs. These

The Silent Revolution in Nineteenth-Century Government

289

were written by opposed partisans in the heated contemporary debate over the ideological and economic rights and wrongs of elected local authorities collectivizing and running commercial services in their localities. Both were highly critical of the recent practices of local government throughout the land, but for diametrically opposed reasons: one because they had done too little, the other because they had done too much.31 Sidney Webb, as a leading force behind the Progressives’ “gas and water socialism” program of the new London County Council (LCC), believed that most local authorities had done nothing like enough to use and coordinate the administrative and financial resources at their disposal to transform the lives of their citizens. As Anne Hardy has pointed out, it has been particularly unfortunate for the historical reputation of Victorian public health that it was under the London vestries that a geographically comprehensive set of metropolitan MOH jurisdictions was first established, by the 1855 Metropolis Local Management Act.32 Their reputation has consequently suffered from guilt by association with the vestries, the principal target of Sidney Webb and the Progressives, in their successful campaign to vilify the vestries in order to change the structure of government in London.33 More generally, the monumental nine-volume Fabian history of local government by Beatrice and Sidney Webb exposed severe limitations, inefficiencies and absurdities in an administrative apparatus of great antiquity. It had grown in an entirely ad hoc and nonsystematic way through a long series of accretions and halfhearted reforms into a set of overlapping, partial jurisdictions, none of which were quite the same in any two parts of the country.34 On the other hand, the more concise interpretation of the nineteenthcentury history of local government published in 1905 by the old-style liberal, A. V. Dicey, deplored, on libertarian political and economic grounds, the novel trend towards collectivism. It was both an abrogation of the sacred free market, “crowding-out” private firms, and a supposedly dangerous accretion of unaccountable sources of income and therefore power on the part of local governments and their unelected officials.35 The local authorities seem, then, to have been caught in this ideological crossfire, with their historical reputation being the chief victim.36 The third reason for the invisibility of the role of local government is the closely intertwining relationship of its health and social services

290

Health and Wealth

with the parochial operation of the dreaded Victorian Poor Law, despite their statutory separation in 1834.37 The two parallel systems for provision of local “welfare” services were administered under the same department of central government from 1871 onwards, the Local Government Board (LGB). This department always remained under the predominant influence of the parsimonious Poor Law tradition, which the first definitive history of the period, published in 1936, pointed to as especially fateful.38 Through this association with the Poor Law, therefore, Victorian local government and the LGB itself have both been tarred with perhaps the largest of the several dirty brushes that reside in the nineteenth-century historian’s capacious pot of tar. But all this conceals a positive history of numerous local initiatives in research and expansion in service provision and funding during the last decades of the Victorian era, led in many respects by the MOHs.As the following section will exemplify, a major consequence of the Treasury’s successful stifling of the LGB at the center was that new ideas, experiments, and their revisions were carried out in scores of local contexts instead. Thus, when plans for ambitious social services to combat urban poverty, infant mortality and unemployment came to be required in the Edwardian period by a Liberal central government at last interested in nationally funded social policy, an embarrassment of choice came flooding forth from locally employed professional and administrative experts and their associations. By then they had a long history behind them of developing and improving their schemes on the ground, out in the provinces, and in London.They worked with their local government employers where they could, and cajoled them with scientific investigations and reports when they could not.39 The rough and tumble of relationships with local authorities over three decades had done much to cement the professional esprit de corps that had developed within the national associations of the public service professions by the turn of the century.40

The Influence of Local Government Experience in the Public Health Field As Anne Hardy has pointed out, whereas central government “did not provide a career for any significant number of doctors during the

The Silent Revolution in Nineteenth-Century Government

291

period,” it “was in local government that there proved to be real opportunities for both professional and administrative expansion.”41 Many then went on to pursue later careers in central government bringing their experience and ideas with them.The obvious and outstanding examples at this time are George Newman and Arthur Newsholme, both of whom launched their successful careers in Whitehall from a background as MOHs in local government. The Factory Inspectorate provides another case in point: Peter Bartrip has found a rather sluggish late Victorian Factory Inspectorate in Whitehall, laboring under the same blight of “Lingenism” as everybody else. It was finally transformed with the arrival from the provinces of B. A.Whitelegge, appointed as Chief Inspector in 1896. He was a medical professional qualified in public health with twelve years’ experience and practice in the field, as MOH for Nottingham and then for the county of Yorkshire’s West Riding.42 Assiduous MOHs actively inquired into the reasons for the stubbornly high levels of mortality from certain specific diseases in the area under their jurisdiction and pioneered locally the research and the preventive systems that were subsequently to influence national solutions and legislation. For instance, the first notification systems for tuberculosis were initiated in the late 1880s by Robert Philip in Edinburgh and James Niven in Manchester (who became John Tatham’s successor as MOH there, 1894–1922). This system was noticed and then advocated by Arthur Newsholme when he became MOH in Brighton and finally became embodied as part of a national scheme in 1913, after Newsholme had become the LGB’s Chief Medical Officer. John Tatham,William Farr’s second successor as Superintendent of Statistics at the GRO, perfectly illustrates this process of recruitment of initiative and ideas into the central government service from the experienced local government sphere. As an MOH for twenty years (first for Salford and then for Manchester) he had a number of significant public health administrative innovations to his credit when he joined the GRO as its Statistical Superintendent in 1893. Chief among these, he had instigated a comprehensive scheme for the notification of infectious diseases and he had asked his council for—and obtained—the resources for a domiciliary house-to-house health visiting team of thirteen female health visitors in Manchester.43 Thus, Tatham was drawing on highly relevant personal administrative experience when he gave evidence in 1897 to the

292

Health and Wealth

House of Lords Committee for their Bill for the Better Protection of Infant Life and, again, to the important Interdepartmental Inquiry into Physical Deterioration of 1904. His views on the problems of urban poverty and disease and on the realistic means to remedy them derived from this apprenticeship and career of practical prevention in local government; and this was therefore reflected in the kinds of analysis he elected to perform on the statistics collected by the GRO, which he presented in evidence to these central government inquiries. Another important example of the way in which local authority initiatives did not simply occur in a vacuum, hermetically sealed off from Whitehall and Westminster, is provided by the innovation of school medical inspection. It is well known that in 1907 a national system of inspection was established by the New Liberal government.What is much less well known is that the origins of this policy lay in local government. In June 1893 W. P. Byles and James Hanson, respectively the only female and the only working-class member of Bradford’s School Board (this was before the arrival in Bradford of Margaret McMillan), prevailed upon their colleagues to appoint Dr. Kerr to the country’s first full-time post of school medical officer.44 In 1902 the LCC itself followed suit, poaching the impressive Kerr in the process. Finally, twelve years after Bradford’s pioneering scheme and following its endorsement by the Interdepartmental Inquiry on Physical Deterioration, the central government duly took up the policy, enacting a nationwide school medical inspection service in 1907. By the opening years of the new century, therefore, the numbers, powers, and self-organization of local officials, inspectors, and civic servants had grown and matured enormously. Above all, the leaders of this diffused movement were medical professionals, especially the widening stream of graduates who had been emerging from the nation’s postgraduate public health courses each year since the mid-1870s.45 Clause 21 of the 1888 Local Government Act had made possession of a sanitary diploma compulsory for appointment as MOH to any large local authority (above 50,000 population). Such accredited MOHs numbered 263 in 1886, and nearly 700 by 1900.46 Hence, two-thirds of the witnesses who appeared before the 1903–4 Interdepartmental Inquiry of the Physical Deterioration Committee were medically trained, mostly in public health.47 The strong sense of professional continuity and solidarity within

The Silent Revolution in Nineteenth-Century Government

293

the public health branch of the medical profession by the beginning of the twentieth century is nicely illustrated by the desire of the founding editorial board of the new Journal of Hygiene (Arthur Newsholme, G. H. F. Nuttall and J. S. Haldane) to obtain a contribution to their first issue in 1900 from the eighty-six-year-old Sir John Simon, active over half a century earlier as the City of London’s and then the nation’s first Chief Medical Officer (to the Privy Council).48 The first generation of sanitarians had been preoccupied with cleaning up the unpaved, dung-laden streets and stagnant cesspools that substituted for sewers so as to avoid the poisonous miasmas that they believed these nose-sores emitted.49 By the early 1890s, MOHs had begun to direct the growing investigative resources at their disposal towards the related knot of problems surrounding working-class diet, housing, domestic hygiene practices, and social behavior. Increasingly MOHs and their staffs were concerned, first, with the disease-promoting mores of urban working-class communities;50 and, second, with the gross inadequacies of hygienic facilities inside the overcrowded, unplumbed, working-class back-to-backs, huddled together around tiny courtyards where they often shared a single, irregular water supply and a single, indescribable privy. Germ theory suggested that together these created perfect conditions for the spread of infectious micro-organisms both directly between people and from the infected, unclean foods they prepared for themselves in their inadequately equipped homes. However, this new focus of attention was by no means due only to the contagionist implications of the germ theory of disease (fully accepted in Britain only by the late 1880s).51 The only systematic research showing the practical activities of Britain’s local public health professionals across the period as a whole is Anne Hardy’s important study of London MOHs. She shows that the much greater attention paid to the homes and habits of the population in the last decade was primarily an extension of earlier practices and policies. It was a spin-off from the success that the MOHs finally achieved in their decades-long efforts to establish a fully integrated preventive system to “stamp out” communicable diseases. This system involved the coordinated mechanisms of outbreak notification, isolation of victims, and disinfection of all contacts and premises. It had been culturally rooted libertarian objections to forcible detention or isolation of persons that delayed the adoption of such an integrated plan to

294

Health and Wealth

deal with human afflictions.The public health movement was not granted the essential machinery of compulsory notification for those diseases recognized to be infectious until the 1890s. As Anne Hardy has pointed out, in consequence it was only in the field of veterinary policy, specifically in response to the rinderpest epidemic of 1865, that such “stamping out” policies were first fully implemented. It was the spectacular practical successes of this approach over the ensuing decades that particularly impressed the hard-nosed empiricist Anglo-Saxon mind, rather than the perfection of germ theory.This efficacy gradually convinced medical professionals and wider public opinion alike that the cost to human liberty of such a comprehensive preventive apparatus was worth paying.52 Thus, for a quarter of a century an increasingly powerful, professionalized body of medically trained public servants had been arguing for and expanding, piecemeal, a variety of local forms of regulation of industrial capitalism and of collectivist responsibility for poverty. Following the war in South Africa, they found themselves in possession of a great opportunity to advance their cause, as the nation’s savior in the face of crisis.They were not unprepared for the moment of opportunity. When Sir Frederick Maurice cast about him for wider evidence and views on the all-important issue of national physique, he found himself surrounded on all sides by a veritable crowd of well-informed professionals, fully organized into national associations actively exchanging ideas and information through their journals, offering evidence, roundly formed opinions and experimental policies with which to combat many aspects of the problem he had identified. The early years of the new century witnessed a spontaneous political offensive into the national arena by the phalanxes of locally employed professional public servants. By virtue of their chosen vocation, the vast majority were practitioners of an interventionist, implicitly “environmentalist” approach to the problems associated with the urban population’s standards of health. Organized into their professional associations, they were the agents of a de facto acknowledged collectivist responsibility on the part of most local authorities for the conditions of the poor. This responsibility had been gradually and haphazardly but nevertheless widely assumed by the beginning of the new century, through a protracted sequence of local policy decisions, albeit often grudgingly taken and stretching over many decades, much of it the sequlae of the universal compulsory education acts, which gradually

The Silent Revolution in Nineteenth-Century Government

295

brought local government into more direct contact with the children— and the parents—of the poorest elements of the community.53 These professionals were men and women who had previously had a voice only in local affairs and at specialist conferences of fellow professionals. For instance, both the Journal of State Medicine ( Journal of Preventive Medicine from 1905), organ of the Royal Institute of Public Health founded in 1892, and Public Health, the journal of the Incorporated Society of MOHs, had each provided for over a decade a forum for detailed discussion and for organized political lobbying on preventive health issues. The former concentrated more exclusively on matters relating to administrative control of environmental factors in infectious diseases and relevant developments in bacteriology, while the latter also included coverage of diet, domestic hygiene and education.54 But certainly they had always entertained strong aspirations for greater influence: starting in 1889 the Society of MOHs was served by a committee devoted to vetting all relevant parliamentary legislation, often resulting in important proposals for amendments.55 Of course, there always remained wide differences of opinion among the hundreds of doctors involved and interested in public health work, including even those such as C. K. Millard (MOH, Leicester) and Sir James Barr (Professor of Clinical Medicine, Liverpool University) who had strong eugenic leanings.56 But, as G. R. Searle has argued, apart from specialists in certain pathological and hereditary conditions, the vast majority of medical practitioners were hostile to the hereditarianism of eugenics, especially those who were MOHs, who by the Edwardian period inclined towards, if anything, Fabian socialism.57 This general point would certainly be borne out by the diminutive membership of doctors in the Eugenics Education Society as a proportion of the profession (though doctors were a major occupational group within the relatively small membership of the Eugenics Education Society).58 Furthermore, for many persons who became members of this Eugenics Society, both before and after World War I, their membership reflected a more general disposition in favor of “science.” For many it was their commitment to the search for and promotion of scientifically rational methods for dealing with social problems in an ordered fashion that put them in sympathy with the broad aims of the eugenics movement, rather than any strong belief in an exclusively hereditarian evolutionism.An increasingly scientific

296

Health and Wealth

medical profession was therefore particularly likely to yield a certain degree of open-minded interest in the possibilities that might be offered by knowledge of hereditary aspects of incapacity. Such members included, for instance, the MOHs Dr. James Niven of Manchester and Dr. John Robertson of Birmingham, neither of whom can be accurately characterized as hereditarian eugenicists.59 Only the most politically and ideologically astute minds within the profession—Arthur Newsholme and Alfred Eicholz among them— could clearly discern at this time the political importance of the illiberal and exclusionary implications that lay at the hereditarian core of the eugenicist position. A “leading caucus” of such percipients has been identified within the Edwardian Society of MOHs.60 They included E. W. Hope, G. F. McCleary, George Newman, and Arthur Newsholme. As a group these men also shared the ambitious long-term aim of bringing about a centrally funded and organized preventive health service for the nation, free from the whims and capricious parsimonies of local politics. This was conceived as a grander, more rational and efficient vision of the social role of medicine than the mere reactive, curative conception of clinical medicine. There were compelling ideological and professional reasons for the attractions of this strategy to a relatively new and young, and therefore inevitably low-status, section of that most gerontocratic of professions, medicine. Public health doctors were attempting to throw off the Poor Law Medical Officer connotations of public work in medicine and experiencing some difficulty in establishing satisfactory tenure arrangements with a melange of corporate employers.61 However, there was an equally important and independent set of wider scientific and political developments during the first years of the century that were also impelling the organized public health movement towards the novelty of an explicit, positive endorsement for a program of collectivist health and welfare systems for the nation as a whole.

The Environmentalist Response to Hereditarian Eugenics Previously, public health professionals had broadly acquiesced in the conventional individualist, liberal Weltanschauung of Victorian educated

The Silent Revolution in Nineteenth-Century Government

297

society, which is to say no more than that these Victorian medical practitioners were normal educated men of their class and times. Laissez-faire, free trade, and self-help were, of course, popular rhetorical slogans, not accurate descriptions of Victorian society. They most accurately expressed not so much a shared conviction in the social ideal of a free market anarchy of perfect competition (itself an oxymoron as a normative idea) as a pervasive belief in the desirability of economic independence as an ideal and moral way of life for the individual—particularly for the adult male, voting head of household, as sanctioned in Lockean constitutional theory.62 As a result of their acceptance of these conventional Victorian tenets, public health environmentalists were constrained within a consensus that accepted the economic relations of the market— in particular the labor market—as simply not amenable to any form of systematic policy manipulation.Any attempt to tamper with the invisible hand was immoral and doomed to failure. Wages, wage levels, and the demand for labor were, generally speaking, among the givens of nature. It was simply not considered a worthwhile subject for discussion where the main issues that preoccupied the public health movement were concerned: the poverty, disease and unfitness of the urban poor and how practically to alleviate their plight. Despite this prevailing normative consensus, radical ideas for a more comprehensive system of state intervention to promote the nation’s health had been mooted by some medical men, although the institutionalized heads of the public health movement such as Chadwick, Farr, Simon and his successors as Chief Medical Officers at the LGB had not found it politic—some to their cost—to champion such schemes too zealously.63 In the first decade of the twentieth century, however, leading figures in the public health movement, such as those identified by the Porters (1988), were now showing their heads above the parapet, displaying a willingness to argue for certain national measures to be taken, notably the provision of school meals for needy children, which amounted to state-sponsored income support for the poor. It is certainly not the intention here to give the impression that such limited proposals by public health professionals represented the leading edge of new ideas and policies concerning the relationships between the state, fiscal redistribution, and citizenship. Since the 1880s unemployment and old-age dependency had been the principal fields in

298

Health and Wealth

which such innovations in municipal and official policy had been pioneered. Local authorities and the local government-groomed president of the LGB, Joseph Chamberlain, can be seen from the mid-1880s groping towards an implicit acknowledgment of collective responsibility for the vagaries of the labor market and a recognition of the social value of schemes designed to deflect its harshest aspects. Chamberlain’s famous circular of March 1886 authorized non-pauperizing municipal public works for the unemployed.64 Furthermore, there had been much radical new thinking, especially during the 1890s, on the problems of dependency in old age (although the nettle of full state provision of old-age pensions was not finally grasped until 1908).65 Edwardian public health specialists were, then, joining social theorists, political figures, and progressive civil servants who were already involved in radically redefining the legitimacy of a much expanded role for the collectivist state.66 However, these new views among public health professionals were not merely derivative from the initiatives pioneered in other fields of social policy. They were also an independently generated product of a galvanizing clash over the correct “scientific” analysis of the causes of urban poverty, physical unfitness, and child development, issues that were specific to their own field of expertise. In this confrontation with the views of hereditarian eugenicists, environmentalist public health officials found themselves substantially making common cause with those involved in implementing the nation’s evolving universal education policy over the cluster of issues surrounding child development and appropriate measures for the abnormal child. It had not been until the final two decades of the nineteenth century that children of the poorest of the poor were finally being forcibly drafted into the nation’s elementary schools. Indeed it was only in the closing decade of the century that schooling was being made effectively compulsory—through the diligence of the school attendance officers— and also genuinely free, through the assiduous implementation under A. H. D. Acland’s vice presidency of the Committee of Council on Education, 1892–95, of the Assisted Education Act of 1891.67 The appearance in elementary schools of the very poor stimulated a wave of renewed concern among the local health and education professionals involved.This was not merely disquiet at the contagionist health risk that such children represented for their fellow classmates. Confronted with

The Silent Revolution in Nineteenth-Century Government

299

the appalling condition of many of these new child wards emerging from the slums, teachers, attendance officers, and school managers now joined MOHs and their staffs and the NSPCC as first-hand, professional observers of the effects of chronic material deprivation. They experienced for themselves the impaired powers of concentration and learning capacities of the hungry poor. Even in London, for instance, this eventually led to a formal survey of hunger among school children conducted in 1889 and the immediate setting up of the London School Dinners Association in response to the results.68 The sheer numbers involved and the financial implications of different potential solutions were forcing those in positions of responsibility to address more rigorously than ever before the difficult administrative decisions of how best to accommodate and teach those with learning difficulties and special needs, where scarce resources of teachers and buildings were already overstretched. These were policy questions whose answers crucially depended upon matters of correct definition and classification of different kinds and degrees of impairment, an area of scientific speculation where issues closely paralleled those at the heart of the nature-nurture conflict.69 Which kinds of defect—blind, deaf, dumb, lame, as well as mental—rendered children truly uneducable in a normal school? Which problems were food- or health-related only? And was the pedagogically adequate remedy (free school meals) also politically acceptable in such cases? What were the visible or behavioral signs for diagnosis of these varying conditions? These were the practical problems, demanding scientific and administrative solutions, that the local health and education professionals were facing in the last decade of the century. Central government commissions took evidence while local government school boards took initiatives. By the beginning of the new century, there were a growing number of medically trained or pedagogic practical professional experts: managers of asylums and special schools, local or central inspectors of schools, some MOHs, some teachers, and the country’s first School Board Medical Officers (Dr. W. R. Smith and his assistant Dr. F. D. Harris in London, James Kerr in Bradford). The National Society for the Prevention of Cruelty to Children (NSPCC) and the COS were also considered important sources of expertise and experience.The COS in particular had a long-standing interest in devising the

300

Health and Wealth

most efficient and appropriate care for the feeble-minded as these were disproportionately represented among its destitute clientage. Its own specialists in these affairs at the turn of the century were Dr Francis Warner (Physician to the London Hospital), Dr G. E. Shuttleworth (Superintendent of the Royal Albert Asylum), Miss Mary Dendy, and Mrs Ellen Pinsent (both School Board members, from Manchester and Birmingham, respectively). These individuals were the leading campaigners in the National Association for Promoting the Welfare of the Feeble-Minded, founded in 1896. Their principal policy priorities were to deal with the danger and “waste” (i.e., cost) to society that the uncontrolled proliferation of defectives represented, on the assumption that deficiencies in their age-specific physical and mental development and in apparent learning capacities were primarily something naturally inherited, or at least an ingrained familial character that was best not reproduced. Segregation and control were the main measures they envisaged, as practiced from 1902 on Mary Dendy’s “Farm” at Sandlebridge, Cheshire. There were strong affinities with Francis Galton’s antienvironmentalist eugenics, an association formally signaled in Francis Warner’s anthropometric survey of 100,000 school children, 1888–93, inspired by Galton’s earlier work and supported by the COS.70 Opposed to these segregationist policies were to be found those educationists who preferred instead to emphasize the importance of the vast number and range of subnormal, disabled, or underachieving children who could be assisted to develop positively and without the need for institutionalized segregation. Among these were such figures as Dr. W. Leslie MacKenzie, Dr. James Kerr, Dr. Alfred Eicholz, Dr. George Newman, Rachel and Margaret McMillan, W. H. Libby, and the MPs Thomas Macnamara and Sir John Gorst, several of whom will appear in the account that unfolds below.71 There was much overlap and experience held in common with public health environmentalists, as the doctors’ names above suggest. Rachel McMillan originally trained and worked as a sanitary inspector; her sister, as an Independent Labour Party (ILP) representative on Bradford School Board, had participated in James Kerr’s first recorded official school medical inspection in 1899.72 They were impressed with the importance of environmental deprivations in causing many of the children’s problems and with the devising of effective measures to alleviate these hindrances.They stressed the great possibilities for

The Silent Revolution in Nineteenth-Century Government

301

rehabilitation of deficient individuals, rather than their segregation, as the most promising means to attain greater social and economic national efficiency (although conceding that a small group of the grossly defective would still have to be detained). These were the voices alongside whom public health environmentalists found themselves testifying for similar measures at the 1903 and 1904 official inquiries and thereafter.

The Environmentalist Understanding of Social Classes During 1903–4 the consonance of interests between practicing environmentalists among local government officials and administrators, educationists, Fabian collectivist “permeators,” and eugenic academic biologists briefly welded together by nationalist and imperialist politicians, was sufficient to secure government recognition of the gravity of the public’s anxieties over the nation’s physical condition. Finally, an Interdepartmental Committee on Physical Deterioration (PDC) was appointed, despite the fact that a Royal Commission on Physical Training in schools (in Scotland) was currently examining strongly related issues.73 The terms of reference of the PDC were: (1) To determine with the aid of such counsel as the medical profession are able to give, the steps that should be taken to furnish the Government and the Nation at large with periodical data for an accurate comparative estimate of the health and physique of the people; (2) to indicate generally the causes of such physical deterioration as does exist in certain classes; and (3) to point out the means by which it can be most effectually diminished.74

These terms of reference in fact represented an amplification of the original remit, which had been merely to inquire into “allegations concerning the deterioration of certain classes of the population.”75 The final formulation was the product of an extremely significant exchange of views that had preceded the setting up of the committee. Evidently the committee itself recognized the importance of this preliminary debate because the relevant correspondence and memoranda were reproduced as Appendix I of their report, from which the following account is reconstructed. It fully

302

Health and Wealth

reveals the nature of the fundamental scientific division of opinion between the hereditarians and the environmentalists and shows that this was keenly appreciated on both sides. Broadly speaking, it can be labeled a nature-nurture division, but it was simultaneously a reflection of the political and ethical differences between vocational ideologies. The public health branch of the medical profession was the most coherently organized and prestigious unit within the constellation of interventionist public servants who were involved in a daily battle with the social and environmental causes of poverty and disease. They were very much on their mettle, and on the offensive to wrest the direction of practical social policy from what they correctly perceived to be the meddling and dangerously quixotic opinions of certain biological scientists, economists, and moralizing politicians who were comfortably removed from the harsh realities of the urban slums.As far as they were concerned winning the battle against the entrenched individualist and laissez-faire attitudes to secure a greater level of state intervention to combat destitution would be a hollow victory if such intervention were to take the segregationist form of labor colonies and prohibitions on marriage of the poor. Public health environmentalists wanted an enlarged attack on inadequate living conditions and ignorance, a strategy that they believed had already proved itself to be effective. A battle to establish the correct scientific interpretation of poverty and disease, in order to control the strategy of remedial social policy, therefore began in earnest in 1903. In the preliminary exchange recounted below, it will be noted that the notion of hereditary causation was immediately singled out for attack by the public health leaders of the medical profession. Whereas the Fabians wanted national efficiency whatever the means, and biometricians believed in the importance of heredity whatever the consequences, public health doctors and other public officials would not relinquish their vocational conviction in a thoroughgoing environmentalist analysis of the sources of disease and debility.As we shall see, under the pressure of having to respond to the claims being advanced by hereditarians, leading practical exponents of this environmentalism were to be found broadening and deepening their analysis to encompass, ultimately, a theory of the socially structured and economically induced causes of poverty and social inequality. Such, then, were the conflicting aims of the important interest groups within the National Efficiency movement.

The Silent Revolution in Nineteenth-Century Government

303

The preliminary terms of reference of the Interdepartmental Inquiry, referring to “allegations concerning the deterioration of certain classes of the population,” had certainly implied that some form of physiological, hereditary degeneration was under discussion.This reflected the suspicions of the original memorandum sent to the Secretary of State for the Home Department on 2 April 1903 by Sir William Taylor, DirectorGeneral of the Army Medical Service. This suggestion was taken as read and therefore addressed by both the Royal Colleges, of Physicians and of Surgeons, when Taylor’s memo was forwarded to them by the Secretary of State to sound their opinions on the need for, and terms of reference of, a possible official investigation. Both colleges immediately pointed out that the statistical evidence, presented by Taylor, concerning rejection ratios at recruiting stations and reasons for those rejections over the period 1893–1902, was inadequate to support the contention that a physical deterioration had occurred in the classes referred to.76 On being reconsulted, Sir William Taylor clarified his position, agreeing that the figures he himself had produced did not support an interpretation of progressive physical deterioration but rather attested to a disturbing current state of affairs, which nevertheless merited investigation.77 The impression that he had been making a case for hereditary degeneration was overwhelming in the original memo, as the responses of the two colleges indicate. That impression had been due initially to Taylor’s extensive quotation in that document of the views of General Sir Frederick Maurice78 and Sir Lauder Brunton,79 both of whom strongly suggested that the low standard of physique was more prevalent among the urban dwelling population.80 Taylor had then juxtaposed the recent work of Rowntree on York, and it was noted that his finding of a total of 28 percent of the town’s population in poverty was similar to the figure of 30 percent found for London some years previously by Booth.81 Thus, a putative rise in poverty in the growing towns was strongly, but only implicitly and not formally, linked to a deterioration of national physique. In fact the PDC Report itself referred to only one official source in which it was specifically stated that there was a gradual deterioration of the physique of the working classes.This was the 1902 Annual Report of the Inspector-General for Recruiting (Major-General H. C. Barrett, one of the witnesses called before the inquiry).82 The Physicians and Surgeons had imputed that this was Taylor’s meaning—an inheritable

304

Health and Wealth

and cumulative deterioration—because of the stridency at this time of the claims being made by the hereditarian eugenicists. The interchange of correspondence that preceded the setting up of the PDC’s inquiry additionally reveals the first signs of the process whereby the significance of social classification for interpreting “data” was coming to be perceived by anti-hereditarian environmentalists in the medical profession as a central methodological issue. The Royal College of Physicians had appointed a subcommittee of five to deal with the issues preliminary to setting up the inquiry.83 The subcommittee focused their attention on Sir William Taylor’s usage of the established system of the Army Medical Department for classifying candidates presenting themselves for medical inspection prior to recruitment into six different categories according to their former occupation.84 They took him to task for his assertion that examination of a series of figures classified into these six categories showed that “the proportion of the different classes remains remarkably constant from year to year, and the figures indicate that the bulk of our soldiers are drawn from the unskilled labour class, and consequently from the stratum of the population living in actual poverty or close to the poverty line.”85 The subcommittee pointed out that this classification scheme could not adequately capture significant changes in the proportions recruiting into the army from different parts of the labor market, and so did not support the main point that Taylor was trying, rather obliquely, to make: that an alleged change in the average physique was not due simply to changes in the proportions recruiting from different strata. Of the six classes used by the Army Medical Department, Category 1, which accounted for over 60 percent of all recruits examined, compounded together all kinds of laborers: rural and urban, regularly employed factory “hands” and the casual “residuum of the labour market.” It was observed that there was strong reason to believe that a well-documented recent trend rise in the relative real wages of agricultural laborers could have caused a serious fall-off in the recruitment into the army of this, the most physically fit section of the overlarge Category 1.86 The classification system’s inadequacies were, thus, rigorously exposed. In fact, by the time the PDC report was written this critique was already being acted upon: In supplement of the request for a more detailed subdivision of the classes denominated “Labourers” in the Recruiting Returns . . . it was

The Silent Revolution in Nineteenth-Century Government

305

subsequently suggested to both the Admiralty and the War Office that the subheads might with advantage follow the classification shown in the Census Summary Volume for 1901 and the Committee have reason to believe that the Admiralty have already adopted the suggestion.87

Although this incident shows a keen awareness among the physicians that classification of the population into large categories for purposes of hypothesis-testing and presentation of evidence was a practice requiring great care and scrutiny, it does not establish conclusively that any strong notion of social class or socioeconomic stratification had been at issue in their eyes. However, when it comes to the proceedings of evidence taken by the PDC, we do indeed encounter ideas and research that explicitly utilize the notion of a socioeconomic stratification in society and that refer to the existence of social classes as institutions that are in some way strong causal determinants of the substantive issue at stake: the extent, causes, and remedies for the current state of physical health in the nation. What is important, though, about those witnesses to the inquiry who did mobilize and argue and give evidence using social classes in this way is that they did so with the aim of discrediting the entire hereditarian interpretation of poverty and social structure.Thus, conflict over the implicit meaning of social classes—whether they were “natural” as the hereditarians maintained, or socially formed as the environmentalists would argue—became a critical issue in the battle over interpretation of empirical evidence that ensued between these two camps. To anticipate the following account, it was the environmentalists who ultimately prevailed in 1904 with their environmentalist interpretation of the sources of social class inequalities.The PDC’s summary report concluded that, with the exception of syphilis and possibly alcoholism, “[s]o far as the Committee is in a position to judge, the influence of heredity in the form of the transmission of any direct taint is not a considerable factor in the production of degenerates.”88 In coming to this conclusion the committee expressed itself strongly influenced by the evidence of D. J. Cunningham, Professor of Anatomy at Edinburgh University, Dr.Alfred Eicholz, Her Majesty’s Inspector of schools (HMI), and Dr.W. Leslie Mackenzie, MOH for Leith and Medical Inspector for the LGB of Scotland.89 The last-named had also been an important witness before the 1903 Royal Commission on Physical Training (Scotland),

306

Health and Wealth

as had Mr. J. C. Legge, HMI of reformatory industrial schools, who was now cast in the role of investigator, as member of the PDC. It is known from the evidence Legge presented in 1903 to the Scottish Royal Commission that he was quite convinced of the powerful effect that environmental factors could have, at least on physical development, from his own analysis of anthropometric data in Scottish and English reform schools.90 Leslie MacKenzie had also stated to that inquiry: “What I wish to emphasize is that the scope for improvement by improved nurture is almost unlimited.”91 He had distinguished there between “transmissible degeneration” and “generational degeneration . . . confined to the particular generation concerned, and . . . capable of removal by the improvement of the environment—improvement that is in housing and nurture.”92 MacKenzie had specified that this included precisely those diseases whose symptoms might easily, to the untrained eye, be imagined as evidence of the nation’s alleged hereditary physical deterioration: “rickets, anaemia, tubercular bone disease, and the multitude of diseases that result in deformities, in impairment of physique.” He was even prepared to conclude this list with “malnutrition of the nervous system, with consequent mental deterioration” as a condition definitely open to environmental improvement.93 In the proceedings of the PDC, Dr. Eicholz’s evidence provided by far the most intellectually penetrating and extensive case that had yet been made for the environmentalist interpretation of the social statistics of physical deterioration.94 Although other witnesses went politically further in their evidence—notably both Rowntree and H. J.Wilson (HM Inspector of Factories) in suggesting that the wages of the very poor should be improved—Eicholz’s analysis was the most conceptually advanced in relation to social class. His presentation to the inquiry constitutes, in effect, the extension of the environmentalist view of debility into a comprehensive social (as opposed to naturalistic) understanding of the dynamic cultural and economic forces producing the measurable phenomena of inequalities between the social classes in developmental growth and the incidence of fatal disease. Eicholz commenced his presentation by invoking a simple notion of social stratification, with the urban nation divided into three broad classes distinguished by their employment and income prospects and associated consumption and social habits:

The Silent Revolution in Nineteenth-Century Government

307

Elementary education has contributed to the stratification of the large urban population into a distinct series of social levels. There is an upper class well to do and well cared for, to whom our methods of education afford every chance of mental and physical improvement. . . . At the other end of the scale we find the aggregations of slum population illnourished, poor, ignorant, badly housed, to a small extent only benefited by our methods of training. They are the degenerates for whom this inquiry is presumably instituted. Between these two is the third and largest stratum consisting of the average industrial artisan population in which bread-winners are in regular employment.95

He then distinguished, as had Leslie MacKenzie to the Scottish inquiry, between “physical degeneracy” and “inherited retrogressive deterioration.” Eicholz’s investigations of schools in London, Manchester, Salford, and Leeds consisted, first, in measuring the heights of random samples of twenty students at each age and, second, in interviewing the head teacher, the manager, local medical officers, and lay workers “as regards the circumstances and signs of degeneracy and their causes, and as to the evidence of hereditary deterioration.”96 His measurements showed clear signs that poverty was causing temporary debilitation, but no justification for assuming a cumulative inherited effect. More significantly, Eicholz was able to demonstrate from his secondary investigations that “In every case of alleged progressive hereditary deterioration among the children frequenting an elementary school, it is found that the neighbourhood has suffered by the migration of the better artisan class or by the influx of worse population from elsewhere.”97 In fact, of thirty-five head teachers interviewed, nineteen thought that if anything there had been an improvement in children’s health and fitness and only four spoke for the view that deterioration had occurred.98 The main strength of opinion in favour of progressive deterioration came from Salford. I therefore made a special point of visiting their black spot Greengate, as I have observed and discovered that the schools which are now free as regards fees used to charge a 6d. fee, and drew from a good artisan population which has now gone outwards.99

In the case of London, Eicholz generalized this point to note that over the years there had been a 31 percent increase in the number of children scheduled on the London School Board census, and attendance

308

Health and Wealth

had been raised from 74 percent to 85 percent, therefore increasingly including the children of the poor and the very poor: “in other words the schools are touching a much larger percentage of children than formerly.”100 In his evidence Eicholz had summarized this view on the various effects of the increase in school attendance through the operation of the compulsory system: The more rigourous scheduling of children of school age and the abolition of school fees in elementary schools, have swept into the schools an annually increasing proportion of children during the last 30 years.These circumstances are largely responsible for focusing public notice on the severer cases of physical impairment, just as at a previous stage in educational development they established the need for special training of the more defined types of physical deficiency.101

This was, of course, the same kind of argument as that used by the Royal College of Physicians to question the validity of hereditarian inferences from the recruiting ratio figures: that the degeneration scare was a statistical artefact of unrecognized changes in the underlying social composition of the observed population. But, whereas the colleges had talked only in terms of sectors within the labor market to make this point, Eicholz proceeded to articulate a wider socioeconomic theory of stratification in the labor market, which quite clearly attributed to such stratification the causality for the kind of physical defects and debilities that he had found among the school children. Eicholz saw the structured labor market as an integral part of an encompassing, repetitive social process that systematically inflicted differential environments and life experiences on various parts of the population.This created the consistent, wide divergences in living conditions and economic opportunities that sustained the marked differences in behavior and culture that characterized the division of society into social classes. Eicholz elucidated the causes of the social class differentiation of the poor from the rich, a process amounting to a trans-generational cycle of poverty or deprivation, as entirely due to environmental economic and social factors. His analysis was certainly not the first in the new century to invoke the central importance of impersonal, systematic socioeconomic forces in both causing and perpetuating working-class poverty. It had been Rowntree’s study of York, published in 1901, that had demonstrated the

The Silent Revolution in Nineteenth-Century Government

309

inevitability of a demographically induced pattern of life-cycle poverty for virtually all proletarian family households. During the period when the number of small growing children was greatest, the family’s income was usually at its lowest, dependent solely upon the father’s wages because of the wife’s full-time engagement in domestic work and the lack as yet of adolescent children (who would be able to earn for the household).Taking in a lodger was almost the only source of additional income available for families at this stage of their development, at the cost of even greater overcrowding in the home. J. M.Winter has also pointed to W. L. MacKenzie’s evidence, presented to the Scottish Royal Commission of 1903, as the first classic description of the self-reinforcing vicious circle of childhood malnutrition, overcrowding, chronic disease, and high infant and child mortality.102 But Eicholz’s presentation was the first time in a highly influential official document that the environmentalist approach to poverty and illness had been fully developed, in the context of a compelling, concrete empirical analysis, to its logical conclusion as a dissection and critique of the fundamental social and economic causes of inequality. Eicholz dismissed the hereditarian arguments, often advanced to support a eugenic policy, that the greater mortality and morbidity of the poor was due to their inherent unfitness.The biometricians believed that congenital physiological weaknesses and deficiencies in intellectual or learning capacities resulted in the hierarchical stratification of society. Eicholz advanced strong environmentalist interpretations to account for both these conditions: To discuss more closely the question of heredity may I in the first instance recall a medical factor of the greatest importance. . . . In no single case has it ever been asserted that ill-nourished or unhealthy babies are more frequent at the time of birth among the poor than among the rich or that hereditary diseases affect the new born of the rich and the poor unequally. . . . The interpretation would seem to follow that Nature gives every generation a fresh start.103

In his summary of the conclusions, Eicholz spelled out the policy implications thus: Other than the well-known specifically hereditary diseases that affect poor and well-to-do alike, there appears to be very little real evidence on

310

Health and Wealth the pre-natal side to account for the widespread physical degeneracy among the poor population.There is, accordingly, every reason to anticipate RAPID [sic] amelioration of physique so soon as improvement occurs in external conditions particularly as regards food, clothing, overcrowding, cleanliness, drunkenness and the spread of common practical knowledge of home management.104

As to broad differences between the children of the well-fed upper classes and those of the laboring poor in their apparent learning abilities and “intelligence”—differences that were being talked of as inherited conditions by Francis Galton and his supporters—Eicholz did not deny that such differences existed. But he offered a radically alternative, environmental analysis of why they existed and where the learning problems of the children of the poor originated: There is very little memory power, and with children, who in a normal condition depend entirely upon their memory for getting hold of things and who only reason later this is a fatal handicap for any mental progress. The want of food, the absence of any home training and self-control will account for any absent power of endurance.105

Hence his conviction that: “I hold a very firm opinion . . . that food is at the base of all the evils of child degeneracy.106 It has already been noted that Leslie MacKenzie was prepared to attribute poor mental performance to feeding deficiencies. The committee heard evidence in similar vein from other experienced educationists:W. H. Libby, an elementary school teacher and secretary of the East Lambeth Teachers’ School Dinner Association, the MPs Sir John Gorst and Dr Macnamara, and Dr. O.Airy, HMI. In the report, they singled out Airy’s evidence of the long-established system of school dinners for the needy, which had been initiated twenty years earlier in Birmingham by George Dixon, MP, as a model of thrifty organization.107 Significantly, the PDC report noted that “The testimony of the teachers is unanimous that the system pursued enables the children to do the ordinary school work, and they report that the difference is perfectly extraordinary.”108 Proceeding from the establishment of this fundamentally environmentalist premise that bad feeding was the ultimate root cause of most

The Silent Revolution in Nineteenth-Century Government

311

of the evils that they were charged to investigate, the committee sought the reasons for this, weighing the evidence before them in regard to the issue of parental responsibility. They expressed concurrence with their witnesses among whom, “With scarcely an exception, there was a general consensus of opinion that the time has come when the State should realise the necessity of ensuring adequate nourishment to children in attendance at school.”109 But this did not apparently necessarily imply a positive policy endorsement. Indeed, the rider on this recommendation showed quite clearly the residual retention in the report of the “less eligibility” Poor Law anxiety that indiscriminate welfare could pauperize. The committee declared itself against the somewhat dangerous doctrine that free meals are the necessary concomitant of free education;110 and declared that society “should aim in the first instance, at the restoration of self respect and the enforcement of parental duty.”111 However, the committee most definitely did depart from nineteenthcentury moralizing individualism, the significance of which seems to have been missed by many commentators, in its acceptance of the findings of an alternative method of analysis of the causes of poverty. Individual integrity was maintained only as the ultimate aim of social work and social policy, but there was no longer a relentless methodological individualism employed as the direct approach to and diagnosis of the problems under discussion.112 Rather, the committee came to an appreciation and public acknowledgment of the operation of certain transindividual social and economic forces that would have to be reckoned with in order to prevent the evils of poor infant and child feeding.They were particularly impressed here with the study presented to them by Miss A. M.Anderson, HM principal Lady Inspector of Factories.113 The report referred to her convincingly argued evidence for clear connections between infant mortality, bad feeding, overcrowding of one- and tworoomed tenements, and the factory employment of mothers.These were elements of a syndrome.114 Anderson enumerated the causes of mothers having to work as including death or desertion of the husband, or his lack of employment, or inadequacy of his wage.115 It was true that the mother’s factory employment led to such apparently culpable practices as feeding babies with stale cow’s milk and other even more unsuitable foods instead of from the breast, leaving them in the care of siblings too young to cope,

312

Health and Wealth

and not maintaining household cleanliness or adequate cooking arrangements to feed the family properly. Nevertheless, Anderson conclusively showed that the original need for the mother to work all day often in exhausting conditions, from which the supposed neglect of her parental duties all followed, was usually a compelling requirement, if destitution was to be avoided. The committee concluded that it had no doubt that the employment of mothers in factories had evil consequences but that it could not suggest remedies such as prohibition because of the genuine needs for the income required by many of the mothers who did work.116 The direct implication contained in this conclusion was the nearest approach the committee’s report made to an overt acknowledgment of the extremely politically charged issues of the adequacy of wage-levels and of availability of work for certain sections of the working-class poor.117 Rowntree and H. J. Wilson in their evidence to the PDC had each explicitly raised lack of adequately paid employment as a primary cause of the problem of poverty, the former offering a careful analysis of the vicious circle of malnutrition and overcrowding that resulted from it.118 But the summary report of 1904 cautiously shaded around such contentious matters, retaining certain “individualist” caveats, as exemplified above over the issue of free school meals. For the professionals of the public health movement, however, it was the evidence that the committee heard, and not the hesitancies in the final report that mattered most.The inquiry had provided an official and public forum in which the default “individualist,” pessimistic, “social Darwinist,” moral and scientific predisposition of a quarter of a century’s standing had been thoroughly reviewed, tested, and found wanting. The potential power of a more thoroughly environmentalist and collectivist strategy to deal with a set of old and vexing problems had now been very publicly rehearsed in a forum that brought together a host of previously disparate professionals, each approaching from their own particular sphere of responsibility. Certainly Galton, Pearson, and the eugenicists were stung by the outcome of the PDC report: the formation of the Eugenics Education Society was a propaganda response by them to this apparent failure of the eugenic message at its first major public test.119 The PDC sat and reported on the eve of a subsequent rapid change in the prevailing ideological and political consensus, which it did much

The Silent Revolution in Nineteenth-Century Government

313

to precipitate itself: the movement towards a much greater acceptance in national politics of collectivist principles of social responsibility for citizen’s health and welfare legislatively embodied in the famous social policy reforms of the New Liberal administration after 1906. Indeed, part of the reason for the historical importance that has always been accorded to the PDC, a mere interdepartmental inquiry, was that several of its most significant detailed recommendations—of a decidedly collectivist and environmentalist character—were in fact implemented relatively quickly.120 While certain of the report’s more guarded aspects can easily, with hindsight, be portrayed as backward-looking, there can be little doubt that the effects of the legislative measures it positively promoted acted as a fly-wheel upon the ensuing, rapid momentum in social policy of the next five years—momentum towards a much greater acceptance of collectivist provision of health and welfare services at central as well as at local level, and an enhanced confidence in this approach among public service professionals themselves.

The Environmentalist Scientific Alternative to the Hereditarians The last two decades of the nineteenth century witnessed the gradual rise to scientific prominence of Francis Galton’s long-held conviction in the overwhelming importance of hereditarian over environmental factors as the sources of most human variation. Galton’s own role in bringing this about was, however, only secondary. During this period he devoted himself primarily to his statistical anthropometry (and not unproductively so, either: correlation, the bivariate normal distribution, and the celebrated work on fingerprints were all developed at this time). But it was the German, August Weismann’s, microscopial cytological work during the 1880s that appeared to establish most firmly the empirical basis for a rational belief in the primacy of heredity. Weismann’s work revealed that there was a clear distinction to be made between the microscopic “germ” plasm (what he later began to call the chromosome material) and the macroscopic soma.121 The latter represented the bodily form and structure attained by any individual of the species and was therefore in principle subject to all the environmental conditions, both positive and

314

Health and Wealth

negative, that could affect growth during the individual’s development. The germ plasm, by contrast, was invariant with respect to the environment. It was the intergenerationally transmissible material carried from birth by each fertile individual of the species in their reproductive cells. It was, therefore, particularly Galton’s strongly hereditarian views that initially benefited from the impact of August Weismann’s apparent disproof of use-inheritance.122 Indeed, Galton had already adumbrated Weismann’s dichotomy, as a result of his own experiments.123 During the 1880s Galton had perfected his statistical theory of reversion (“regression”) towards the population mean as the explanatory basis for his proof that an individual’s stature was an inherited correlate of that of their parents.124 It was from the basis of these empirical findings, regarding physical attributes, that Galton believed it to be legitimate—within the self-imposed intellectual confines of his nakedly materialist empiricism and his inductivist epistemology allied to a radical sensation psychology—to argue, by analogy, for the natural inheritance of mental abilities, moral character, and, ultimately, even “civic worth.”125 Although there were very significant differences between Galton and Pearson in their understanding of the exact mechanisms of natural inheritance, what importantly united them and defined them both as eugenicists was, first, their perfectionist goals. The essential difference between the positive program of eugenicists and the merely negative admonitions of urban degenerationism was that the latter seemed to imply that only the “pure” selective conditions of a mythical state of nature could guarantee the health of the race through survival of the fittest. Eugenicists accepted that natural selection was in abeyance in any urban and civilized society: they did not advocate a return to primitive or bucolic, rural conditions but proposed instead a perfectionist future to be achieved through artificially selective breeding policies guided by a scientific knowledge of the biological mechanisms involved. Eugenicists were genuine “reactionary modernists”: their techniques and scientific knowledge were contemporary, if not positively futuristic, and they wished to change society. But their goals—describing the society that they desired to create—were profoundly reactionary and neo-aristocratic.126 Second, as hereditarians, Galton and Pearson shared the conviction that the only means that could successfully improve the nation in this

The Silent Revolution in Nineteenth-Century Government

315

sense were those that worked through direct manipulation of the survival chances of the inherited matter, the germ plasm that individuals transmitted to their progeny.127 This belief, of course, directly led to the conclusion that no significant evolutionary effects of a perfecting kind could be hoped for from the environmentalist measures proposed by the public health and welfare lobby. Such measures merely affected the superficial, short-term conditions in the somatic environment of individuals. The hereditarians instead threw the weight of their emphasis on the germ plasm itself and therefore on breeding patterns; not on the somatic relationship with the environment. This view supported an emphasis on policies to affect breeding—negative or positive eugenics—at the neglect of welfare policies. This, then, was the critical point of conflict in the new century between hereditarian eugenicists and the environmentalists of the public health movement: their diametrically opposed views on the principles that should inform the overall strategy of a social policy designed positively to raise the standard of the nation’s health. The principal focus of attention throughout most of the Victorian era had been on the prevention of disease and the battle against the threat of rising mortality, with the ameliorationist public health movement finding itself dogged by those pessimists such as Henry Letheby128 who, at bottom, feared that all interference with the processes of nature were doomed to failure. With proof of definite, if modest, gains in the nation’s longevity finally becoming evident by the close of the century, the political and cultural discussion shifted towards a debate over the state of physical and mental health of this less mortal population; and to the correct means to effect positive improvements in the nation’s health; and, hence, to questions of “quality.” The public health environmentalists were themselves slowly raising their sights and groping towards a more comprehensive strategy of attack on the problems of disease and poverty, designed to enhance the nation’s health and not merely protect it. But they now found themselves confronted with a new variant of the evolutionary school of thought, with its own radically alternative, positive program: the eugenics movement. The 1890s had represented a period of growing confidence among hereditarian biologists in the correctness of their views, in particular buoyed up by the apparent vindication of the importance of heredity implied in Weismann’s work. This was the decade in which a distinct, if

316

Health and Wealth

at first small, “school” of “biometric” evolutionary science began to form around the old master, Francis Galton, as first Karl Pearson, then W. F. R. Weldon and others gravitated towards him as their figurehead.129 Their intellectual and scientific position was in fact never as strong or coherent as they themselves believed it to be, as the events of the early Edwardian era were to show. In fact Pearson and Galton held opposite views on the central scientific issue of saltationism versus gradualism in the origin of species. It was Pearson who made the running when it came to strong public statements on the importance of heredity and it was quite clearly Pearson who encouraged the aging Galton to lend his public support to promotion of the eugenics viewpoint after the Boer War debacle.130 However, this was also the moment of overreaching for Pearsonian biometric science just at the point when his confident public pronouncements were attracting sufficient attention to help bring about the instigation of a major government inquiry, the Interdepartmental Committee on Physical Deterioration. For this was also the point at which the biometric eugenicists, with their gradualist view of species variation, were beginning to lose ground scientifically to the saltationist alternative, championed in Britain by William Bateson and gaining strength from rediscovered Mendelism.131 Within the field of evolutionary biology the first fifteen years of the new century were witness to a remarkable period of scientific activity from within the Mendelian framework. The principal landmarks along the way were Hugo de Vries’s rediscovery of Mendel’s work in 1900, W. L. Johanssen’s specification in 1909 of the phenotype/genotype distinction, and T. H. Morgan’s classical exposition of Mendelism in 1915, Mechanism of Mendelian inheritance, based on his team’s empirical study of sexual reproduction in Drosophila.132 The Mendelian theory implied significantly different conclusions from those of the biometricians, though sharing a recognition of the importance of the germ/soma distinction. In particular, the validity of the principal biometric methodological assumption was called into question: the utility of measuring observable physical characteristics to make inferences regarding the underlying causes and laws of individual variation within a species. Mendelism held that each species, including homo sapiens, had a fixed “center of regression” for each of its outwardly measurable characteristics. For Mendelians these outwardly visible,

The Silent Revolution in Nineteenth-Century Government

317

morphological properties of the species were the net result of interaction and combination among an immense complex of non-observable underlying, formational genetic elements. The former, phenotype characteristics were invalid as guides for direct inference regarding the nature of, and relationships between, the latter, the underlying genotypes. Individual organisms in a population exhibited wide variation about the species mean in their physical appearances—individual phenotypes—due to the virtually infinite permutations possible in the exact configuration of the large number of fundamental determinate genotype elements, which all the individuals possessed in equal numbers in common as a species. Environment was important in determining whether or not any given individual actually expressed in phenotypic, observable form, the genetic potential inherent in its particular permutation of genotypic endowment. Therefore, especially given the importance of development through growth, the effects of the individual’s biographical history of exposure to varying environmental conditions and influences—more or less favorable to full expression of the different aspects of the genotypic endowment—were hopelessly admixed with underlying hereditary factors in any observable or “achieved,” phenotypic characteristics. However, environmental influences did not significantly affect the content of that genotypic endowment which the individual was most likely, in turn, to pass on to its offspring and therefore each generation had a fresh start. In 1904, the controversy between these two schools over whether measurable characteristics of individuals could be used as an indicator of the underlying principles of genetic inheritance was at the height of its ferocity in Britain. There was a vivid confrontation in that year at the meeting of the British Association when Bateson, the leading Mendelian in Britain, debated face to face with Pearson and Weldon of the biometric school.133 The immediate effect after 1900 of the rapidly expanding alternative Mendelian paradigm was to deprive the biometric school of the apparent scientific authority that it had only recently believed itself to have acquired, post-Weismann. Of particular importance to the story being recounted here, this development returned the whole field to a state of expectant conjecture, placing a large question mark over the validity of any attempts to propound rigorously hereditarian views as a “scientific” basis for the formulation of social policy.Thus, throughout the

318

Health and Wealth

ten years leading up to World War I the hereditarian and eugenic science of society was increasingly on the defensive in scientific terms.134 This certainly provided a context that assisted public health environmentalists both to formulate with more conviction and to assert—apparently politically successfully—their radically opposed, environmentalist interpretation of poverty and physical unfitness, a view that in fact seemed to be carrying all before it by the end of the war itself. In the evidence actually submitted to the PDC, the Mendelian resurgence, despite—or perhaps because of—its extreme contemporaneity, did not directly provide the principal positive scientific ammunition against the hereditarian diagnosis of the causes of physical deterioration and its appropriate remedies. It was, instead, recently reported evidence from novel fieldwork in physical anthropology and experimental psychology derived from A. C. Haddon’s expedition to theTorres Straits—alongside palaeontological evidence from Egyptologists—that was presented as appearing to prove conclusively that human racial stocks or “types” were long-established and essentially immutable “givens” of the natural world.135 It followed from this essential fixity of racial type that the perfectionist aims of eugenicists were chimerical: no amount of selective breeding within a racial group could significantly alter the basic configuration of hereditary material that was the blueprint for each of the major racial types.The observable phenomenon of individual variation about the mean value for each such type was due merely to the plasticity of superficial characteristics adaptive to the environment; it did not indicate any potential for fundamental modification to the race’s genetic identity, as the eugenic biometricians wished to argue.136 The principal expert witness on evolutionary theory before the PDC was D. J. Cunningham (1850–1909), Professor of Anatomy at Edinburgh University.137 He was at that time promoting the establishment of a national anthropometric bureau, through a committee of the British Association.138 This project was based on the understanding that no reliable inferences could be made about the nation’s physique and changes in it until the basic parameters had been rigorously identified: what variation there was in “normal” physique within a population, what constituted “normal” development and growth in an individual. Only then could individuals and groups be confidently identified as abnormal or different and only then would theoretical discussion of causes of

The Silent Revolution in Nineteenth-Century Government

319

abnormality, deterioration, or improvement become meaningful and empirically focused.The PDC’s formal recommendation that a system of school medical inspection be instituted represented their acceptance of Cunningham’s views on the matter.139 In their report, the PDC quoted Cunningham’s announcement of the recent theory of “anthropologists” that differences in physique between classes in Great Britain were entirely due to environmental effects on the individual organism, since there was a mean physical standard that was the inheritance of the people as a whole: “The tendency of the race as a whole will always be to maintain that inherited mean.”140 They also quoted extensively from Karl Pearson’s ultra-pessimistic Huxley Lecture of 1903 where, in contrast, he had claimed: The mentally better stock in the nation is not reproducing itself at the same rate as it did of old; the less able and the less energetic are more fertile than the better stocks.The only remedy, if one be possible at all, is to alter the relative fertility of the good and the bad stocks in the community. Let us have a census of the effective size of families among the intellectual classes now and a comparison with the effective size of families in the like classes of the first half of the century. . . . Compare in another such census the fertility of the more intelligent working man with that of the uneducated hand labourer. You will, I again feel certain, find that grave changes have taken place in relative fertility during the last 40 years. We stand, I venture to think, at the commencement of an epoch which will be marked by a great dearth of ability. . . .[I]ntelligence can be trained, but no training or education can create it.You must breed it.141

However, this passage in the report was followed by the comment that “The Committee have not been able to obtain decided confirmation of this view,” and they then quoted Professor Cunningham’s response to Pearson’s views: “I think that the statement is a pure assumption. I do not know how we can possibly measure this supposed loss of inherited intelligence.” And: “It should be borne in mind that it is stocks and not classes that breed men of intellect. . . . No class can claim intellect as its special perquisite.”142 Finally, the committee cautiously concluded that, “in view of the statement made by Professor Pearson it might be as well if here as in America, steps were taken to obtain by means of a proper census, accurate information on the point.”143

320

Health and Wealth

However, this recommendation for a fertility inquiry cannot be claimed as a “victory” for the hereditarian eugenicists. Cunningham himself had been enthusiastic for it when asked. He was quite certain that the recent decline in fertility among the upper classes was due entirely to their employment of “artificial restraints” and not to any decline in physiological fecundity, and that only a proper census could demonstrate this conclusively.144 Furthermore, the fertility of the different classes was itself part of the environmentalist’s explanation of the possible changes occurring in measures of the nation’s average physique. If the wealthiest and healthiest section of the population was steadily contributing proportionately less to each generation because of a tendency—for whatever reason—towards smaller families, then this shift in the compositional make-up of the population as a whole would inevitably produce the appearance of a fall or deterioration in the average value of any measure of the nation’s health and physique, as a purely statistical artefact. Thus, contemporary scientific controversy in biology and physical anthropology was brought squarely into the debate over social policy during the deliberations of the Physical Deterioration Committee. Now that the scientific coherence of the biometrician’s hereditarian position was challenged, a more rigorously environmentalist interpretation of the structure of society was able to gain currency, as more than simply the expression of a minority opinion.

Conclusion:The Scientific and Social Emancipation of Medical Environmentalism Of course, there was no clean divide in 1903–4. The emergence of a coherent anti-hereditarian interpretation in the deliberations of the official inquiries of 1903 and 1904 was only the start of a protracted scientific and political battle that was to continue through to the next decade and beyond. This conflict provided a powerful stimulus for ideological and political reassessment among those trained in preventive medical science, including the relevant staff of the GRO.The default acceptance of a previously conventional assumption, that responsibility for individual’s poverty lay primarily with themselves, was overturned as much greater

The Silent Revolution in Nineteenth-Century Government

321

emphasis was now laid on the impersonal economic and cultural forces trapping individuals into their impoverishment. Careful empirical social research pointed toward the mode of operation of these self-reinforcing causes of social inequalities. The urgent need for a response to the diametrically opposed assertions of the hereditarian eugenicists forced the environmentalists to develop fully and to amplify the national policy implications of their analysis. This political dynamic effectively and rapidly drove them towards a strongly collectivist position, since the corollary was that it was the responsibility of the community as a whole to deploy its formidable resources to break these bonds of perpetual impoverishment. In Britain, the first empirical social survey that really did break with the conservative, individualist consensus had been relatively independent of the influence of developments in the supposed applicability of evolutionary theory to social analysis. This was Seebohm Rowntree’s Poverty, published in 1901.This book provoked a vitriolic response from the leading representatives of the COS, which forced Rowntree to defend his work by outlining these underlying divergences in approach and policy: I imagine that the difference between Mrs. Bosanquet [of the COS] and myself goes deeper than anything represented by the criticisms I have been considering. Mrs. Bosanquet, as is well known, belongs to the extreme wing of the Individualistic school. This school unduly magnifies what may be done for the amelioration of social conditions through the personal effort and self-reliance of the individual, and correspondingly minimises the sphere of State intervention.145

Until recently the methodological novelty and importance of Rowntree’s work has remained somewhat obscured by his own deliberate emphasis on the similarities between his survey and that of Charles Booth. In his introduction he lauded Booth on every page and in the text he printed a letter from the great man congratulating him on the closeness of agreement between each of their estimates of poverty.146 E. P. Hennock has convincingly argued that consequently there has been a failure to appreciate the truly independent significance of Rowntree’s work in its contribution both to the framing of the subsequent “national efficiency” debate, and simultaneously in providing the pioneering outlines of an effective environmentalist brief in this debate.147

322

Health and Wealth

By explicitly linking his findings to Booth’s and emphasizing the supposed similarity that about 30 percent of the population in each city was in poverty, Rowntree claimed that this indicated there was an enormous national and general problem, whereas Booth,Alfred Marshall, and the government’s Labour Bureau had preferred in the 1890s to envisage only a metropolitan dilemma, due to the supposedly unique problems of the capital. Rowntree further underlined the connections between his findings in York and national problems of health and efficiency by citing the topical rejection rates for recruits that the journalist Arnold White was so publicizing at this time. Finally (and this is where his work is most clearly original), Rowntree offered a putative “scientific,” hard measurement of poverty, which addressed the essential social and political issue of the relation between economic means and physiological requirements. This was the famous poverty line calculation, where the nutritional science of human dietary needs was used to show that the incomes of many families in York throughout much of their life-cycle were below the costs of an indisputably frugal subsistence budget and diet.148 Mortality indices and anthropometric measures of children’s growth rates only reported health outcomes, however, leaving much room for debate between hereditarians and environmentalists over the causes. Rowntree’s approach more directly analyzed the relationship between physiological adequacy and economic means.149 As has been noted, the PDC was particularly impressed with the evidence and argument from educationists relating to the inadequate feeding of many working-class children and its undesirable effect not merely on their physical development but also on their learning capacities. The more radical novelty of Rowntree’s approach can perhaps be explained to some extent by his cultural isolation and independence from the metropolitan tradition of conservative and biologized empirical social science. Here his background is relevant: a provincial upbringing and education outside Oxbridge and London, at Owen’s College, Manchester; the strong influence of his father’s humanitarianism; and his Quaker faith.150 This background imbued him with a more genuinely egalitarian attitude towards his fellow men than that held at this time by the devout paternalists of the Established Church, whether High Church or Evangelical, self-helpers or the COS. His Quakerism prevented him from seeking explanations for the plight of individuals in terms of their

The Silent Revolution in Nineteenth-Century Government

323

inherent failings and moral inferiority. Furthermore, he explicitly rejected any a priori claims for the relevance of biological science to social analysis, following the careful counsel of T. H. Huxley.151 Rowntree was definitely unusual at this time, in both having a conviction in the value of practical, “scientific,” empirical study of the conditions of the poor and yet remaining relatively unimpressed with the findings of the natural sciences as having any direct relevance for questions of social organization. Other students of social problems, such as the idealist L. T. Hobhouse or the socialist liberal Graham Wallas, were similarly unconvinced that the natural sciences had any direct lessons for human social organization. But, by virtue of this, they tended also to subscribe to a more profound philosophical distrust of the status of inductively derived, practical and positivist knowledge per se. Medical science and medical professionals, on the other hand, hailed from an almost diametrically opposite approach to the study of humankind, in the sense that they had a vocational commitment to practical observation and to positive, empirically based ameliorative action, rather than abstract reflection. There was an understandable general association for medical professionals between the commitment to practical, positive action and a respect for the ordered principles and methods of scientific empiricism. This was the model for a rational and efficacious approach, of which the natural sciences, including evolutionary biology, appeared to offer the most successful and promising examples to medical scientists. It is interesting, then, to compare Rowntree’s intellectual development in this respect with that of the medically trained Arthur Newsholme. There were important similarities. Newsholme was also a nonconformist Yorkshireman, brought up in Haworth, who recalled in his memoirs the importance of Evangelicalism (Wesleyan in the case of Newsholme) “as a potent factor in determining the social and hygienic as well as the moral uplifting of the nineteenth century” because “Evangelicalism meant an enormously increased solicitude for one’s fellow men and not merely or chiefly that ‘other-worldliness’ attributed to it by Matthew Arnold.”152Yet, as a trained medical professional, a particularly able epidemiologist and a bacteriological scientist, Newsholme was inevitably much more cognizant than Rowntree of the claims and apparent validity of the scientific and evolutionary perspective on poverty and disease.With Weismann’s ostensible

324

Health and Wealth

confirmation of Galton’s claim that heredity was all-important, science appeared in the 1890s to be ratifying in biological form the long-standing “individualist” conviction that poverty and unfitness reflected the reproduction of innate flaws in the individual and not the malfeasance of social forces. In retrospect, discussing the views that he held in the 1890s, Newsholme admitted that “in some measure I then endorsed the ‘deterrent principle’ of the Poor Law Act, 1834. I view with dismay the strict C.O.S views which I then expressed: but I confess them as illustrating the views then generally held and the rapid emergence from them.”153 His autobiographical account of his own “rapid emergence” from such a position towards a thoroughly collectivist view of the need for public health reforms dated his conversion to some time before 21 October 1904. Appropriately in Rowntree’s York, this was the date of a speech in which Newsholme had first expressed the anti-individualist view that “most poverty is a symptom of disease and not a disease in itself.” He went on proudly to recall that the following year, in an article coauthored with T. H. C. Stevenson, he had made a stand against the “ultra Calvinistic attitude of Galton and his disciples.”154 He had claimed, echoing Cunningham’s dismissal at the PDC inquiry of Pearson’s “pure assumption,” that “Very few would venture to assert that the line of intellectual ability or of physical endurance is horizontal and not oblique, or possibly almost perpendicular in relation to social position.”155 For a medical scientist like Newsholme, therefore, a nonconformist prior commitment to certain Christian principles of human fellowship was insufficient, alone, to engender in him a radical alternative to an individualistically and naturalistically premised analysis of the causes of urban poverty. He was subject to the conventional, supposedly scientifically backed wisdom current in the metropolis in the final decades of the nineteenth century where he learned his trade. For this leading figure in the medical profession, however strong his egalitarian religious beliefs, the apparently compelling claims of advanced biological science were not to be shrugged off lightly. In his retrospective explanation of his own “conversion” in 1904, Newsholme explicitly linked together the COS moral individualism and Galtonian hereditarian social Darwinism as mutually supporting forces largely responsible for his earlier views. Hence the importance of the dissolution, at the beginning of the first decade of the new century, of the apparent scientific authority of the

The Silent Revolution in Nineteenth-Century Government

325

post-Weismann biometric, hereditarian position on evolution.This facilitated an intellectual emancipation among the leaders of the preventive health tradition in the medical profession, enabling them to reassess the rational grounds for their current social assumptions, and to develop and promote more confidently their own rigorously social and environmentalist analysis of poverty. In formulating a more thorough environmentalist position in rejection of the biological “Calvinism” of the predestinarian hereditarians, a previously unexamined attachment to the political orthodoxy of liberal individualism also came under scrutiny. The interpretation offered here differs somewhat from other accounts of Newsholme’s ideas, notably J. M. Eyler’s.156 I have followed through the implications of Newsholme’s own recollections in seeing a definite “conversion,” or radical transformation, in his thinking occurring in 1903–4. He underwent a fundamental change from a previously conventional, predominantly individualist, to a more thoroughgoing collectivist approach. I believe that this was an extremely significant shift and that within the public and preventive health community Newsholme was the leading individual in this respect and one whose influence was important in bringing about a similar (though usually less thorough) shift in priorities among others within the profession. It follows that it is vital when addressing any of Newsholme’s writings to distinguish whether they were composed before or after the watershed of 1903–4, since it is invalid to cite material from before 1903 as illustrative of his views when Chief Medical Officer and, of course, vice versa.157 Thus, by the opening years of the new century the country’s leading public health officials and salaried educationists were gradually piecing together a perception of the detailed operation of certain impersonal social and economic forces—self-perpetuating circles of impoverishment and disadvantage—acting within and upon the country’s poorer communities. Employing the methods of the skeptical rational scientific empiricism in which they had been trained, MOHs and others sifted through the evidence before their eyes to probe for preventable “causes” in the recurrent patterns that they encountered.158 Despite a continuing common-sense attachment to an individualistic ontology (the confidential relationship between caring doctor and individual patient was then, as now, the primary ethical rule of medical training), a new understanding of the intractable, imbricate nature of poverty was dawning upon

326

Health and Wealth

practically involved medical professionals. These were conclusions they were increasingly forced to draw and to articulate to each other as a professional group from their close and daily observation of the problems, the families, and the individuals involved.The rise of the public service professions, led by the MOHs, was so significant in this period because they brought and sustained the analytical approach of their professional training to the wider issues of poverty and the conditions of life of the poor. This complex subject was now addressed and discussed as the routine business of a potentially powerful social grouping—a set of middle-class professions. Urban distress was no longer known only as the exotic or the moral, “exposed” by maverick investigators or evangelized by the holy. However, what seems to have really catalyzed this newly emerging social perspective on poverty into a truly self-conscious and assertive program was the concurrent hardening of the traditional, “individualist” viewpoint into an uncompromising and extreme variant, the form purveyed by the hereditarian eugenicists.Theirs was an absolutely opposed, alternative analysis of the dynamic causes of poverty and unfitness in society, aggressively claiming full and exclusive scientific authority for their approach. Previously, there had been no absolute and inevitable philosophical or practical conflict between the “soft” individualism of conventional, high Victorian, Evangelical, and revivalist philanthropy and the emerging view among late Victorian educationists and health workers that impoverished individuals were subject to vicious circles of economic and cultural disadvantage beyond their immediate control. This analysis could be read as simply adding another level of strategic missionary activity—attending to the pernicious circular forces—while not ruling out the continuing value of face-to-face missionary work, encouraging personal independence, and so on. That formidable COS figure, Octavia Hill, had, after all, long been the figurehead of sustained philanthropic attention to housing conditions, urban parks, and open spaces, an implicit acknowledgment that uplifted individual souls flourished best in an uplifting shared environment, ultimately finding manifestation in the highly statist and collectivist notion of the National Trust.159 The “Broad Church” environmentalism that had characterized the hard-pressed and understaffed Victorian public health movement would in fact happily continue to cooperate and live with the much-needed small armies of

The Silent Revolution in Nineteenth-Century Government

327

philanthropic volunteers right through the interwar period, especially in view of the increasing professionalism of the latter, encouraged by the intellectually formidable COS, which had become particularly active in training and education for social workers during the last decade of the century.160 But in its “first generation” militant and evangelical manifestation (Galton himself viewed the Edwardian eugenics movement as a primarily religious rather than scientific organization), the eugenicist, hereditarian version of “individual responsibility” for manifest physical or mental inadequacy was ruthless and uncompromising. Its truths excluded all other interpretations.Therefore its rapid rise to public prominence after the turn of the new century clarified the thoughts of practical professional environmentalists. It called forth a necessarily clear and convincing riposte. As a result, the relatively tentative findings of systematic vicious cycles of immiseration that were emerging in the course of their professional work, on the part of an extremely practical and empiricist collection of MOHs and a small but influential number of school medical officers, were transformed through the forcing school of sharp public contest and debate with the hereditarian eugenicists. The extremism of the hereditarians pushed the public health movement to rediscover the challenging political and ideological implications—for an English liberal individualist consensus—of a rigorous environmentalism.This was the moment at which the radical, socioeconomic theory of disease was finally rediscovered and expounded by the most advanced among English mainstream exponents of public health. Originally formulated by the leaders of the French school of hygiène publique in the first third of the nineteenth century and championed at the same time by W. P. Alison in Edinburgh, “the social theory of disease” had been politically castrated by the dominant English influence, Edwin Chadwick, when he adapted its findings to support his merely sanitary idea, “the filth theory of disease.”161 In fighting to oppose the exclusive claims being made for nature, the Edwardian public health movement rediscovered and for the first time publicly championed the radical political potential of the argument from nurture. It was only the close combat with the hereditarians, 1903–4, that crystallized the new ideas for those such as MacKenzie, Newsholme, Newman, and Eicholz, identified by the Porters as the leading collectivist

328

Health and Wealth

and environmentalist caucus; hence, it is difficult to find any mainstream medical figures expressing such views before 1903.The leading environmentalists were being pushed into discerning more clearly the methodological individualism common to both the traditional, moralistic COS position and the new, aggressive hereditarianism, and the limitations that acceptance of such premises entailed for the health and welfare aims that they cherished.162 The polarizing ferocity of the hereditarian arguments of the eugenics movement finally clarified and confirmed for the most politically aware and intellectually cogent leaders of the environmentalist public health movement that their future, their true beliefs, and their interests lay with the idea of collective provision for health promotion of the nation as a whole. Pearson, Galton, and the hereditarians writing of degeneration and deterioration in the opening years of the century had succeeded in forcing an hereditarian, national interpretation of evolution on to the national stage as a political issue. As a result, the public service professionals wishing to see the nation’s health and welfare services continuing to expand as the major weapon against poverty and disease were forced to mobilize their own national-scale arguments in order not to lose the political debate. Through the forum offered by the wide-ranging government inquiries, particularly the PDC, this necessity prompted and facilitated a pooling of their intellectual resources. Representatives of the practical observers and helpers of the nation’s poor—educationists, voluntary workers, public health officials and social scientists—found the conclusions emerging from their several specialist perspectives pointing in common towards the kind of comprehensive social analysis most fully expressed by Eicholz. Furthermore, it was increasingly being appreciated that the countervailing scientific evidence of certain anthropologists, comparative anatomists, and the new Mendelian geneticists provided an effective challenge to the “degenerationist” and hereditarian viewpoints.With the Mendelian challenge growing ever stronger during the decade or so before World War I, medically trained public health proponents of environmentalist policies felt increasingly able to take on their scientific detractors and to campaign for further expansion of national social and health policy.163

The Silent Revolution in Nineteenth-Century Government

329

Notes 1. Even liberals such as Ritchie, Kidd, and Hobson were deeply involved in the “socialising” of Darwinian theory. Herbert Spencer was initially responsible for tying together biology and sociology within a social evolutionary perspective: Spencer (1873); and Spencer (1876). Only Huxley and Hobhouse among the Progressive Liberals staunchly argued against the direct applicability of a theory of selection by “natural” characteristics of individuals to a theory of man and society. Hobhouse developed his concept of “orthogenic development” as an idealist alternative to the Spencerian notion of superorganic evolution (see Szreter (1996), 220–21); Collini (1979), chap. 6; Freeden (1978), 80 and 186–89; Abrams (1968), 90–92. 2. For early expression of this thesis by two Fabians in 1896, see Fabian Tracts 69 and 72, respectively: Webb (1896); and Ball (1896). The best general study of the Fabians remains McBriar (1966). For Pearson’s social Darwinism, see MacKenzie (1981), 83. 3.They were still essentially in agreement on all this as late as 1930, six years before Pearson’s death: Soloway (1990), 189–90. As a result of its capacity to appeal to materialist rationalists in this way, there was a complex relationship throughout the first four decades of the century between eugenics and political positions of the right and the left. See Paul (1984). 4. On the significance of anti-Napoleonic propaganda in propagating the popular myth of libertarian Britain, see Colley (1992), especially chap. 7. 5.These were collected together and published with some other material as Efficiency and Empire (1901).The original article of October 1899 was entitled “The cult of infirmity,” published in the National Review. For further information on Arnold White (1848–1925), see Searle (1973). 6. “Where to get men” (published under the pseudonym “Miles”), and “National health: a soldier’s study,” published in the Contemporary Review in January 1902 and January 1903, respectively. See PDC, Evidence, paras. 283–88. MajorGeneral Sir J F. Maurice (1841–1912), son of (J.) F. D. Maurice (the leading Christian Socialist), was a prominent army reformer. 7. See Gilbert (1965), 144–47, on the reluctance of the Balfour government to become embroiled in the issue.The Clerk to the Privy Council, Sir Almaric Fitzroy, was, however, very keen to have an inquiry appointed; and was able to ensure this through his great ally, the Duke of Devonshire (Spencer Compton Cavendish, 1833–1908), Balfour’s President of the Privy Council. Fitzroy had worked continuously with Devonshire, first as his Private Secretary and then as Clerk to the Council, since Devonshire’s appointment in 1895 as Salisbury’s President of the Council in the previous Conservative and Unionist administration. Fitzroy was to repeat this initiating role when he successfully encouraged another friend and subsequent Lord President of the Council, the great Liberal John Morley, to back the setting up of the Royal Commission on Venereal Disease in

330

Health and Wealth

1913. Apparently Fitzroy’s diaries reveal that his determination to investigate the threats of physical deterioration and venereal disease was prompted by more than just a sense of the public interest: they record a long-standing quasi-romantic infatuation with the bodily perfection that he perceived to be manifest in young peers and peeresses of the realm. He was forced to resign his high office in 1923 after being charged with importuning girls in Hyde Park. See Davenport-Hines (1990), 213–14. On Fitzroy’s earlier career, see Szreter (1996), chap. 3, note 75. 8. MacKenzie (1981), 78. 9.The country’s earliest MOH appointments dated from the 1840s and an Association of Metropolitan MOHs had been founded as early as 1856, immediately after the 1855 Metropolis Local Management Act had established forty-eight such posts for London’s newly defined vestries and districts. But it was not until the Public Health Act of 1872 that there was a statutory obligation laid on all local health authorities to appoint MOHs. By the end of the nineteenth century there were 1,770 MOHs in post: Brand (1965), 109. It was not until 1888 that the growing subprofession launched its influential national journal, Public Health, which accompanied the formation of its national organization, the Incorporated Society of MOHs, formed by the amalgamation of various regional societies. One of the earliest other such national associations of local preventive health officials had been the Society of Public Analysts, founded in 1874 and comprising 224 members by 1882: Wohl (1983), 54,195. The sanitary inspectors’ Royal Sanitary Institute of Britain held its founding conference at Leamington in 1877, with Burdon Richardson in the chair (Edwin Chadwick himself, the pioneer exponent of “the Sanitary Idea” a generation earlier, chaired the second year’s conference held at Stafford). Its transactions ran as a journal from the next year. The Institution of Public Health Engineers, the Association of Municipal and Sanitary Engineers and Surveyors, the Sanitary Inspectors’Association and the National Union of Sanitary Inspectors were among the other public service professional organizations all founded at this time, their journals commencing in the 1890s. 10. Meacham (1987); Dowling (1963); Behlmer (1982); Prochaska (1980). Commonly known as the “COS,” the organization’s proper title was The Society for Organising Charitable Relief and Repressing Mendicity, founded in 1869. 11.As B. S. Rowntree saw it:“two great departments of human effort . . . may be brought to bear upon the problem of poverty. All history speaks of the enormous and far-reaching influence of law upon the character of a people. . . .Wise legislation must, however, be based upon facts, and it was as a contribution to the knowledge of facts in relation to poverty that my inquiry was undertaken.” Rowntree (1903), 29–30. O’Day and Englander have speculated that an identical disposition in Booth’s case may be traceable to his formative immersion in the Comtian Positivist “religion,” which swept the liberal intellectuals of his generation, and particularly his family in the 1860s and 1870s (his cousins included the Crompton brothers, E. S. Beesly and W. S. Jevons): O’Day and Englander (1993), 20, 144–46.

The Silent Revolution in Nineteenth-Century Government

331

12. Of the sixty-seven witnesses before the PDC, there were five MOHs and sixteen public servants whose professional activities would fall into the first category outlined above. There were eleven philanthropists—the second category. Of the remaining thirty-five witnesses to be accounted for, nearly two-thirds were other medical experts, leaving four investigative philanthropists of the third category, four military witnesses, and five miscellaneous, including the MPs John Gorst and Thomas Macnamara. It should be remembered that those giving evidence often represented many more. For example, Dr. Alfred Eicholz claimed to represent “the members and officers of the Education committees of Manchester, Salford, Leeds and many officers of the London School Board” (PDC, Evidence, para. 432). 13. For instance: Semmel (1960); Searle (1971); Freeden (1978); Collini (1979); McBriar (1987). 14. Prochaska (1980); Harris (1989). However, for an earlier study that did acknowledge the local government contribution to new initiatives in social thought in this period, see Harris (1972), chaps. 4–5. 15. See his eulogy of the schemes for feeding school children in Glasgow, and of Lady Health Visitors in Manchester, which he had encountered on being asked to speak in each of these cities over the previous year. PDC, Evidence, paras. 279–81, 283. 16. Sir F. Maurice, in PDC, Evidence, para. 325. 17. Note that the emphasis here on the narrative importance of practical policy implementers is complementary rather than antagonistic to Freeden’s emphasis on the ideological context for the efflorescence of the new policies, as he himself acknowledges: Freeden (1978), 195. 18. On the political impact of these newly admitted sections of the populace—middle-class women and the male working class—see, for instance, Simon (1965); and Hollis (1987). In general, see Read (1994);Waller (1983). 19. MacLeod (1967); MacLeod (1968a); MacLeod (1988), 16–18. 20. Although Maurice Wright’s argument must be respected: tight control of the Treasury over the rest of the civil service as a whole (as opposed to the LGB in particular) can be exaggerated for this period and probably applies most rigorously to the interwar period: Wright (1972). For more on “Lingenism,” see Szreter (1996), chap. 2, notes 58, 127, and 114–15. 21. On the importance of local self-government throughout the nineteenth century, see Bellamy (1988); Prest (1990). 22.This was true even in the early part of the period: Lambert (1962–63). 23. Hanham (1969), 373. 24. Figures for 1870 calculated from Mitchell and Deane (1962), 416 and 426. Figures for 1905 from Peacock and Wiseman (1967), table A-20. 25. See Szreter (1996), 252–53. 26. For important new research on the expansion of local government expenditure and sources of finance during this period, see Wilson et al. (1993); Millward and Sheard (1993).

332

Health and Wealth

27. See Offer (1981) for the most penetrating analysis of the resulting conflict between interest groups, in particular chaps. 15–16. 28. Against this historiographical invisibility, the study that has most fully documented and advocated the interpretation favoured here is: Behlmer (1982). In his summary chap. 7 (p. 218), Behlmer notes that at least one contemporary analyst of government growth, the economist Kirkman Gray, was fully aware of the devolutionary nature of British government and the consequent mix of voluntary and local government activism in influencing its policies and providing its execution: Gray (1908). 29. Sidney Webb, Times, 23 August 1902. 30. Bellamy (1988). 31.Webb and Webb (1906–29). Dicey (1905). 32.Wilkinson (1980), 320. 33. After languishing for almost a century, the London vestries have recently been treated to a revisionist account, which at least salvages something of their reputation for the last two decades of the century: Davis (1988). 34. Webb and Webb (1906–29). The obvious point must be made that the attention that they lavished on this subject reflected the high hopes they held for the gradualist transforming potential of local government in British society. Also, of course, practically manifested in Sidney Webb’s prominent role in the Progressive party of the new LCC of the 1890s. This reflected the political strategy of Fabian “permeation” for the introduction of socialism, named after Rome’s defender against Hannibal, Quintus Fabius Maximus, “Cunctator” (“the delayer”). 35. Dicey (1905). 36. It is symptomatic of this historiographical distortion that Gray’s more balanced and perceptive account (see n. 28 above), though published at the same time as the Webbs’ and Dicey’s work, has exerted relatively little historiographical influence and had to be “rediscovered” by Behlmer in 1982. 37. For instance, a particular, direct problem for the public health movement was the difficulty experienced in gaining working-class cooperation for the vaccination program against smallpox, due to its administration by the Poor Law. Wilkinson (1980), 168, 182. On the Poor Law generally, see Crowther (1981); Rose (1985). 38. R. C. K. Ensor’s influential contribution to the Oxford History of England: Ensor (1936), 126, 516–17. As a Fabian in close contact with Beatrice Webb at the time of her work as an appointed commissioner to the Royal Commission on the Poor Laws, Ensor had been made keenly aware of the enormous disappointment experienced by those with progressive ideas, when confronted with the attitudes of the ex-Poor Law secretariat of the LGB and its completely assimilated political “master,” the President John Burns. On Ensor and Beatrice Webb, and on Beatrice Webb’s view of Burns, see McBriar (1987), 215–16, 108, 309. 39.There is a wealth of detail on the difficulties that MOHs faced—and frequently surmounted—in their dealings with their local authority employers in Young (1964).

The Silent Revolution in Nineteenth-Century Government

333

40. For instance, from her detailed work on MOHs in several London vestries, Anne Wilkinson has concluded that the relatively poor pay of Victorian MOHs was on the whole a paradoxical source of strength and independence in their dealings with their local authority employers.As they usually had an additional source of income from a teaching post or from medical practice, they were not so much in fear of dismissal and could afford to ride their luck when proposing unpopular measures.Wilkinson (1980), 321–22. 41. Hardy (1988), 129. 42. Bartrip (1988). 43. The Manchester and Salford Sanitary Association had pioneered in 1860 a system for weekly notification of sickness and infections, launched by the public health campaigner, Arthur Ransome. Tatham significantly expanded upon this in 1888 by coordinating a mutual exchange of the weekly information then being collected in various places by thirty-three different local authorities, which had each independently set up such schemes. See Newsholme (1896). On the health visitors, see Dowling (1963), 227. 44. Hollis (1987), 182–83, 117. On Margaret McMillan’s subsequent role in Bradford education, see Steedman (1990), chap. 2. 45. The first diploma in state medicine was offered by Trinity College, Dublin, in 1871.This initiative was then followed by the universities of Cambridge (1875), London (1876) and Durham (1879). The examination for Diploma in Public Health was standardized by resolution of the General Medical Council, 1 June 1889, which recognized fourteen licensing bodies. Watkins (now Porter) (1984), 114, 121. 46. MacLeod (1968a), 224. 47. Of the sixty-seven witnesses, twenty-two were acknowledged medical experts from the Royal Colleges of Physicians and of Surgeons; and a further twenty-one were local and central government administrators and inspectors with medical qualifications and duties, such as Medical Officers of Health, Factory and School Inspectors. 48. They were duly gratified by the short dedication that he wrote to them and that they printed at the commencement of the first volume. 49. Wohl (1983), and Hardy (1993), are the best general accounts of the work of local MOHs during the second half of the nineteenth century. 50. For instance, the normal response to serious sickness among the poor unfortunately entailed increased rather than diminished social contacts: Wilkinson (1980), 301–6. 51. Since publication of Pelling (1978), it has been clear that a mix of miasmatist and contagionist ideas had always coexisted within the British public health movement. 52.Wilkinson (1980). Hardy (1983), chap. 1; and see Szreter (1996), 106–7. 53.See Szreter (1996), 516–20. 54. Porter and Porter (1988), 97–100.

334

Health and Wealth

55.Watkins (1980), 187–88. 56. Greta Jones has interestingly pointed out that membership of the eugenics movement was geographically highly clustered, with its main centers of activism apparently confined to London, Birmingham, Leicester, Manchester, Liverpool, Brighton, Cambridge, Edinburgh, Glasgow, and Belfast: Jones (1986), 26–27, 55. There has been little systematic research into this local aspect of the eugenics movement and its implications. For some further details on Manchester and, especially, Birmingham, see Lowe (1979; 1980). Note, however, that Gillian Sutherland (1984), 25–26, offers a different interpretation of the wider significance of this local evidence. 57. Searle (1981), 224–26. 58. They probably formed about 20–25 percent of the membership, about equal with “academics” in 1914, when total national membership was 1,047: MacKenzie (1981), 22–23.This, then, represented approximately 1 percent of the 23,469 men and women returning themselves as “Physicians, surgeons and registered practitioners” at the 1911 census (Census, 1911, vol. 10, table 3). 59.Their membership is mentioned by Greta Jones (1986), 20. 60. Porter and Porter (1988), especially 101. 61. Porter and Porter (1988); and see also Watkins (1984). While MOHs were certainly well aware of their distinct aims as a group and were politically well organized through the Society of MOHs, it is possible to exaggerate the degree of separation that existed in practice between public health doctors and others at this time, since many MOHs combined their public health duties with a variety of other medical work. On professional rivalries within medicine, see Honigsbaum (1979). 62. For discussion of the complex issues of “character,” “manliness,” and the franchise, see Szreter (1996), 156–57, 460–62, 484–88. 63. Of course, Chadwick himself was the first and foremost such casualty, “let go” by his Whig masters in 1854. His biographer, Benjamin Ward Richardson (1828–98), evidently took the lesson to heart, presenting his own most radical ideas in 1876 as a utopian excursion: Hygiea. Richardson also published in 1879 A Ministry of Health; H. W. Rumsey’s Essays on State Medicine is often cited as an early exposition of an ambitious system of state medicine. 64. Harris (1972); Davidson (1985). 65.Williams (1970); Hennock (1987a), part 2. Charles Booth’s call in 1891 for universal, noncontributory pensions of 5 shillings per week for all above age seventy had originally created a minor sensation, coming as it did from a socially conservative quarter (ibid., 122). 66. The principal administrative innovations concerned were those of the Progressive, or New Liberal Asquith government after 1908, creating overtly redistributive fiscal arrangements for centrally funded mechanisms of social security and insurance against sickness, old age, and unemployment.This entailed an altogether new degree of regulatory intervention into the workings of the economy, particularly the conditions of the labor market. The best general introductions are: Hay

The Silent Revolution in Nineteenth-Century Government

335

(1983); Thane (1996); Fraser (1984). There has also been a definitive narrative account of the politics of the birth of the insurance scheme: Gilbert (1966). 67. Sutherland (1973), chaps. 10–11. 68. Rubinstein (1969), 81–82. 69. Sutherland (1984), chap. 1. In addition to Gillian Sutherland’s important study, these formative debates in the discipline of educational psychology have received an extremely stimulating treatment in Rose (1985). For further explorations of related fields, see the collection edited by Cooter (1992); and Wooldridge (1985). 70. Sutherland (1984), chap. 2; and Szreter (1996), 186. 71. For further information on Gorst and Macnamara, see Szreter (1996), chap. 5, notes 17, 18. 72. Aldrich and Gordon (1989). 73. See Gilbert (1965). 74. PDC, Report, v. 75. Ibid. 76. Their replies to this first inquiry by the Home Office are reproduced as Appendices lb and Ic in the PDC Report. 77. PDC, Report, Appendix Id. 78. From both of Maurice’s articles in the Contemporary Review: “Where to get men” and “National health.” 79. Uncited. But from Brunton’s later evidence, we learn that Sir William Taylor was quoting from Brunton’s letter to the Lancet, 14 February 1903, calling for the appointment of a commission. The National League for Physical Education and Improvement was the organization Brunton was promoting at this time, following upon the recommendations of the Royal Commission on Physical Training of 1903. 80. PDC, Report, Appendix Ia, paras. 2 and 3, respectively. Sir Frederick Maurice was again quoted in the conclusion: Appendix Ia, para. 12. 81. Ibid., Appendix Ia. 82. Ibid., para. 8. When examined as a witness Major-General Barrett acknowledged that the basis on which he had made this statement (in para. 150 of his Report for 1902) was statistically unsound: PDC, Evidence, paras. 163–73. 83.This included: Dr. G. B. Longstaff (see Szreter 1996, chap. 2, note 94); Dr. J. F. W. Tatham, the immediate predecessor to T. H. C. Stevenson, as medical statistician at the GRO; and Arthur Newsholme (for more on Newsholme, see Szreter 1996, 232–34, 240–46, 254–56). The other two were a Dr. Poore and a Dr. Pringle. 84.The six were: “Labourers, servants, husbandmen, etc.”; “Manufacturing artisans (cloth workers, weavers, lace makers, etc.)”; “Mechanics employed in occupations favourable to physical development”; “Shopmen and clerks”; “Professional occupations, students, etc.”; and “Boys under 17 years of age.” Clearly these categories were designed with some idea in mind of classifying by physique as well as by average income or status of occupation. PDC, Report. Appendix Ia, para. 5.

336

Health and Wealth

85. PDC, Report, Appendix Ia, para. 6. 86. Ibid., Appendix Ib. 87. Ibid., para. 10. 88. Ibid., para. 246. 89. Ibid., para. 250. 90. J. G. Legge’s cross-national comparative data showed no trend physical degeneration over the previous twenty years among the most underprivileged elements of the town population: Royal Commission on Physical Training (Scotland) (hereafter RC on PT), Appendix 1. This reform school data showed Scottish boys with a marginally better physique at age 14 than the English boys; but by age 17, after at least two years at reform school in each case, the English boys were ahead. Legge attributed this change to the fact that physical training was more developed in English reform schools than in the Scottish equivalent. RC on PT, Evidence, paras. 740–43. 91. Ibid., para. 6893. 92. Ibid., para. 6893. 93. Ibid., para. 6893. 94. Alfred Eicholz (1869–1933) had been the first Jew to be elected to a Cambridge Fellowship (Emmanuel College, 1893). After medical training at St Bartholomew’s, he became an HMI, 1898–1907, and then an Inspector for the new Medical Department of the Board of Education, created on the recommendation of the Report of the PDC. He succeeded George Newman as Chief Medical Officer at the Board of Education (a post he held until 1930), when Newman left in 1919 to become the new Ministry of Health’s first Chief Medical Officer. Sources: Who Was Who 1929–40; Aldrich and Gordon (1989). 95. PDC, Evidence, para. 429. 96. Ibid., paras. 439, 433. 97. Ibid., Report, para. 69; and Evidence, para. 435. 98. Ibid., Evidence, para. 552. 99. Ibid., para. 556. 100. Ibid., para. 556. 101. Ibid., para. 435 (9). 102.Winter (1985), 17. 103. PDC, Evidence, para. 556. 104. Ibid., para. 435 (7). 105. Ibid., para. 438. 106. Ibid., para. 475. 107. Ibid., Report, para. 345. It was reported that in Birmingham sixteen centers fed 2,500 children daily—2.5 percent of the relevant school population— at a cost of 1/2d. p.cap. p.diem. George Dixon (1820–98) had been cofounder (with Joseph Chamberlain, R. W. Dale, and George Dawson) of the National Education League in 1869, an early campaigner for universal compulsory education involving payment of fees for the poor. Dixon had been mayor of Birmingham in

The Silent Revolution in Nineteenth-Century Government

337

1866, and was Liberal MP 1867–76, and Liberal Unionist MP 1885–98. Dixon succeeded Chamberlain as chairman of Birmingham’s school board, 1876–97. George Dixon and the National Education League represent the strength of provincially organized pedagogic opinion, something that was distinct from that of the better known Oxford Balliol nexus. The latter was given such prominence in the account in Szreter (1996), chap. 3 because of their relative dominance over national educational thinking and policy through control of the proactive central government Education Department. Incidentally, the latter was the only major example of strong programmatic central government leadership in “social policy” issues during the second half of the nineteenth century and the only major exception to the general thesis being argued in this chapter: that provincial and local government was more active and was the true originator of most social policy initiatives, belatedly adopted by central government. In the capital, where the influence of the COS was at its strongest, the London school board never formally broached the problem of “underfeeding” of schoolchildren until 1884, concentrating instead on the problems of extracting fees and arrears from impoverished parents: Lewis (1982), 308; and see Szreter (1996), chap. 9, note 204. 108. PDC, Report, para. 347. 109. Ibid., para. 348. 110. Ibid., para. 365. 111. Ibid., para. 365. 112. On the many different possible manifestations of “individualism” in the social sciences, see Lukes (1973). 113. PDC, Report, para. 241. 114. Ibid., Appendix V. 115. Ibid., para. 255. 116. Ibid., para. 260. 117.The “Right to work” campaign of Keir Hardie’s ILP was at this time running alongside the Fabians’ slogan of the “National Minimum” as two major political demands on behalf of organized labor. 118.This was noted by Winter (1985), 17–18. 119. Soloway (1990), 29–33, 46. 120. This was, for instance, in marked contrast to the fate of the proposals emanating from the great, lumbering Royal Commission on the Poor Laws, which sat 1905–9. 121. Jones (1980), 84–86. Weismann’s breakthrough came as a result of applying the successful German microscope technology developing at this time, in the field of cytology, to the observation of the elemental growth germs posited by recapitulation theory, a school of thought that was also particularly strongly developed in German biology (see Szreter 1996, chap. 3, notes 49–50). 122. Galton had never subscribed to a gradualist, adaptationist theory, accurately observing that nature afforded too many examples of radical discontinuities between species. MacKenzie (1981), 130; Jones (1980), 78, notes that Darwin was

338

Health and Wealth

also impressed by this evidence originally in his Origin of Species. It was only later in the The Descent of Man that he increasingly abandoned “transmutation” (saltationism) in favor of Lamarckianism. 123. MacKenzie (1981), 60. 124. Ibid., 60–68. 125. Norton (1981), 293. According to sensation psychology, the powers of the mind were ultimately a function of the physiological capacities of the senses, through which all information was received. Jones (1980), 104–5, notes that Galton’s methodological notion of “observability” was identical with that of the phrenological paradigm. 126. On racialist eugenics as a species of reactionary modernism, see, for instance, Herf (1984), which, however, uses the term only of Nazi Germany. 127. See MacKenzie (1981), 86–91, for Pearson’s views; Norton (1981), 296–99, for Galton’s. 128. Szreter (1996), 90–95. 129. MacKenzie (1981), 85–91. 130. Searle (1973). 131. For discussion of whether Mendel or his rediscoverers were truly responsible for the crucial distinction between phenotypic and genotypic analysis, which is basic to modern Mendelian genetic theory, see Olby (1973). 132. MacKenzie (1981), chap. 6; Bowler (1989), chaps. 9, 11; Allen (1978). 133. See MacKenzie (1981), 121–22, and chap. 6 in general for a detailed account of the conflict. 134. In the longer run, by the 1930s, there was to be a reconciliation between the “populationist,” macroscopic, empiricist approach, still being advocated by Pearson—and independently advanced by many zoologists studying the peculiarities of actual geographical distribution and differentiation of species—and the microscopic, laboratory study of genetic structures in chromosomes and their laws of reproductive recombination.The result of this synthesis was to be the emergence of the modem field of population genetics, with the work of R. A. Fisher, J. B. S. Haldane, Sewall Wright, and the Russian, Theodosius Dobzhansky, among many others, playing central roles. Bowler (1989), chap. 11. Provine (1971; 1986) has provided the most detailed historical studies. 135. See Kuklick (1991), 133–54; Stepan (1982) 89–91 and chap. 4. The results of Haddon’s famous Cambridge University Torres Straits expedition confirmed the views of W. M. F. Petrie (1853–1940) and Grafton Elliot Smith (1871–1937), who had shown from their analysis of the palaeontological evidence of Egyptian mummies that typical racial characteristics were apparently extremely stable across thousands of years.The expedition’s careful and innovative research in experimental psychology and anthropometrics, particularly the work on hearing and vision and especially color perception and sensitivity, was undertaken on the Melanesians by C. S. Myers, William McDougall, C. G. Seligman, S. Ray, and A. Wilkin, under the direction of W. H. R. Rivers (1864–1922). Its significance was

The Silent Revolution in Nineteenth-Century Government

339

that it showed remarkably little differences in natural endowments and sensory perceptions between the islanders and the Europeans who had been studied since 1884 in Galton’s anthropometric laboratory in Kensington and also in Dublin, where D. J. Cunningham and A. C. Haddon had worked together in a similar anthropometric laboratory. 136. Although, as has been mentioned, Galton had been one of the principal individuals responsible for a relaunching of the physical anthropology of racial difference in the 1870s and 1880s by reinvigorating its study with his quantitative anthropometric technology, by the beginning of the new century Galton and Pearson were finding it increasingly difficult to excite the Anthropological Institute with their eugenic ideas. Soloway (1990), 29–30. 137. See note 135, above, on Cunningham’s close association with the anthropometric work of Haddon and Galton. The study of comparative anatomy had been intimately associated with evolutionary theory, since Cuvier’s pioneering anatomical and embryological work, arguing for the necessary fixity of species through study of the functional integrity and balance of organisms’ developmental growth.The definitive study of Cuvier in the English language is Coleman (1964); see also Bowler (1989), chaps. 3, 5; Gould (1977). Anatomy was also used in the attempt to establish a science of racial differences: Stepan (1982), xiii. 138. See Royal Anthropological Institute Occasional Papers No. 2 (1905). 139. For Cunningham’s case put to the committee, see PDC, Evidence, paras. 2244–61; and for the extensive discussion of such a scheme in the committee’s own report, see PDC, Report, paras. 46–66.The expeditious embodiment of this idea in legislation, through the Education (Administrative Provisions) Act of 1907, represented a particularly significant triumph for Robert Morant’s manipulative arts. Sutherland (1984), 49–50. 140. PDC, Report, para. 43. For Cunningham’s original statement, see Evidence, para. 2210. 141. Cited in PDC, Report, para. 212. 142. Quoted in PDC, Report, para. 213, from Cunningham’s statements in Evidence, paras. 2270 and 2271, respectively. 143. PDC, Report, para. 215. 144. Ibid., Evidence, para. 2268. 145. Rowntree (1903), 28. 146. Rowntree (1901), 355. 147. Despite the popular elision of their findings and methods, the president of the COS, C. S. Loch, cogently destroyed the illusion of corroboration between the two surveys in a careful, critical review of their two works for the Physical Deterioration Committee. PDC, Report, Appendix III. However, this analysis by Loch seems to have been virtually ignored by contemporary sociologists and by historians ever since. He anticipated many of the important points concerning Booth’s classification system, which were only more recently exposed by E. Hennock

340

Health and Wealth

(1976). See especially PDC, Report, Appendix III, paras. 20–25, for comparison with Hennock’s analysis. 148. However, see the further discussion that has developed over the rigor of Rowntree’s methods:Veit-Wilson has shown that Rowntree did not, in fact, use as fully as he could have done the comprehensive income data for York’s working class that was undoubtedly at his disposal. Hennock has argued that this was because he preferred to repeat Booth’s methodology of counting observers’ impressions of “apparent poverty” in order to carry out his original aim of ensuring comparability between his findings and those of Booth’s. Veit-Wilson (1986); Hennock (1991), 194–200. 149. The principal follower of Rowntree’s lead in this direction was the mathematical statistician,A. L. Bowley, in his work over the next two decades, both for the Labour Department and also funded by the Ratan Tata foundation. As Hennock shows, Bowley was particularly attracted to the development of statistical probabilistic solutions for the two major measurement issues raised by Rowntree’s work: first, the national representativeness of necessarily local, detailed inquiries into household budgets; second the problem of the weightings for components of any comparisons of “cost-of-living” estimates, either over time or between different parts of the country. Hennock (1987b). 150. Briggs (1961), 4–14. 151. Ibid., 23–24. 152. Newsholme (1935), 26. This discussion of his articles of faith was one of the few personal details that he permitted himself, in his exceptionally catalogic memoirs. 153. Newsholme (1936), 68. 154. Newsholme (1935), 298. 155. Ibid., 296. 156. Eyler (1993; 1989); and see also Porter (1991). 157. John Eyler is quite right to stress Newsholme’s Huxleyan view that humans’ capacity for reason, cooperation, and morality meant that they were not subject to the brute forces of biological evolution, and his Hobhouseian belief that recent history, such as the abolition of slavery and campaigns against cruelty to children, showed that progressive moral evolution in the individual character was occurring, towards altruism and civilization and away from the selfishness and vice that were encouraged by a deprived and deficient environment. However, in assessing Newsholme’s views on the relative importance of individual responsibility and collective provision, we should distinguish his attitude towards the deprived and towards the privileged.After 1904 Newsholme consistently emphasized the priority of collectively organized and collectively resourced environmental improvements as the key to raising the prospects of the poor: a necessary condition to enable and facilitate the desirable moral evolution of individuals’ characters to take place. Whereas in discussing the behavioral shortcomings of his own social peers—those individuals already fortunate enough to enjoy a beneficial environment—

The Silent Revolution in Nineteenth-Century Government

341

Newsholme could be severe and censorious, invoking weakness of character in individuals because he believed that they had no (environmental) excuse for their failings and “selfishness.” See, for instance, Newsholme’s The Declining Birth Rate, 41–42, 56–63, for this differential approach towards the poor and the comfortable. For Eyler’s discussion see Eyler (1993), 202–5. 158.Wilkinson (1980), 284, 321, 330–34. 159. Darley (1990). 160. Harris (1989), 34–35. 161. La Berge (1988). See Szreter (1996), 87–88. 162. On methodological individualism, see the elucidatory Lukes (1973). 163. See Szreter (1996), chap. 5.

PART III HISTORY AND POLICY From the Past to the Future

10 HEALTH, CLASS, PLACE, AND POLITICS Social Capital, Opting in and Opting out of Collective Provision in Nineteenth-Century and Twentieth-Century Britain*

This chapter will present some historical evidence that indicates a longstanding geographical dimension to what we call class differentials in health and inequality. It will also offer some initial thoughts on how these influences of place and region may assist in understanding the long-run sociopolitical history of health inequalities during the last two centuries.

* This chapter is slightly revised from its first publication in Contemporary British History 16, 3 (2002).

345

346

Health and Wealth

These cannot be explained through any straightforward account. A number of important studies have shown both a remarkable persistence of health inequalities during the twentieth century and also no linear pattern of either gradual decline or gradual improvement.1 Thinking about the interactions between class and place and their associations with regional interests and identities in recent British history may provide a helpful way to begin to examine the possible influence of the nation’s changing political and ideological climate of opinion. It may also provide a link with the most recent development in this literature examining the relationship between health, inequality and social capital.2 A series of contemporary class differential statistics on mortality do not exist for the nineteenth century.3 Although there were a number of attempted forays in this direction from both government officials and others, which have left some scattered indicators, I have written at length elsewhere about the reasons for this relative absence of attention to systematic class measures of health in the nineteenth century.4 The British Association’s innovative Anthropometric Committee created a scientific tool in the early 1880s that demonstrated the class distribution of heights among teenage boys, and that set the important methodological precedent of defining social classes primarily in terms of male occupational categories.5 But it was not until the analysis associated with the fertility of marriage inquiry mounted at the 1911 census that the state’s social and medical statisticians became sufficiently interested in the survival rates of the different social classes of the nation that they went to the trouble of constructing a measure of class differential infant mortality.6 This model, which I have called “the professional model” of social classes, is the well-known one composed of five ranked status gradings, designated by Roman numerals I—V.7 This is the official classification scheme originally designed and perfected by Dr. T. H. C. Stevenson for the 1911 and 1921 censuses and associated decennial supplements on mortality, which has dominated twentieth-century social and medical policy; and it is this model with which Sir Douglas Black and his team worked in their report of 1980 (see note 1). Victorian epidemiologists and public-health officials were in fact much more interested in comparing the mortality statistics of different places than different social classes. As a result we have some of the best historical data in the world on spatial differentials in mortality from the very beginning of the Victorian era.There was an extremely good, practical

Health, Class, Place, and Politics

347

Table 10.1: Local Government Expenditure as Percentage of Total Government Expenditure, and as Percentage of GNP 1820–1999 Date

% of total govt expenditure

% GNP

1820 1870/71 1905 1918 1925 1935 1945 1950 1979 1998/9

12.5 32.0 51.1 5.7 34.6 38.8 9.4 23.4 27.9 23.9

2.7 3.0 6.3 3.0 8.4 9.6 6.2 9.1 11.6 (10.7 GDP) 9.2 (GDP)

Sources: for 1820–1955,A.T. Peacock and J.Wiseman, The Growth of Public Expenditure in the United Kingdom, 2nd edn (London: George Allen and Unwin, 1967), chap. 3, esp. table 1 and p. 39, and Appendix, table A-20; for 1979, Government Expenditure Plans (London: HMSO, 1979); for 1998/99, Public Expenditure. Statistical Analyses 2000–2001 (London: HM Treasury, 2000, Cmd 4601), tables 1.11 and 4.1.

reason for this, as can be appreciated by examining the historical statistics on local government expenditure as a percentage of total government expenditure displayed in table 10.1. With the dominant mid-Victorian, classical liberal political economy and free market ideology of low taxation and minimal government intervention, it was principally local government that was expected by the electorate to get things done, insofar as the local environment and public health matters were concerned.There was, in fact, one abortive episode of attempted centralism during the 1840s, led by Edwin Chadwick, that culminated in the nation’s first-ever general Public Health Act of 1848 (see Figure 2.1, p.27).8 Chadwick was also one of the few nineteenth-century officials to think seriously about the possibility of constructing social-class measures of mortality.9 But local voters all around the country were so incensed at the clauses in the 1848 Act that threatened to force them to spend on their local environments that a national populist campaign against Chadwick and his Public Health Act resulted in the downfall of both during the ensuing decade of the 1850s.10 As Table 10.1 reflects, the principle of local self-government was vigorously reasserted, resulting in local government expenditure continuing

348

Health and Wealth

to rise as a proportion of all government expenditure throughout the remainder of the nineteenth century. Consequently the Victorian publichealth movement faced a classic collective action problem in every locality throughout the country. In order to improve the health of each urban population and its environment, public-health officials were effectively requiring the local property-owning ratepayers to vote for hefty local taxation upon themselves.11 With only minimal central-government subsidies until the last decades of the century, local taxation was the principal source available to fund the measures required. For the constantly increasing proportion of the national population living in towns during this period, the measures needed ranged from street paving and lighting, through sewerage and the provision of a safe domestic water supply, to the establishment of fever and isolation hospitals and paying the salaries of sanitary inspectors and medical officers of health.12 None of these were cheap undertakings. The reform of the national and municipal franchises in 1832 and 1835 had produced an electorate in each town that was synonymous with its local ratepayers, who were predominantly drawn from the precariously respectable class of small property-holders. As Table 10.4 shows, this did not change until the era of the second and third Reform Acts of 1867 and 1884, which significantly further extended both the municipal (Municipal Franchise Act 1869) and national electoral franchises to include a majority of non-property-owning working-class men. Before this, local politics throughout the early and mid-Victorian decades was dominated by the interests of an anxious petty bourgeoisie.These voters were predominantly neither the most prosperous businessman nor the larger landowners and landlords, but shopkeepers and small-scale employers, the infamous “do-nothing” shopocracy organized into their ratepayers’ associations, whose battle cry was “economy.”13 Faced with the choice of heavy demands on their pockets through the local rates or attempting to deal with the problems of urban and industrial poverty, overcrowding and lack of sanitary facilities in some other way, those among the propertied classes who could, chose the other way: they simply opted out of these insanitary conditions while continuing to vote for “economy” on the rates. How did they do this? By physically moving their families out from the crowded and smoky city centers and setting up home in the growing

Health, Class, Place, and Politics

349

suburbs.The lower panel of Table 10.2 shows how the growth of the suburban registration district (in italic) many of Britain’s major cities increasingly outstripped that of the old center (bearing the name of the city) from the 1850s onwards. Of course by no means all of the lesser propertied classes found this move possible or practical, and some just accepted filth and ill-health as a fact of life; but many of those who were disturbed by the problem chose this option rather than staying and paying to improve the city center’s environment. Away from the city center, their families could live in cleaner, lighter, and larger houses.14 For the upper and middle classes this lifestyle would include a servant or two to do the fetching and carrying. Here, the costs of creating sanitary facilities, such as running hot and cold water and WCs were much more manageable when they were to be privately or locally provided only for a relatively exclusive neighborhood, rather than for the whole town and its thousands of poor families who couldn’t even afford to pay a water bill.Thus Britain’s nineteenth-century industrial cities and towns were characterized by this centrifugal movement of residential “escape” on the part of the wealthier classes, a social counterflow against the massive centripetal movement inwards from the countryside and from Ireland of the migrant poor looking for jobs within walking distance of the factory gates.15 This, then, was social class in action through place: the process of residential re-assortment. As can be seen from the upper panel of Table 10.2, where this happened it was strongly associated with a class differential in life expectancy. From a health and social status point of view, class in Britain has increasingly manifested itself, since the beginning of the Victorian era, as different kinds of places in which families live and where children grow up. However, it is not just that these places have experienced different health outcomes simply because they have contained different proportions of (healthy) middle-class households and (unhealthy) working-class households.There was also a sociopolitical dimension to the difference in each environment’s relative salubrity. The residential suburbs such as leafy Edgbaston or Handsworth in late Victorian and Edwardian Birmingham were healthier than the inner districts of, say, Nechells and Saltley, not simply because they contained proportionately more families headed by doctors, solicitors, bankers, and big employers and proportionately fewer families headed by gasworks employees, transport workers, and all the small tradesmen and waged laborers of a busy industrial

350

Health and Wealth

Table 10.2: Expectation of Life at Birth (E0,) and Population Size of the Central and Suburban Registration Districts in Seven of England’s Largest Provincial Cities, 1851–1901 Registration Life Expectancies Districts 1851–60 1861–70

1871–80

1881–90

1891–1990

Bristol Clifton Sheffield Eccleshall Newcastle Gateshead Leeds Hunslet Birmingham Aston Manchester Chorlton Liverpool West Derby

37 45 35 42 37 39 37 39 37 43 32 38 28 39

39 48 38 43 40 42 39 42 39 46 35 41 29 40

43 50 39 46 42 44 41 40 38 45 36 42 30 41

Mid-census population (000s) 1851–61 1861–71

1871–81

1881–91

1891–1991

Bristol Clifton Sheffield Eccleshall Newcastle Gateshead Leeds Hunslet Birmingham Aston Manchester

60 147 173 101 141 93 177 124 239 178 255

57 180 194 126 174 118 207 150 246 234 282

106 167 216 157 214 150 237 179 245 283 310

35 42 34 40 34 37 34 38 35 42 30 37 27 38

66 86 116 51 101 54 109 99 193 84 236

36 42 33 40 34 39 34 36 35 42 29 36 25 35

64 111 146 75 121 70 128 118 222 124 247

Health, Class, Place, and Politics

351

Table 10.2: (Continued) Mid-census population (000s) 1851–61 1861–71

1871–81

1881–91

1891–1991

Chorlton Liverpool West Derby

235 224 410

279 184 525

319 153 615

147 264 190

190 254 284

Source: Derived from S. Szreter and G. Mooney, “Urbanisation, Mortality, and Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-Century British Cities,” Economic History Review 51 (1998), table 2. (The article is slightly revised in this volume as chapter 6).

center. The professionals and big industrialists made it their business to use their “voice” to influence and, if necessary, some of their own resources to ensure that all around where their families lived the streets were properly paved and kept swept and tidy, parkland was provided, and building and planning regulations were observed.16 All residents of such areas benefited from such attention, not just the most wealthy households. The entire district benefited in health terms as a result of a combination and synergy between what was lavished on their own properties, families, and streets by the wealthy and the associated pursuit of the collective needs of the whole district by a powerful set of citizens. Where a critical mass of such a class of wealthy, well-connected, and observant householders did not reside in sufficient numbers and density, the environment would not benefit from the same careful attentions and political influence—to the detriment of all. Furthermore, there is evidence that certain elements within the propertied classes—notoriously slum landlords—actively conspired to block costly street and house improvements in the poorer districts.17 This interpretation, that the relative salubrity and health of whole districts or social environments conferred benefits or harm on all resident families, regardless of their social class affiliation (as measured by the occupational status of the head of household) has been confirmed at the individual level of analysis in recent research investigating patterns of mortality among the young from detailed individual household records for the period 1891–191l.18 This evidence is drawn from 13 contrasting places in England and Wales, each of which can be further subdivided, making a total of 53 relatively small and socially specific localities.19 Each

352

Health and Wealth

of these 53 localities has then been classified either as “agricultural” or as one of three urban types of environment according to whether the occupational complexion of the locality was predominantly “white-collar” (professional, managerial, and clerical), that of the established “staple industries” (mining, iron and steel, engineering, textiles, and potteries) or else, third, a more mixed, residual category characterized by both some industry and some service-sector employment.20 Examination of this very detailed, individual-level data has been able to show, through multiple regression analysis, that the categorization of these 53 localities into these four distinctive social types of residential environment is a superior and more robust discriminator of differentials in mortality among the young than is the social-class affiliation of the individual family households themselves. Thus, families who were allocated to a low social class (class IV or V) on the basis of the occupation of the head of household had much better infant and child mortality than expected, when they were residing in localities classified as “white-collar” social environments. Conversely, middle-class families (classified to class I or II) residing in staple industrial environments suffered corresponding detriments to their children’s survival chances. This way of looking at the problem of health and mortality differentials and their evolution over time, in terms of place and social environment rather than just in terms of social class differentials alone, becomes even more significant when we take into account the manner in which there has also been a long-standing and large-scale gross geographical imbalance between North and South in the distribution of “white-collar” as against industrial and proletarian environments. As can be seen from Table 10.3, if all the 1,827 local authority districts into which England and Wales was divided in 1921 are classified into one of the four environment types, almost all districts with a strong “white-collar” presence and “voice” were found in the five southern regions of England and Wales (Census Divisions I–V; these 11 regional divisions are those used by the Registrar-General in 1921 to divide up England and Wales for broad geographical analyses). By contrast, virtually all localities dominated by the industrial working class were found in Census Divisions VI—XI, the six northern and midland regions, including Wales (whose population was predominantly “northern” by virtue of the majority drawing its living from the Glamorganshire coalfield).

Health, Class, Place, and Politics

353

These findings carry two sociopolitical implications. First, in the recent past the South (comprising a little under half of the national population between the late nineteenth century and the late twentieth century) has always historically contained a large proportion of residential environments and local authorities that found they could largely maintain themselves in a reasonable sanitary state through the middle classes’ private spending on themselves and their own neighborhoods. They could thus avoid heavy and systematic local taxation of themselves for the benefit of larger urban collectivities—of which there were many fewer in the South (except for London, which, however, also contained the greatest concentration of extremely wealthy neighborhoods). Indeed, many of these residents in the many white-collar environments of the South were unlikely to encounter examples in their daily lives of the need for such collective expenditure, living as they did in their healthier, self-supporting local environments, relatively free from the sights, sounds, and smells of urban congestion and poverty. It would therefore always have tended to seem perfectly reasonable to a large swathe of this better-off section of the population, living in the South, to vote for opting out of any form of mandatory collective expenditure—especially higher rates of central government taxation. The populace of the North, on the other hand, has had a much higher density of environments with too little private resources for this kind of strategy of autarkic self-help to be effective.Thus, it would always have been in the overall strategic interests of the more proletarian North and Midlands, as a whole, to opt in to a system of collective central provision of resources to combat the health problems in their environments, which their own citizens have not possessed the private means to address.21 This was all the more necessary as a strategy for northern towns and cities because the truly wealthy and comfortable classes were so thinly spread that they were found in significant numbers only in a few small enclaves (such as Birkenhead and Southport, at the far reaches of Liverpool, or Edgbaston and Handsworth at the southwestern and northwestern edges of Birmingham). However, throughout most of the nineteenth century, the proletarian North and Midlands did not have the political clout to impose this as a national government strategy upon the much more politically powerful South which had historically been much more populous and wealthier.

354

Health and Wealth

Table 10.3: Geographic Distribution of Population Living in Each of the OPCS Environments: England and Wales Census Divisions (Percentages Based on 1921 Population Figures) Census Divisions

OPCS “Environment” Agricultural White Collar

I II III IV V VI VII VIII IX X XI N of total population (in 1000s) “Environment” population as % of total

London 0.0 South 17.9 Eastern South 12.8 Midland Eastern 11.7 South 14.7 Western West 11.3 Midland North 8.2 Midland North 4.9 Western Yorkshire 6.5 Northern 3.9 Wales 8.0 Total 100.0 5,892

15

Light Staple Total Industry Industry

24.3 30.2

18.7 4.7

0.0 0.1

11.8 10.8

12.4

8.0

0.0

7.5

5.6 9.8

8.4 2.1

0.9 0.8

6.3 5.3

3.4

12.8

15.1

11.2

1.1

6.9

9.2

6.5

6.7

18.8

24.6

15.7

2.5 7.9 24.1 1.2 6.8 12.5 2.7 4.8 12.5 100.0 100.0 100.0 7,883 13,698 10,421

11.0 6.8 7.0 100.0 37,894

21

36

28

Source: The original version of this table is to be found in Garrett et al., Changing Family Size in England and Wales 1891–1911: Place, Class and Demography (Cambridge: Cambridge University Press, 2001), table 6.2.1. Population figures taken from General Report, Census of England and Wales, 1921, tables 10 and 11.

Health, Class, Place, and Politics

355

Furthermore, the dominant ideology of the age, economic liberalism and self-help, which was embraced among the northern manufacturers and shopkeepers as fervently as anywhere, was not at all conducive to thinking in terms of such national collectivist solutions to local and regional problems of health and the environment (hence Chadwick’s dramatic fall from office in the 1850s). All this changed, however, over the course of the period c.1865–1945. This shift in policy and ideology started gradually and locally, its almost unseen nature acutely summed up by Sidney Webb in 1889 in his much-cited caricature of the dour northern man of business: The individualist town councillor will walk along the municipal pavement, lit by municipal gas and cleansed by municipal brooms with municipal water, and seeing by the municipal clock in the municipal market that he is too early to meet his children coming from the municipal school, hard by the county lunatic asylum and municipal hospital, will use the national telegraph system to tell them not to walk through the municipal park, but to come by the municipal Tramway to meet him in the municipal reading room by the municipal art gallery, museum and library where he intends to consult some of the national publications in order to prepare his next speech in the municipal town hall in favour of the nationalisation of canals and the increase of Government control over the railway system. “Socialism, sir,” he will say, “don’t waste the time of a practical man by your fantastic absurdities. Self-help, Sir, individual self-help, that’s what made our city what it is.”22

As this telling observation suggests, the move towards collectivism proceeded in northern and midland towns with an inexorable momentum over a number of decades, while perceived by many of its beneficiaries for much of the time as no more than English pragmatism in dealing with the provision of specific goods and services that the market apparently could not or would not provide, rather than as the implementation of a social philosophy. Nevertheless there was a distinct, burgeoning collectivist ideology behind this movement, which flourished in Birmingham in the late 1860s as the civic gospel, infused with nonconformist Christian concern for the welfare of the poor. Gathering momentum, it became known by its detractors as the “gas and water socialism” of British provincial cities of the late nineteenth century and attained its most articulate political form

356

Health and Wealth

as Sidney Webb’s advanced Progressive program for the government of the London County Council (LCC).23 Ultimately it led to its logical conclusion, resulting in national, centrally funded collectivist social legislation enacted before World War I and, finally, a fully fledged welfare state for the whole nation legislated after World War II.This marked the historic high point of the rise of the strategic interest of the North in a politics of collective provision, full victory—at least for a generation.

From Opting Out to Opting In: Britain c.1865–1945 The causes of such profound changes over so many decades are inevitably many and complex, involving politics and ideology and the political classes’ perceptions of threats to national and imperial survival—from socialism within and from other industrial powers without—and therefore the need to spend on the nation’s resources of manpower on both counts.All this is well known—the relationship of imperialism and war to social spending.24 But what is less well understood is the changing sociodemographic history that provided the context for these political developments, in terms of the interactions among class, place, and region. The long-term demographic “rise of the North” is a factor of cardinal importance. In terms of the same eleven regions represented in Table 10.3, in 1701 the inhabitants living in the then-poor and sparsely populated “North” (the five northern and midland English regions, plus Wales) comprised much less than one-third of the population of England and Wales.They still represented much less than one-half by 1851 after a century’s rapid expansion in the coalfields.25 But, as Table 10.3 shows, by 1921 almost three-fifths of the population lived in these six regions, almost double the proportion in 1701 and a historic tipping of the scales in terms of the nation’s demographic balance. Only a minority of 42 percent of the nation’s population now lived in the historically favored and previously much more populous five southern regions. But numbers do not automatically equate to political power, of course.After centuries of marginalism, the political and electoral representation and power of the urban and industrial populace of the North and the Midlands lagged behind its growth. Its representation was famously and deftly held back by the incumbent landed interest of the South throughout the initial period of its

Health, Class, Place, and Politics

357

massive disproportionate expansion, with successive governments buying off the propertied middle class in 1832 and facing down the Chartist demand for manhood suffrage in the 1840s. Many towns like Manchester did not even have a single MP to voice their interests in the House of Commons until 1832, by which time they had long passed a total of 100,000 inhabitants. As Table 10.4 shows, only a minority of all adult males had the right to vote until as late as 1884, as did a minority of adults of both sexes until 1918. The formation of the national political party of the North, the Labour Party, the party of the industrial workforce and the party of the poor majority of voters, did not even occur until 1900. The party of Northern industrialists, merchants, and shopkeepers, the Liberal party, which was formed from the Whig party in the midnineteenth century, did attempt to come to terms with the wishes of the new mass electorate created between 1884 and 1928, notably through the cluster of centrally funded and nationally organized welfare policies, aimed primarily at the social security needs of the working man, enacted between 1906 and 1914 during a period of unprecedented, sustained industrial unrest.26 But the Liberal Party at this time could never quite bear to go far enough in endorsing the national collectivist principles for a minimum wage, health, welfare, housing, and environmental reforms that this predominantly northern and midland working class was increasingly becoming convinced it had the right to demand. Consequently, the Liberal Party could not stave off the rise of the northern proletariat’s own Labour Party after 1918 following the enfranchisement of all working men.27 Nevertheless Labour’s rise to power was remarkably slow and it was not until the first majority Labour government came to power— and even then only in the special political and ideological circumstances of 1945—that fully collectivist national solutions to the long-standing problems of the laboring poor’s material deprivations and health problems were really put into operation. Only now were the riches and wealth of the South put into a common pot to fund services for all the population. In 1945 the nation opted in. This new collectivist solution to poverty and health inequalities depended on several structural elements. First was a national government and Treasury officials committed to running a full-employment policy with the assent of the nation’s bankers in the City of London. These were the high priests of the alternative priority of low inflation,

358

Health and Wealth

Table 10.4: Electorate of England and Wales, 1831–1969 Date

Size

Percentage of Population

1831 1832 1866 1867 1885 1917 1918

435,000 700,000 1 million 2 million 4.4 million 8 million 21.5 million

1928 1969

30 million* 39 million

10% adult males (0% females) 20% adult males (0% f ) 17% adult males (0% f ) 33% adult males (0% f ) 66% adult males (0% f ) 62% adult males (0% f ) 100% adult males > age 21 50% adult females > age 21 100% adults (m & f ) > age 21 100% adults (m & f ) > age 18

Sources: C. Cook and J. Stevenson, Longman Handbook of Modern British History 1714–1980 (London: Longman, 1983); Cook and Stevenson, Longman Companion to Britain Since 1945 (London: Longman, 1996).

which had historically dominated government and orthodox economic thinking throughout the pre-Keynesian era in the form of adherence to the gold standard. Second was a range of universal free social and health services, especially the National Health Service (NHS) itself of course, but also noncontributory child allowances (the Family Allowance), universal national insurance against unemployment, sickness, and disability, a universal state pension, and universal education provision to secondary level.The third element was a national consensus accepting that a markedly progressive fiscal regime was morally legitimate. This factor was vitally important in guaranteeing the financial underpinning, as the range and quality of public services was significantly raised over the next two decades to improve the living standards of the poor. Finally, the fourth, crucial enabling element was the universally acknowledged “social leveling” experience of the war. This was the widely attested fact that through a variety of wartime experiences— service in the armed services, “Dad’s Army,” and the numerous other home-front activities such as the Land Army, the ARP, and the women’s armed services, along with evacuation (dispersal of working-class urban children), the necessary welcoming of large numbers of foreigners as

Health, Class, Place, and Politics

359

allies (such as Polish airmen and, later, American GIs), right into their communities, and the common cause in grieving together and following together the course of an uncertain war—the barriers of class antipathy went into abeyance for the best part of a decade.28 This happened because the classes shared informal space and place in all these activities to an unprecedented extent, permitting sympathy and respect to grow between social groups previously content to know each other only through distance-preserving formalities and class stereotypes. These are precisely the kind of extensive relationships of understanding and respect, bridging across different parts of society, whose existence or absence is emphasized as being so important in the social capital literature.29

The Gradual Return to the Politics of Opting Out: Britain Since 1945 How and why, then, has all this apparently changed once again just a generation or so later? As Table 10.4 confirms, there has been no significant turning back or restriction of the franchise.Yet a society with full representation for the northern and midland working class, which committed itself to the principle of opting in during the 1940s, had apparently, just over three decades later, voted positively for a sequence of British governments from 1979 until 1992, whose explicit policies were clearly aimed at overturning the postwar settlement of the Attlee Labour Government and returning British state policy to the ideology of opting out, which had primarily suited the interests of a nondemocratic, petty bourgeois minority electorate during the mid-nineteenth century. How can this be explained in terms of the interpretation offered here? The principal explanation I can offer is that of historical irony, or unintended consequences, one of the most powerful forms of causation known to historians. This is to invoke the paradox of the self-defeating successes of the Beveridge/Labour welfare state of the 1940s. But before spelling out this argument, it is first necessary to discuss three sets of arguments in the literature that would seem to question the premise of this thesis.

360

Health and Wealth

It has become commonplace to question the achievements of the postwar welfare state on a number of related grounds: first, that poverty was still found to be surprisingly persistent in Britain in the mid-1960s and into the early 1970s, even before the historic abandonment of the full employment commitment in 1976;30 second, that the only significant long-term redistribution of income achieved after 1945 was from the top 10 percent to the next 40 percent;31 third, that class differentials in health were found to be as pronounced in the 1970s as they had been during the 1920s—the disturbing allegations that had originally prompted the Labour Government in 1977 to commission the Black Report.32 However, these reservations, important though they undoubtedly are, do need to be interpreted within a balanced historical perspective. The observation that poverty still existed after a quarter-century of the welfare state does not ask how much poverty was removed by the welfare state? Instead, it focuses on a shortfall against the implicit standard of complete removal of all significant poverty. In fact, in reducing the proportion of the population living in households whose income was less than half of the national average to just 10 percent by 1961, the postwar British welfare State did as well as most of its western peers.33 Similarly, the statistic relating to redistribution of income ignores, first, the importance of full employment and the underpinning of psychological and existential security that this gave to the lives of the laboring poor for the first time in living memory. Insecurity and irregularity of income was as devastating to the working-class standard of living throughout the previous century-and-a-half as was the lowness of wage levels. Second, the statistic takes no account of the value of the important services in kind that the state now provided free for wage-earning families, notably health and secondary education. Contrary to these negative views, two measures of what was positively achieved indicate substantial absolute gains (including for the poorest among the working class) during the three decades after 1945. First, it needs to be remembered that the real poor throughout the late nineteenth century and the first half of the twentieth century were the hundreds of thousands of families, running into millions in the 1930s (and, sadly, once again in the 1980s and 1990s), where the family’s principal breadwinner was persistently unemployed or underemployed.The very fact that all-but-normal frictional unemployment for adult males

Health, Class, Place, and Politics

361

ceased to exist for nearly three decades after 1945 necessarily meant that poverty and insecurity were much reduced for working-class families. It means, for instance, that the doubling in the national average real wage, 1945–75, actually corresponded, more or less, to a doubling in the real wages of the households of the very poor as well as everybody else.34 The poor were now in the labor market, whereas for any period before 1940 (or since 1975) it has been precisely their marginal contact with the labor market that has constituted the principal structural cause of the poverty of the poor: if you’re not in the labor market you can’t share in the rising real wages of the majority of the population who are in work. Second, a direct measure of the impact of full employment and the welfare state on the working poor is provided by the study by Rowntree and Lavers, who were able to compare incomes and living standards in the town of York in 1899, 1936, and 1950. Rowntree had found in York in 1936 that almost 30 percent of working-class families were still at that time living under his not very generously drawn poverty line, the same percentage that he had found in 1899; and that there was still a 31 percent unemployment rate in the town. But in 1950 Rowntree and Lavers found only 4.6 percent of working-class families below the poverty line and only a 3 percent unemployment rate.35 In fact recent research has suggested that the strength of these findings for the immediate postwar improvement may have been somewhat overestimated, but even this revisionist analysis of the methodology of Rowntree and Lavers still concludes that the incidence of poverty had been reduced by two-thirds in York by 1950 relative to its 1936 level, a phenomenal and historic reduction considering the almost complete absence of net improvement over the several decades from 1899 to 1936.36 As for the third set of reservations, the literature on health inequalities is technically complex and difficult to interpret with any certainty.37 It also raises similar issues regarding balanced historical judgments over the significance and implications of absolute, as against relative, gains for the poorer and richer halves of the populace. Just as in the case of absolute income and material living standards, the three decades after 1945 saw substantial absolute health gains for the working class as a whole, in common with the rest of the population, reflected in rising life expectancy at birth. However, it seems probable that most of the health

362

Health and Wealth

gains for the working class came primarily from improved infant survival and early childhood health. By contrast, the age-specific death-rates of adults of working age of both sexes have shown much less improvement than those of the middle classes, and many analysts have even shown deteriorations in the rates at these ages. However, the disease-specific nature of the poor health record of the adult working class in this period points to a complex causation, whose implications for our judgment of the overall experience of the working class during the three decades after 1945 are far from straightforward. The principal causes of death from which adults in the working classes suffered disproportionately—and even increasingly—were coronary heart disease, lung cancer, accident, and suicide. These represent a combination of diseases precipitated by “stress,” meaning both the kind of difficult home and neighborhood relationships (including a lack of them) studied by Brown and Harris in their classic Social Origins of Depression, and also the more specific meaning of workplace lack of control over tasks and destiny, studied by Marmot and Shipley in their “Whitehall Study.”38 But there is also a distinct possibility that the increased material affluence of the working poor is implicated, via the capacity to consume more alcohol and cigarettes as a response to stress.This would, at least, remove one apparently obvious contradiction between, on the one hand, the thesis of reduced poverty for several decades after 1945, which also appears to be confirmed in the improved health of the working-class young, and, on the other hand, the epidemiological findings showing poor and even worsening adult health. Thus I would argue that, despite continuing health problems for adults of both sexes, the postwar settlement was correctly perceived by the majority of the working class as having had a remarkably positive impact on the reduction of absolute poverty, mortality, and the experience of chronic income insecurity in Britain.This may well have been of more sociopolitical significance in influencing popular political attitudes and expectations than the welfare state’s apparent failure to redress relative income differentials and health inequalities.The latter are the issues that have, understandably, detained many academic and sociologically informed analysts. But these were obscure and irrelevant matters in the eyes of a populace experiencing improvement in their own terms. Harold Macmillan’s election-winning phrase “You’ve never had it so good” did not ring hollow to the electorate in 1959 and his government

Health, Class, Place, and Politics

363

was reelected. It was in this sense, then, that the success of the welfare state and a full-employment, planned economy was paradoxically conducive to producing the political conditions for its own future demise, in the form of a more comfortable working class no longer perceiving itself and its interests to be those of “the poor.” The historic creation of a mass electorate does not, therefore, guarantee automatically that the interests of the poor and very poor shall continue to be given a high priority in a liberal democracy in perpetuity. It is certainly likely that policies will have to be formulated to benefit the poor if the majority of the nation’s voters actively perceive themselves and their interests to be those of the poor (Marx’s crucial point about the importance of the self-consciousness of the underprivileged for their capacity to express their true political interests). This more or less corresponded to the situation in Britain for two generations after the electoral reforms of 1867–84. But what if the majority of voters in a liberal democracy cease to be numbered among the poor, or at least cease to see themselves and their interests in this way? Just such a sense of relative comfort and modest affluence became a dominant and secure self-perception among the majority of the working class during the two decades following the end of World War II—not because they were affluent and comfortable by middle-class or by subsequent standards but by their own standards, whose reference point was the preceding quarter-century and beyond. The interwar years, for all their gradual improvements in the average standard of living for those in work (in the South and Midlands) were far too fraught with industrial unrest and job insecurity for such a general development in proletarian attitudes. But for the postwar generation a world of dependable wages and steadily rising affluence produced, after a further two decades, a politically malleable complacency that no longer heeded the importance of the once-novel Beveridgean and Keynesian structures supporting that reliable prosperity.The affluent nation arrived during the 1950s and 1960s quite specifically as a consequence of the measures put in place by the postwar settlement, notably the commitment to full employment and all that followed from it, along with increasing funding for public services. Hence, the most acute sociologists of that period discussed the “embourgeoisement” of the British workingclass and researched the political preferences of “the affluent worker” to

364

Health and Wealth

explain the phenomenon of three successive election victories by the Conservative Party during the 1950s.39 This lasting relief from poverty and insecurity of income for the overwhelming majority of the working class became, eventually, a necessary condition for the subsequent abandonment of electoral support for the ambitious, “opting in” model of the welfare state. In the 1950s it would still have been electoral suicide for the Conservative Party to ignore the electoral arithmetic of all-too-recent proletarian memories and to have attacked the structural underpinnings of the working class’s nascent sense of material security. But by the end of the 1970s, it was no longer clear that the interests of the majority of working-class voters were more or less the same as those of the poor.With over three decades of gradual leveling-up and narrowing income equality now behind them, due to strong labor unions bargaining in a tight labor market, the majority of those undertaking manual work were now sufficiently well paid that they were taxpayers, ratepayers, and also aspiring home-owners (something keenly observed by the Conservative Party in the late 1970s but not sufficiently grasped by Labour). Once again, therefore, as in the mid-nineteenth century after the 1830s reforms enfranchised the nation’s petty bourgeoisie, the center of gravity of political self-interest within the voting majority had potentially swung back to this constituency of opinion, the small property-holder.Those on the right of the Conservative Party appreciated that if only the appropriate political arguments and rhetoric could be found, this property-holding and aspirational section of working-class voters could be persuaded to see their interests as distinct from those of the poor, and then the postwar national collectivist consensus on the welfare state and all that went with it, including a progressive tax system, could be brought into question electorally. Opting out of collective provision would once more become the dominant ideology. It was in this context during the early 1970s that Sir Keith Joseph first convinced himself that unemployment had never really been the problem it had been portrayed as, and then went on to put forward the insidious proposition that since there was no more “poverty” in affluent Britain, the interfering, expensive, and bureaucratic “nanny state” could now safely be rolled back and tucked away as an item of history.40 As history since 1979 has amply proven, this sciolistic reasoning contained an

Health, Class, Place, and Politics

365

egregious fallacy: its ignoring of the fact that the maintenance of low levels of poverty was entirely dependent on the continuation of all the machinery of the historic state commitment to full employment and to the provision of substantial welfare services. Once these were dismantled, absolute poverty and health inequalities would be all too likely to reappear. A perfect experiment, one might almost conclude, has been conducted over the last two decades, verifying this prediction.While the record of the postwar Labour government’s welfare state has been impugned by its left-wing critics for succeeding only in removing absolute, not relative, income and health inequalities, the alarming effects of its dismantling has at least proved that it certainly was responsible for achieving that much. Britain has once again, during the last twenty years, become a society prepared to countenance mass unemployment and the persistent disconnection from the labor market of a substantial underclass. A large enough proportion of the electorate has been prepared for two decades to support once again a government endorsing the politics and ideology that historically suited the strategic interests of the communities of affluence: that of opting out of proper collective national provision for the plight of the less fortunate, the low paid and the unemployed, and replacing this with local and private self-provision only. As always, the changed principles of national fiscal policy express this altered climate of opinion precisely. Thus, the proportion of the nation’s wealth, taken in taxes of all kinds, which provide the principal funds to support the poor, showed no net increase over the last two decades of the twentieth century, even though there was a rise in the burden of need because of mass unemployment, a larger proportion of the population, especially children, below the poverty line than in the late 1970s, and a higher proportion of the dependent elderly in the population. Furthermore, with the progressive principle of taxation much attenuated by the Thatcher government during the 1980s, a much greater proportion of government revenue was raised through VAT’s indirect taxes, which take disproportionately from the poor themselves.41 In fact, the exclusive, primary commitment of the national government to maintaining full employment, the top priority for the interests of labor, was originally repudiated in acknowledgment of the competing claims of a commitment to controlling inflation—the top

366

Health and Wealth

priority for the interests of capital—by a Labour government in the mid-1970s, at the insistence of the IMF in the sequelae to the oil crisis that exposed the British economy’s structural weaknesses. But it was the completeness of the repudiation of the principle under the ensuing Conservative governments of Mrs.Thatcher that undoubtedly wreaked the greatest damage on Britain’s poor, thereby contributing to the reestablishment of levels of income and wealth inequality not seen since before World War II, along with all the associated patterns of class-differential inequalities in health. As a result, then, of the abandonment of Beveridge’s full-employment principle and, especially, of the absolute moral commitment to the material and social security of poor communities that this principle directly implied—along with the corollary of a return to the promotion of the political ideology of privacy, individualism, and opting out—Britain by the early 1990s had already become a society in which about one-quarter of the population lived in households on or below the level of income support benefit (13.7 million in 1992, equal to 24 percent of the population, almost a doubling since 1979, when 7.7 million were so classified, equal to 14 percent of the population at that time).42 Meanwhile core public services in kind, from which the poor benefit disproportionately, such as state education, were allowed to suffer real cuts in funding. Government expenditure on education, once the rising salaries of staff have been taken into account, experienced negative real “growth” of as much as minus 0.5 percent per annum during the whole decade from 1979 to 1990, mainly accounted for by the removal of 50,000 teachers from the workforce in this sector, a 10 percent cut in staff levels.43 It may have been a defensible government policy to permit the demise of some of Britain’s oldest-established industries if they could not be rendered internationally profitable. But this was allowed to occur by a government that also absolved itself of any responsibility for the enormous social consequences that were bound to flow from creating geographically intense redundancy on such a scale. Committed by the early 1980s, for doctrinaire reasons, to policies of low taxation and minimal government intervention in the hallowed arena of the free market, the Thatcher governments, clothed in a self-righteous ideology, had no interest in investing their energies in devising the enormous and

Health, Class, Place, and Politics

367

multifaceted sets of programs that would have been required to assist the many affected areas to make their transitions from old to new forms of employment. The social infernos created by exposure to the free market in this way were simply left to burn and, as a result, the human embers are still glowing and consuming their victims twenty years later, as the geographical health inequality statistics and rising social exclusion of the last two decades show.44 Politicians and the dialectical conflict of competing political ideologies, reflecting upon Britain’s changing position in the world, must, then, play a major role in the ultimate explanation for recent trends in health inequalities. But the return since the late 1970s to the political ideology of opting out of collective provision, with all its social and health consequences for the poor, is at least partly accounted for also by the continuing influence of the underlying relationships of class and place in British society.The baleful interaction of class and place was not permanently weakened by the interlude of the 1940s when the nation’s classes learned to talk to each other for a while. Class distance returned because its pervasive influence and the importance of dealing with it had never really been appreciated by the designers of the 1940s welfare state, who were themselves shot through with profound class prejudices, albeit of a relatively benevolent and paternalistic form. During the 1970s, when the ideological vanguard of the New Right was beginning to talk openly of dismantling the welfare state, at the other end of the political spectrum many of the supporters and proponents of collective provision were coming to fully realize that much was fundamentally outdated, deficient, and requiring radical reform in both the vision and the implementation of the British welfare state. This was, after all, a strong part of the motivation behind the commissioning of Sir Douglas Black’s report, and ideas for solutions featured prominently in the report’s conclusions.

The Missing Link in Britain’s Postwar Welfare State:The Failure to Develop Social Capital The common denominator behind most of these deficiencies lay in the centralist, class-biased paternalism of the welfare state’s 1940s design.

368

Health and Wealth

For instance William Beveridge, the Whitehall mandarin who was the welfare state’s liberal, patrician architect, had assumed male breadwinner families to be a uniform norm for all social services and welfare measures, thus rendering it increasingly obsolete in many respects by the end of the 1960s, when single-parent families, female breadwinners and dual earners out of choice were already beginning to become commonplace.45 The NHS quickly came to be run too much by and for the highly educated, medical professionals, particularly the predominantly publicschool-educated, mainly male hospital consultants, the profession’s elite; and without a recognized place for patients’ rights, this resulted in poor levels of accessibility for the less articulate sections of the community.46 Most significant of all, for the long-term patterns of the politics of opting in and opting out and the relationship of this to the evolution of social class and social capital in postwar Britain, was the 1944 Butler Act. This act carefully adapted the nation’s educational institutions to preserve their fundamental divisiveness for a further generation. Butler finally delivered the long-awaited universal free secondary education to the working class, but on the condition that the vast majority received a very definitely third-class and segregated form of such secondary education.47 Equally crucial to the Butler Act’s consequences for social capital was the preservation of a socially exclusionary enclave of private education, where old wealth could continue to absorb new on its own terms and so safely reproduce itself in relative seclusion from the less privileged remainder of society (the great majority of “public schools” have always been located in the south of England, the regional heartland of old wealth, as we have seen). It has been argued at length, elsewhere, that the characteristics of a nation’s education system are fundamental to its long-term capacity to generate extensive social capital.48 Extensive social capital refers to a widespread state of mutual respect among the members of a nation, synonymous with recent formulations of the virtues of citizenship.49 Extensive social capital underpins any long-term ideological commitment to the politics of “opting in.” It is a politically achieved state, which results in social relationships being characterized by a general consensus of shared affirmation of the value of ethnic, cultural, and personal diversity. This explicit recognition of—and positive moral commitment to—diversity among the members of a society is the essential premise for the possibil-

Health, Class, Place, and Politics

369

ity of establishing the relationships of trust and generalized reciprocity that, in turn, permit the valuable and useful “opting-in” practices of bridging and linking social capital to be pursued throughout society.50 A national educational system that socializes its future citizens in socially exclusionary institutions, that so separates the wealthy from both “the middle” and the rest that they even have a quite different and distinctive accent, is quite antithetical to the formation of extensive social capital, building and reproducing instead a form of social apartheid.51 The social logic of such exclusionary relationships will inevitably infuse the whole society, not merely the elite, and so Britain after 1944 returned, within a generation, to the politics of “opting out.” Of further particular relevance to this chapter’s concerns, it should be noted that the geography of class and poverty was perpetuated after the war. Ambitious and idealistic forms of postwar town planning were soon subverted. The bombed capital and its whole hinterland in the South benefited from the immediate implementation of Abercrombie’s visionary Greater London Plan of 1944, resulting in fourteen wellplanned new towns carefully designed to promote civic life, such as Stevenage and Hemel Hempstead.52 But even these new towns were never popular with the home-owning middle classes. Elsewhere, in the North and Midlands and in inner London, the social divides between home-owners and council tenants became even more pronounced as a result of the kind of new homes being built for the working classes by a patrician government. The long sequence of Tory governments, from 1951 to 1964, sincerely kept faith with its targets of 300,000 new homes per annum, but at the cost of sacrificing quality of the built environment. Multistory blocks and low-cost estates were constructed and were then, in the 1960s, joined by tower blocks—all of these now hemmed in and socially segregated by an overlaid network of urban motorways and link roads crisscrossing the larger cities as they attempted to come to terms with rapidly rising car ownership and suburban sprawl.53 During the 1970s and 1980s, the more affluent and mobile among the working classes moved out of these already-aging estates and tower blocks.Then, just as the contemporary problems of lack of local employment began to become manifest, cash-strapped local authorities—due to centrally imposed restrictions presented as “efficiency savings”—were forced to reduce “wasteful” public transport and the range of public services on

370

Health and Wealth

these council estates (see Table 10.1 on the marked reduction in local government expenditure after 1979). Many families found they could not move out, especially once the massive structural unemployment catastrophes of the 1980s arrived, rendering redundant the skills of entire local workforces and producing mass unemployment as an affliction of whole regions of the nation. After two successive decades of the politics and policies of neglect of the marginal and the poor, many of these estates have now transmuted into geographically segregated, social pariah groups.These are the populations of Britain’s 2,000 large “unpopular,” predominantly councilowned, housing estates, where over half a million households live in socioeconomic ghettos for the unemployed.54 Here are manifest in a concentrated and, frankly, frightening form crime, violence, and all the complex of associated social problems resulting from a situation in which a parental generation has lacked a reliable economic basis to establish its status and authority, thereby simultaneously depriving a younger generation of positive role models who demonstrate the value of legal ways of life.55 Several scores of these estates of concentrated deprivation are, indeed, to be found in the South. Most large cities have some and London is certainly no exception; they also occur in such unlikely “middle England” towns as Oxford and Aylesbury. But the most intensive deprivation and the largest numbers of these estates are predominantly found in the many industrial cities and towns of the North, the Midlands and South Wales, where whole communities and districts were put out of work in the savage rationalizations of the 1980s.56 Meanwhile, the majority of voters, aspiring to own their own homes as a safe investment in respectable neighborhoods, do not live anywhere near these estates and do not propose to go anywhere near them if they can possibly help it. They have been encouraged throughout the last two decades to look primarily to their own living standards and their own street’s neighbors as their metric of well-being and of national prosperity, while protecting themselves, through Neighbourhood Watch, from any undesirable overspill from centers of deprivation.The pro-market and antistate, populist, and libertarian ideology of the “New Right” implies that public duty is perfectly well-served by the lawful pursuit of self-interested personal affluence, subject to the rules of the free market. Consequently, citizens such as these may see a role for the state in providing them with a

Health, Class, Place, and Politics

371

few public goods, notably health, policing, and transport facilities, but they see this less as a manifestation of collective commitment to minimal standards of decency for all in the national community, and more as another form of personal consumption, to be “bought” from the government.They look primarily to “efficiency” from government in providing these services, just as they would typically want value for money in any other purchase. The subtext for this is that the affluent majority have been encouraged to believe they have a right to pay less tax if at all possible, with the direct implication (though not necessarily articulated as such, since it would appear too obviously selfish) that spending on the poor should also be reined in wherever feasible. They want to live in the parts of big cities or outside them where the council tax is lowest and where they can opt out of paying for the expensive collective measures required to halt and turn back inner-city decay among their fellow citizens, even though they also want to continue to draw their comfortable livelihoods from those same cities and enjoy the collective entertainment services and leisure facilities that they offer, the consumption of which substantially defines the free market’s offer of the good life. In the terminology of social capital, this corresponds to a surplus of bonding social capital only, among the comfortably-off, and a deficiency of bridging and linking social capital. Thus, the importance of the interaction of class and place, and its capacity either to impede or to encourage mutual understanding and bridging social capital between the nation’s propertied classes and the poor, shows every sign of being perpetuated. It continues to play an important role in setting the context for the competing attractions of politicians appealing to opposed ideologies supporting the logic of opting in or of opting out, just as it has over the last two centuries. History suggests that New Labour’s recent policy innovations in tackling “social exclusion” from the labor market, and in focusing on assisting whole districts (the health and education action zones), though well-intentioned in themselves, will be insufficient. Attempting to apply policies commensurate with the ideas of the importance of bridging and linking social capital but only on an ad hoc basis and in specific localities, while failing to address head-on an antagonistic encompassing popular ideology deficient in extensive social capital, and that therefore favors bonding social capital, personal affluence, and residential seclusion, is unlikely to succeed. Change in the nation’s moral “common sense” is also required, roughly commensurate to, and in the

372

Health and Wealth

opposite direction from, that achieved by the Thatcher governments.To do this, New Labour, its advisors, and its associated think-tanks would need to provide a clear ideological lead, promoting a coherent moral program of opting in, that would provide a positive alternative to the now-aging New Right ideology of the pursuit of private affluence and opting out from collective provision. The most critical battleground here relates to the nation’s disposition and attitudes towards taxation and public services.The burden of the analysis presented here, in terms of social capital, is that the very long-term future of the nation’s health and its capacity to address the persistent classand-place differentials in health will, in fact, depend on addressing the overall architecture of its education system.The influence of this is critical for the socialization of future generations of citizens into either a familiar, informed, and respectful, or else an exclusionary, exclusive, and suspicious disposition towards “others” from different economic and cultural backgrounds. However, in the shorter term, ironically, it may be the interests of citizens at the other end of the age-range who may hold the key to the political parties’ assessments of their political strategies with regard to the issues of taxation and public service. For the most sensitive and weighty electoral constituency may well be the pensioners, a relatively large and growing section of the population that, on the whole, has a definite structural interest in the politics of opting in and that has already, once in its lifetime, had direct experience of the benefits of living in such an era and under such an ethos, and can also remember what Britain was like before 1945.

Notes 1. Probably the most sophisticated methodology that has been applied to official data purporting to record historical trends in social class differentials in health has been Pamuk (1985). For the most important recent analysis of official data, see Drever and Whitehead (1997). The literature is enormous and continues to grow fast, commensurate with the importance and the intriguingly complex nature of the subject.The most convenient introduction to the subject’s recent history is the second edition of Black (1992), which includes both the 1980 government-commissioned Black Report and Whitehead (1987). The most recent officially sponsored initiative has been Acheson (1998). For an extensive critical response to this report and its recommendations, see Davey Smith, Dorling, and Gordon (1999).

Health, Class, Place, and Politics

373

2.The important work of Richard Wilkinson has been seminal in stimulating enquiry into the relationships between health inequalities and social capital, particularly in the U.S. and U.K.:Wilkinson (1996); and see Journal of Epidemiology and Community Health 54 (2000), 401–11, for important recent statements in the debate, including references to the extensive literature. On the development of the concept of social capital, see Portes (1998);Woolcock (1998). 3. For a well-informed review of the historical sources available and an attempt to construct some indicators for the nineteenth century, see Woods and Williams (1995). 4. See chap. 8, this volume; Szreter (1996), chap.2. 5. Szreter (1986). 6. Szreter (1984b) and Szreter (1996), ch.5. 7. Szreter (1993). 8. Hamlin (1998). 9. Hanley (2002); and see Szreter (1996), 80, 122, 236; and Chadwick (1965), sec. 4, esp. 219–34. 10. Chap. 7, this volume, 221; Prest (1990). 11.This volume, chapter 7, 218. 12. For general accounts of the history of public health in this period, see Smith (1979);Wohl (1983); Hardy (1993); Eyler (1997); Hardy (2001). 13. Hennock (1963); Davis and Tanner (1996). 14. Davidoff and Hall (1987). 15. Dyos and Reeder (1973), esp. 369; Anderson (1971); Pooley and D’Cruze (1994); Pooley and Turnbull (1998). 16. On the concept of “voice” and its relationship to the notions of “opting in” and “opting out,” see the important work of Hirschman (1970). 17. Wohl (1977), 109–40, 250–82; Eyler (1997), 72–84; Goschl (1999), chap.7. 18. Garrett, Reid, Schurer and Szreter (2001), chap.4. 19. The thirteen places are: Abergavenny, Axminster, Banbury, Bethnal Green, Bolton, Earsdon, Morland, Pinner, Saffron Walden, Stoke-on-Trent, Swansea,Walthamstow, and York. 20. For statistical definitions of the four kinds of “environment” see Garrett et al. (2001), sec. 3.5. 21. For a study presenting evidence for the voting patterns in the 1980s and 1990s that confirms the influence of this regional division of political interests and its relationship to the continuing health divide, see Davey Smith and Dorling (1996). 22.Webb (1890), 116–17. 23. Hennock (1973); Briggs (1963); Pennybacker (1995). 24.Titmuss (1950); Semmel (1960); Searle (1971). 25. Population figures for counties in 1701 from Deane and Cole (1969), table 24; county figures for 1851 from Mitchell and Deane (1962), 20–21.

374

Health and Wealth

26. Hay (1983). 27. Searle (1992). 28. On various aspects of this, see for instance Zamoyski (1995); Stone (1998). 29. Bridging social capital is socially inclusive, and refers to the norms of trust achieved between citizens despite their acknowledged differences and lack of common upbringing. Bonding social capital is socially exclusive and refers to the relationships of trust between those recognizing an aspect of shared social identity and personal interest. On bonding and bridging see Putnam (2000), 22–23. 30.Townsend and Abel-Smith (1965). 31. Johnson (1994), 304. 32. See note 1, above. 33. Acheson (1998), Part I, Introduction. 34. Pollard (1992), 218, 272. 35. Rowntree and Lavers (1951), 30–31. 36. Hatton and Bailey (2000), esp. 536. 37. For a judicious summary, upon which this paragraph is based, see Whitehead (1987). See also note 1 and Pamuk (1985). 38. Brown and Harris (1978); Marmot (1986). 39. Goldthorpe, Lockwood, Bechofer, and Platt (1968–69). 40. On Keith Joseph’s personal rediscovery of the traditional priorities of the Right—low inflation and low taxes—see Timmins (1996), 356–57. The imprecision of language permits poverty to be assigned a number of meanings, notably “absolute poverty,” which is close to the notion of destitution, and relative poverty or deprivation, which draws attention to the importance of the social and civic disabilities suffered by the personhood of the poor.The moral philosopher and economist Amartya Sen has offered the most important conceptual developments of the latter approach, within a liberal intellectual framework. For a recent summary of his approach, focusing on the relationship between entitlements, functionings, and capabilities, see Sen (1999). 41. Hills (1996), 72, 78, 81–82. 42. Oppenheim and Harker (1996). See also Gordon, Adelman, Ashworth, Bradshaw, Levitas, Middleton, Pantazis, Patsios, Payne, Townsend, and Williams (2000). 43. Rowthorn (1992), 268–69; Szreter (1997), 99. 44. See work by Davey Smith and Dorling cited in notes 1 and 21. 45.Wilson (1977). 46. Illich (1975); McKeown (1979). 47. Banks (1955) was the classic critique of the system established by the Butler Act and a founding text in the sociology of education. Tawney (1922) had originally raised the clarion call for “Secondary education for all.” 48. Szreter (2000). 49. See in particular Lister (1998); and more generally, Lister (1997).

Health, Class, Place, and Politics

375

50. On bonding and bridging social capital see n. 29 above. Linking social capital relates to the trust-based relationships of exchange that can be established between parties who know themselves to be unequal in their access to resources but are nevertheless endeavoring to achieve a mutually agreed beneficial goal on a basis of trust, respect, and equality of status. See Woolcock (2000), 197–212; Szreter (2002); and chap. 11, this volume. 51. The term used to describe the British education system in Adonis and Pollard (1997), chap.2. 52. Meller (1997), 70–74. 53. Ibid., 78–83. 54. Power (1996), esp. 1538. 55. For a graphic tour de force of investigative journalism documenting the social and human consequences in the mid-1990s, see Davies (1997). See also Gowdridge,Williams, and Wynn (1997) and, for an arresting comparison with the plight of a similar section of the populace three-quarters of a century before, see Llewellyn Davies (1915; 1984). 56.The Cabinet Office (1998) found that the highest concentrations of deprivation in England (excluding Wales) were located in seventeen of the London boroughs but no other places in the south. The twenty-seven other local authorities containing high deprivation districts were all in the North and Midlands, including all of the major population centers from Newcastle in the north to Coventry and Leicester in the Midlands, from Blackpool on the west coast to Hull on the east coast.

11 HEALTH BY ASSOCIATION? Social Capital, Social Theory, and the Political Economy of Public Health*

In the ongoing quest to improve our understanding of the conditions that make for improved public health and wellbeing, scholars, practitioners, and policymakers have recently returned in earnest to a theme with a long and distinguished history in the social sciences—namely, following Durkheim, the importance of social circumstances in shaping the quality of life one enjoys.1 This has been fueled in part by the indifferent performance of a series of high-profile public service delivery reforms, the widening rhetorical appeal of communitarian and neo-liberal policy discourse,2 and a growing recognition that ever-more sophisticated medical interventions and media campaigns have had a disappointing impact on

* This chapter, coauthored with Michael Woolcock, is slightly revised from its original publication in International Journal of Epidemiology 33 (2004).

376

Health by Association? Social Capital, Social Theory

377

some of society’s most persistent social ills (e.g., smoking, depression, teen pregnancy). Within the public health field, these failures of policy have increasingly focused attention on the limitations of a narrowly “individualist” approach to population health, associated with the rise of clinical epidemiology during the postwar era.3 The debate, reviewed below, has centered on the persistence of health inequalities in affluent societies, and the extent to which more effective research and policies should prioritize the psychological experience of individuals and their relationships to others in their community and society, or the material deprivations due to overall economic structures and national political choices. All sides in this debate have deployed the idea of social capital in support of their particular claims, in the process encapsulating many of the (inherent) conceptual ambiguities, dilemmas, and concerns surrounding the term in general. Identifying the nature and extent of the impact of social relationships—generally referred to as “social capital,” following the influential work of Robert Putnam4—has become a veritable cottage industry across the social sciences. Scholars have documented the importance of social capital in fields ranging from economic development and government performance to criminal activity and youth behavior,5 but “in none is the importance of social connectedness so well established as in the case of health and well-being.”6 General guides to how the concept of social capital has been applied to various health issues can be found elsewhere.7 In this chapter we wish to focus instead on (a) the analytical and political controversies that surround this literature, in particular the emerging divide between those focusing on the primacy of (1) support networks, (2) economic and social inequality, and (3) access to resources for explaining health outcomes; and (b) the contemporary policy lessons for public health emerging from both historical studies of public health issues and the broader theoretical and empirical debates in the (ever-expanding) field of social capital research. Our central thesis is that it is desirable and possible to reconcile the controversies surrounding social capital as it applies to issues in public health, but that doing so requires incorporating empirical and conceptual insights from history and the broader social capital literature. Importantly, all camps in the field of public health generally agree that social capital “matters” in some basic sense—unlike in, say, the field of

378

Health and Wealth

economic development, where selected critics paint it as a politically vapid distraction, and argue for its abandonment.8 Most participants also agree that, while imperfect, efforts should be (and indeed have been) made to resolve lingering disputes on the basis of the empirical evidence. Even so, however, with highly provocative summary claims such as those by Putnam—”If you smoke and belong to no groups, it’s a toss-up statistically whether you should stop smoking or start joining”9 (drawing on James House et al.,10 Lisa Berkman,11 and Teresa Seeman,12 but see also Lynch, Davey Smith et al.13)—it is not hard to see why the idea of social capital has generated both acclaim and disdain in the field of public health.14 While taking the critics seriously, we believe social capital, properly understood, can indeed make a significant contribution to public health theory, research, and policy. The chapter proceeds as follows. The first section explores the current terms of the debate between three emergent camps in the field of social capital and public health, and seeks to provide an analytical basis for discriminating between them.The second section outlines a theoretical framework for reconciling the different views. The next provides a historical perspective on a key set of public health concerns from nineteenth-century Britain, demonstrating both the efficacy of the theoretical framework and the more general importance of incorporating historical insights into contemporary policy debates. The fourth section discusses the significance of these arguments for social capital theory and public health.The concluding section offers a brief summary of the policy implications for public health arising from both the analysis presented and the broader social capital literature.

Rival Views of Social Capital and Public Health In the past few years there has been an intensive exchange in the journals and at conferences among several of the leading figures in the field of public health and epidemiology over the concept of “social capital.”15 Social capital has entered these fields principally through the work of two individuals, namely Robert Putnam—whose seminal 1993 book on regional government in Italy, Making Democracy Work,16 drew heavily on (and provided a new empirical base for) social capital theory (but did not

Health by Association? Social Capital, Social Theory

379

itself address public health issues)—and the more directly relevant work of Richard Wilkinson, whose 1996 book, Unhealthy Societies,17 first introduced Putnam’s notion of social capital to the public health field. In addition, Putnam has drawn on, and indirectly contributed to, research on social capital and public health in his most recent study of social capital in the U.S., Bowling Alone, published in 2000.18 Richard Wilkinson, by contrast, has been working for many years19 within the field of comparative epidemiology to further our understanding of the relationship in relatively affluent societies between income inequalities and mortality patterns, and is one of the principal protagonists in the recent debates. The debates generated by these authors have primarily treated “social capital” as if it is a (presumably) more sophisticated formulation of the broader concepts of “social cohesion,”20 “social support,”21 “social integration,”22 or “civil society.”23 Epidemiologists have noted that the term “networks” is often used by the proponents of social capital, and this strikes a familiar note for them with a body of respected empirical literature, dating from Brown and Harris’s path-breaking study, Social Origins of Depression,24 and the Alameda County Study, demonstrating that individual risks from a range of chronic and degenerative conditions, such as myocardial infarctions, are improved where there are good social support networks.25 For the purposes of our present discussion, we call these studies the “social support” school.This is a view of social capital— defined simply as the nature and extent of one’s social relationships and associated norms of reciprocity26—as connected to health outcomes via some variation of a direct social support mechanism.27 The specific research connecting social capital to health outcomes via a social support mechanism is vast. In this sense, social capital has been empirically linked to, among other things, improved child development28 and adolescent well-being,29 increased mental health,30 lower violent crime rates and youth delinquency,31 reduced mortality,32 lower susceptibility to binge drinking,33 depression,34 and loneliness,35 sustained participation in anti-smoking program,36 and higher perceptions of wellbeing37 and selfrated health.38 Where urban neighborhoods and rural communities (and particular sub-populations) are demonstrably low in social capital, residents report higher levels of stress39 and isolation,40 children’s welfare decreases, and there is a reduced capacity to respond to environmental health risks41 and to receive effective public health service interventions.42

380

Health and Wealth

There remain significant ongoing methodological disputes and expressions of skepticism over exactly what this work is demonstrating, particularly in the two central areas of relationships between health measures and both inequality and trust.43 It can be particularly noted that the implications for health and welfare of issues such as trust and reciprocity are likely to be strongly context-dependent. It is entirely commonplace to accept, following Portes,44 that social capital can equally function in both a socially exclusive and an inclusive way, having positive welfare effects for some and negative for others. Kunitz, for example, provides a valuable account of how social capital might be both a part of the problem and a solution to local health problems.45 For this reason, it has been argued that it is still premature (at best) to include social capital measures in official public health surveys.46 Findings have to be interpreted very carefully and certainly cannot necessarily be generalized from one level of aggregation to another. More fully satisfactory evidence and methodologies—such as multilevel modeling and randomized experiments—are still rare in the literature, so that the most recent contributions of Subramanian, Kawachi, and colleagues represent an important advance in this respect.47 But as a general field of research it is hard not to be impressed with the volume and diversity of the empirical evidence indicating that social capital is likely to be a significant determinant of at least some important health outcomes. Furthermore, it is not necessary for social capital to fully explain a vast range of empirical public health outcomes as a precondition for being taken seriously— it would be very useful if it could be carefully linked to just two or three. The issue that animates the academic debates, and that this essay seeks to reconcile, however, is whether social capital is a direct or secondary “cause” of these outcomes—that is, whether changes in the stocks and flows of social capital per se are making significant independent contributions to observed health outcomes, or whether they are merely responding to the changing character of broader political and economic forces. In the mid-1990s, Richard Wilkinson48 led a break from the social support literature, arguing that social capital concerns were relevant to the extent that they were part of the psychosocial effects of widening levels of socioeconomic inequality. He argued that in the handful of most affluent, post-epidemiological transition49 societies (excluding Eastern Europe), where lethal diseases associated with sanitation, infection, and

Health by Association? Social Capital, Social Theory

381

absolute poverty now play only a very small part in determining the overall death rates, significant changes in the degree of socioeconomic inequality have a particularly strong influence over the differentially evolving comparative epidemiology of these populations. He contended that, among the most affluent societies, those which have moved towards more uneven income distributions (most notably a number of liberal market economies such as the U.S. and the U.K. over the last two decades) are characterized by individuals with increased anxiety and declining social support institutions, and by rising levels of violence and disrespect between citizens.This results in poorer population health performances, in terms of national average life-expectancy figures, which fail to improve as much as those of comparable economically advanced societies, such as Canada, Japan, or Sweden, which have not experienced such a degree of widening income inequality and associated decline in civic trust and collective support for social infrastructure.50 Michael Marmot and his colleagues’ long-standing research has been important in identifying a physiological mechanism to explain these results, linking social support with more tractable notions of “stress” such as the absence or loss of autonomy over one’s life-course, or over one’s working or neighborhood environment.51 Prima facie biomedical plausibility for this lies in research showing correlates of such perceptions of stress in states of anxiety and physiological arousal, which result in the enhanced chronic secretion of harmful levels of doses of cortisol, adrenaline, and nor-adrenaline within the body’s neuro-endocrine system.52 Marmot also sees widening absolute and relative inequality as the primary driver of public health outcomes in affluent societies. Wilkinson’s principal critics—John Lynch, George Davey Smith, Carl Muntaner, and their various collaborators53—have argued that inequalities in health are always fundamentally rooted in differences of access to material resources (including housing and relevant neighborhood amenities), which are, in turn, ultimately the product of political and ideological decisions.54 They are concerned that the drift of Wilkinson’s analysis is to support a form of “health transition thinking,” which would deny the significance of the material and the political under advanced economic conditions of affluence. This “transition thinking” would imply that material deprivations are only of significance to health at lower levels of economic development and that, with the withering

382

Health and Wealth

away of “real” (i.e., absolute, survival-threatening) poverty in higherincome societies, only the psychosocial causes remain as significant factors producing health inequalities. This could give succor to the neoliberal position because it appears to imply that such differentials can be fixed “on the cheap” with “social support” and “self-help” networks, without needing to give any serious attention to the more contentious issues of inequalities in ownership of wealth and in distribution of power. In his most substantial response to this critique,Wilkinson55 makes four relevant points in rapid succession: (1) Part of the difficulty with the concept of social capital is that it was borrowed from other disciplines rather than being developed specifically for the health field. (2) No doubt it is a popular concept because it holds out the idea that there are costless ways that poor communities can pull themselves up by their bootstraps. . . . (3) . . . . But an important part of the growing health interest in social capital comes not from ignoring income distribution, but precisely from the opposite direction: from trying to understand why income distribution is important to health. (4) [As such,] the evidence suggests that more egalitarian societies are more cohesive, less violent, more trusting, and foster more involvement in community life.

Moreover, he subsequently added: (5) If we fail to reduce income inequalities, societies will be more likely to show tendencies towards discrimination and victimisation of vulnerable groups. . . . [T]hese dimensions of social reality may have a special salience as determinants of levels of anxiety and physiological arousal in a population. Because members of the same species have all the same needs there is a potential for continuous conflict between them. But . . . human beings can also be the greatest source of [mutual] assistance, [and] support. . . . Similarities between some of the physiological effects of low social status produced under experimental conditions in monkeys and those associated with social status in human beings, suggests that an important part of the social gradient in human health is attributable to the direct effects of social status, rather than to other influences on health like poorer housing, diet and air pollution.

Health by Association? Social Capital, Social Theory

383

Among this sequence of points, we believe that the first is crucial, and will return to it at length later in this article. In fact,Wilkinson’s critics, notably John Lynch, have repeatedly urged this and have cited the wider theoretical literature in their contributions. It is crucial because it is difficult to debate the utility of a fundamentally sociological concept substantively and productively without full reference to its original provenance and its current meaning, as developed in the sociological literature. This requires significant expository work where a concept as potentially powerful, complex, and contentious as social capital is concerned. Wilkinson, in his second point, acknowledges the same political and policy-related dangers identified by Lynch et al. In his third point he comes even closer to the position of his critics, concurring that inequality, of which measures of income distribution form one important index, is highly significant for health outcomes. In his fourth point he endorses the kind of view of the virtues of social capital that Putnam56 developed in his study of differences in institutional performance between Italian regions; this acts as the premise for the key point of difference between the two sides in the epidemiological debate, which emerges from the long, fifth quotation from Wilkinson.This difference is not over whether inequality is highly significant in accounting for class variations in health experience in economically advanced societies, but over the nature of the principal pathways of causation involved. The fifth extract shows that Wilkinson believes that there is something directly psycho-physiological going on, and that this is of prime importance. He believes that the concept of social capital is helpful because it is pointing us towards the source of this biological, evolutionary-programmed health effect, which flows from the relative social cohesiveness (or lack thereof) of a local or a national community. For Wilkinson, the extent to which an affluent society is experienced as either a “hierarchy” or, conversely, a “community of equals” determines the overall extent to which those citizens who find themselves at the bottom of the socioeconomic pecking order will, as a characteristic response, experience states of anxiety and arousal, resulting in longterm damage to their health if this becomes a chronic situation for them. Even in more egalitarian societies, some citizens will inevitably still find themselves in this unfavorable position, possibly for long periods. But this will not necessarily produce the damaging physiological reactions if they

384

Health and Wealth

do not perceive their predicament in the same demeaning and threatening way. It should be noted that this is not a simplistically biological determinist argument, since culturally constructed perceptions play a key role. The physiological mechanism of damage is donated by evolution, but whether or not it is invoked depends crucially on potential victims’ perceptions of their predicament. This in turn depends on whether or not they see themselves as living in a cohesive, egalitarian, social-capital-rich society, or in one that is changing from being more to less egalitarian. It is important to observe, incidentally, that the research on which Wilkinson and others and their critics have so far based most of their claims (and counter-claims) has almost exclusively consisted of statistical comparisons of income inequality measures for national and sub-national populations. However, since it is really perceptions of inequality (and/or lack of opportunity for social mobility) that are at issue, it is arguably a rather different kind of evidence that is truly required to assess the hypothesis. For instance, American society may be very unequal by such income measures and may be fast becoming more unequal.57 However, its citizens’—even its poor citizens’—typical perceptions of the degree of injustice involved in this may be significantly less than that provoked by much smaller absolute increases in income inequality experienced by the inhabitants of another country, which has a strongly established selfimage as an egalitarian society.58 Clearly there must be some correlation between absolute levels or absolute changes of income inequality and perceptions of “hierarchy,” “egalitarianism,” and possibilities for “mobility,”59 but the scope for flexibility in these assessments due to differences in national political cultures and cherished myths—i.e., prior histories and dispositions—should not be underestimated. While Lynch and his colleagues may (or may not) agree that these physiological effects occur in societies that are perceived as unequal, they certainly do not think these effects are anything like as important as the direct health-damaging consequences of what they term the “neo-material” realities of poverty, even in an affluent society. The range of such effects includes poor quality and even dangerous housing, the tendency to be restricted to lower-quality food and clothing, greater exposure to environmental pollutants (including low air quality), higher likelihood of accidents and violence of most kinds, and less likelihood of access to effective medical care when required.

Health by Association? Social Capital, Social Theory

385

The thought naturally occurs to the observer of this debate that both sides have a point. It is certainly the case that if one or the other viewpoint could be shown empirically to be much the more substantial effect, then this would have important and rather different consequences for indicating the priorities that remedial policies should take. In the absence of such compelling evidence, however, it would seem most sensible to assume that both viewpoints could be valid. This might be conducive to the implementation of a superior, third kind of strategy for policy, which could embrace both points of view—indeed, would also embrace the older “social support” view. We will now attempt to arrive at the outline of such a strategy, on the basis of a review and application of social capital theory. It is important to this line of thinking that, despite their dispute with Wilkinson, Lynch et al. remain relatively well disposed to the concept of social capital. They are careful to withhold their approval from many of the narrow policy formulations of social capital that abound (e.g., as being little more than volunteering and charity work); indeed, they are highly critical of it. They insist that the concept has potential value to public health and epidemiology only if properly located within a broad and comprehensive framework, embracing a role for the state and for the motivating role of political ideology. Indeed, we are encouraged that they have cited our work60 in arguing for such a formulation. It seems to us, then, that if the concept of social capital is properly developed and carefully spelled out, it may well provide the means to mediate in this dispute. With the assistance of a more fully elaborated specification of the concept of social capital, the extent of common ground between these positions may then be clarified.

Social Capital and Social Theory Revisited There is a particular need for extended conceptual reflection on social capital as it relates to the public health field because none of the authors who have brought social capital to the attention of epidemiology have themselves been directly involved in developing a detailed theory to locate the concept. Neither Robert Putnam (and his Harvard colleagues) nor Richard Wilkinson—nor, for that matter, John Lynch and his various

386

Health and Wealth

collaborators—have undertaken fundamental theoretical work on the concept. The two seminal social theorists of the late twentieth century who placed social capital in a theoretical context in this way were the French sociologist Pierre Bourdieu61 and the American sociologist James Coleman.62 However, they produced quite distinct formulations during the 1980s, each of which has been highly influential but neither of which is now considered to be a satisfactory or full specification.63 While debate over the concept continues, it seems likely that social capital is destined to become, like “class,” “gender,” and “race,” one of the “essentially contested concepts” of the social sciences.These are concepts that are simply too politically and ideologically important for those at any point on the political spectrum to concede to a definition of the term that they do not see as squaring with their own beliefs, assumptions, and principles. Contested concepts reflect a consensus on the broad nature of the phenomenon they refer to and its great importance, without any agreed-upon closure on the terms of its definition. It now seems likely, after almost a decade of discussion, that “social capital” may join the ranks of the “essentially contested concepts” category. An obvious and enduring point of contention surrounds the very definition of social capital, and, concomitantly, the appropriate unit of analysis to which it should be applied.The narrowest definitions of social capital, not surprisingly, are those of neoclassical economists,64 who regard it as the property of individuals (i.e., their social skills, or capacity to negotiate solutions to joint problems).At the other end of the spectrum, political scientists such as Francis Fukuyama65 have described entire societies as having high or low social capital; empirical cross-country growth research by the economists Stephen Knack and Philip Keefer66 has also been influential in this regard, using data on trust and participation from the World Values Survey to impute social capital scores for whole countries. In between are particular writers who wish to include or exclude additional features such as “norms” and “trust,” and those such as Evans,67 Woolcock,68 and Szreter69 who assign a prominent role to the nature and extent of state: society relations as a necessary part of the theory, if not the actual definition, of social capital. Though contributions across this spectrum abound, the center of gravity in the field as a whole is located far towards the more micro end. This is the realm in which James Coleman pioneered modern research

Health by Association? Social Capital, Social Theory

387

on the topic, and where Putnam continues to lead today. In his most recent formulations, however, Putnam70 has sharply distinguished his position from that of Coleman, who believed that, by definition, social capital could only yield positive outcomes. Putnam’s view, consistent with our own position, and that of Portes,71 is that the purposes to which a given resource can be put should be analytically distinct from how it is defined. Thus knowledge (“human capital”) and technology (“physical capital”) can be put to purposes that most people find thoroughly detestable—for example, building chemical weapons—but this does not, in and of itself, prevent those inputs from still being unambiguously “capital” (or assets). Putnam leans increasingly towards a relatively restricted definition of social capital as the nature and extent of networks and associated norms of reciprocity.72 As such, social capital enables individuals to gain access to resources—ideas, information, money, services, favors—and to have accurate expectations regarding the behavior of others by virtue of their participation in relationships that are themselves the product of networks of association.This occurs as individuals elect to engage in various activities with others in order to pursue their leisure, familial, ethnic, local environmental, or wider political interests. Social capital is thus viewed at a relational level—it is the property of individuals, but only by virtue of their membership in a group.Aggregate measures are thus plausible to the extent that they are summations of responses drawn from an appropriate sample of individuals from a larger population, but, for Putnam, it is only the aggregate per se that “has” social capital. Network scholars73 take a somewhat orthogonal approach, arguing that social capital refers to the resources (e.g., information, social control) that flow through networks, not the network structure itself. In this sense, the “mainstream” social capital literature, represented paradigmatically by the work of Putnam, regards social capital as the “wires” (or social infrastructure) while network theorists regard it as the “electricity” (or social resource).We would want to add that it is crucial to know in what kind of encompassing contexts the networks of wires and their flows of electricity are embedded, particularly with respect to the vertical “topography” of power gradients in society, across which networks may or may not provide links. The idea of social capital has made such an enduring impact on the contemporary academic research and policy agenda largely because of

388

Health and Wealth

the attention it has focused on the role and strength of civic associations. Putnam is particularly worried that there has been a fall-off over the last two or three decades in the propensity of American individuals to join associations and participate together in a range of activities. He attributes this to the lifestyle of the two generations raised since World War II, who have been socialized into suburban sprawl (driveways from the road into garages and no walkways between homes) and long commutes (less time in the neighborhood), the advent of dual careers (and overworking at that), and over-reliance on the television as a (vastly inferior) substitute for local social interaction.74 Putnam is additionally concerned that the kind of social capital that may be proliferating in America today is too often the “wrong” kind.This follows from an important conceptual revision within social capital theory, which occurred in the late 1990s, when the distinction was made between (what are now popularly called) “bonding” and “bridging” social capital.75 It had become apparent that not all networks of association produced norms of trust and confidence between their members that could be said to serve the best interests of the wider community, nor sometimes the best interests of some of those within the network.76 The mafia was an obvious example of this, which Putnam77 had previously dealt with by distinguishing between networks based on “horizontal” egalitarian relations and those that were more “vertical” and hierarchical, with only the former considered to be capable of producing genuine forms of social capital. But more difficult was the case of the dangerously antisocial militia bands of contemporary U.S. society, nominally egalitarian in their associational structure, such as the Oklahoma City bombers. The “bridging” and “bonding” distinction facilitates discrimination between such different kinds of social capital. Bonding social capital refers to trusting and cooperative relations between members of a network who see themselves as being similar, in terms of their shared social identity. Bridging social capital, by contrast, comprises relations of respect and mutuality between people who know that they are not alike in some sociodemographic (or social identity) sense (differing by age, ethnic group, class, etc).The precise nature of the social identity boundaries, and the political salience of bonding and bridging groups are thus highly context-specific. Within the U.S., at least, it then becomes clear that Putnam’s particular concern is the decline of “bridging” social capital.

Health by Association? Social Capital, Social Theory

389

In recent years a further conceptual refinement has been introduced into the social capital literature: “linking” social capital.78 We would define linking social capital as norms of respect and networks of trusting relationships between people who are interacting across explicit, formal, or institutionalized power or authority gradients in society. This refinement seeks to incorporate a distinction among all those social relationships that would otherwise be grouped together in the “bridging” social capital category, namely between those relationships that are indeed acting to “bridge” individuals who are otherwise more or less equal in terms of their status and power (“bridging” is, after all, essentially a horizontal metaphor)—for example, ethnic traders seeking counterparts in overseas markets, participants in artistic activities, or professionals of different nationalities exchanging business cards at international conferences—and those that connect people across explicit “vertical” power differentials, particularly as it pertains to accessing public and private services that can only be delivered through ongoing face-to-face interaction, such as classroom teaching, general practice medicine, and agricultural extension.79 This latter distinction, the “linking” social capital, draws empirical support from a range of studies80 showing that, especially in poor communities, their welfare largely depends on the nature and extent (or lack thereof) of respectful and trusting ties to representatives of formal institutions—for example, bankers, law enforcement officers, social workers, or health care providers. Linking social capital as defined here seeks to introduce a conceptual and empirical distinction as it pertains to individuals’ overall portfolio of social relationships that is demonstrably central to shaping welfare and wellbeing (especially in poor communities). Accordingly, just as health outcomes can be improved by expanding the quality and quantity of bonding social capital (among friends, family, and neighbors) and bridging social capital (trusting relations between those from different demographic and spatial groups), so, too, is it crucial to facilitate the building of linking social capital across power differentials, especially to representatives of institutions responsible for delivering those key services that necessarily entail ongoing, discretionary face-to-face interaction. Linking social capital, it should be added, like bonding and bridging, can also be put to unhappy purposes—for instance, nepotism, corruption, and suppression. To repeat, the definition of social (and any other form

390

Health and Wealth

of ) capital does not turn on the purposes, favorable or otherwise, to which it can be put. In our view social capital must be the property of a group or a network.This is, however, far from clear if the empirical literature on social capital is scrutinized.The reason is that in order to study and, especially, to attempt to measure social capital,81 researchers have tended to develop a methodology that can capture its observable outcomes through individuals’ expressions of degrees of trust in other people. The gathering of information on trusting relationships from individual interviewees has, thus, given the impression that social capital is a property of individuals. Moreover, since another outcome of social capital is that it enables individuals to do things they otherwise could not do, this means that social capital can manifest itself as a resource that individuals can draw on in certain circumstances. Social capital has been measured in many ways: through subjective questions regarding perceptions of trust both general (as popularized through the canonical World Values Survey question and other national surveys) and particular (e.g., politicians, different demographic groups, service providers); through participation rates in local organizations (including the organization’s purpose, demographic composition, and rules governing entry, decision-making, and leadership selection); through the nature and extent of informal or everyday socializing; through sources and forms of social support (both given and received) such as voting rates, access to sources of information and transport routes, political engagement (knowledge of politics, writing to newspapers, protesting/campaigning, running for office); and through various other lenses such as personal efficacy, social cohesion/exclusion, and sources of local-level conflict. Many of the early measures of social capital were derived from secondary sources—that is, from surveys not explicitly designed to measure “social capital.” While obviously imperfect, these attempts nonetheless provided a considerable spur for advancing the subsequent design and funding of primary survey and ethnographic work, a task now being undertaken by groups ranging from local community associations and universities to the OECD and World Bank (and many of their respective member governments).The formal definition of social capital, which we have outlined here, renders it inherently difficult as a subject for precise comparative empirical measurement.82 However, this is to

Health by Association? Social Capital, Social Theory

391

acknowledge no more than that social capital is subject to the same problems that afflict most other important concepts in the social and economic sciences, very few of which can in fact be measured directly and most of which are observed through their imputed effects and outcomes. If social capital is not a property of individuals per se, it is, however, a property of their relations with each other, occupying the abstract sociocultural space of relationships between individuals. One way of envisioning this is as Putnam’s “wires.” However, it has to be remembered that any one of these “wires” connecting any pair of individuals only exists, qua social capital, by virtue of its being part of a larger network of relationships (or wires). Otherwise, the relationship of trust between the two people concerned would be a simple interpersonal dyadic one, carrying no implications for the transitivity or “portability” of their trust in their engagements with other parties in the network. That larger network is crucially premised on its participants having shared norms of reciprocity—and these must be a trans-individual and group property; hence Putnam’s formula that social capital inheres in “networks and norms.” But it is important to think further about what makes those shared norms in a network possible. At one level, this can be explained simply as a form of trust built up by repeated interaction. But one must still ask: might there be crucial preconditions for such interaction to create trusting rather than distrusting relations or indifference? This requires more than just the capacity to communicate via a shared language. For trusting social norms to develop, there needs to be a minimum degree of understanding among the participants in the network in their mutual dealings with one another that they share each other’s goals and purposes, and are working together towards mutually compatible ends.This, in turn, needs to be based upon a shared sense of fairness ( justice in at least a relative sense) and mutual respect. That, in turn, can only be the product of a prior history of political, constitutional, and ideological work to construct the conditions for such a shared sense of fairness to be perceived by those choosing to participate in the network in question.Thus bridging social capital between people who know themselves to be unalike in terms of social identity can only occur spontaneously in a civil society where there already exists a rough and ready approximate equivalence between unalike individuals, in order that these networks, premised on shared norms (despite differences of social identity) can still form.

392

Health and Wealth

Where, however, there are circumstances—sustained by legal institutions (e.g., Jim Crow laws, apartheid), by high economic inequality, by rigid social status differentials (e.g., caste distinctions)—in which not all individuals perceive themselves as enjoying such a rough equivalence, it is entirely unrealistic to expect spontaneous bridging social capital to form between haves and have-nots, or between officials, professionals, or (in less-developed countries) nongovernmental organizations (NGO) and the poor communities they work with, whose compounding disadvantages place them in a position of virtual social isolation.83 In these circumstances, bridging social capital, if it is to exist at all, must be carefully created.The onus in these difficult circumstances is on those with the power and resources to think very carefully about how to create the shared sense of fairness, including mutual respect between all concerned, which is the necessary precondition for shared understandings and group norms of joint goals to emerge and so to create the proliferating networks of trusting relationships between different people, that is, the bridging social capital. Of course, the poor remain active agents, albeit heavily disadvantaged. The initiating push for linking social capital may well still come from the poor themselves, as has been documented, but such studies also show that a sympathetic, skilled response from those in power and authority will be critical, too.84 Social capital created in this way in these difficult circumstances, rather than spontaneously emerging from the (approximately) level playing field of civil society, is a qualitatively different kind, which is what we are calling “linking” social capital. This term reflects the explicit appreciation that it represents relationships of trust between members of a network who know themselves not only to be different in terms of social identity (bridging social capital) but also in terms of their institutionalized endowments of power and resources. Why bother with social capital in these circumstances? Because without attention to the quality of the relationships between those with differential access to power and without paying attention to the need to build extensive transitive networks of respect and trust in such frequently met circumstances, efforts at poverty alleviation, economic development, and service provision to the poor are unlikely to succeed. In the field of health services, in both developing and developed societies alike, this is particularly relevant for the effective implementation of measures to assist the ill, poor, and the “socially excluded.”

Health by Association? Social Capital, Social Theory

393

The three-dimensional approach to conceptualizing the forms of social capital resolves (at least partially) some of the earlier criticisms of social capital theory, especially as it has become manifest in public health and epidemiology. It does so by retaining a relatively parsimonious conceptual and empirical focus (on different types of networks) yet also enables a greater range of important social, economic, and political outcomes (both positive and negative) to be encompassed, while providing a more concrete basis for policy and project responses.We believe it can provide a basis for resolving the disputes between those in the “social support,” “inequality,” and “political economy” camps of social capital and public health, but to do so requires addressing one final theoretical issue, namely the role of the state. As indicated above, for some authors the state itself is part of the definition of social capital (since “societies” are deemed to have social capital properties, and the state is a major component of “society”).This is not our view; the definition of social capital per se should not encompass features of the state.Yet it is impossible to understand how particular networks and social structures are initiated and sustained without reference to the state.The state and its laws are a primary influence upon many of the patterns of association (or lack of them), which students of social capital and public health wish to examine and interpret.This means that while social capital can be empirically studied as if it was merely a phenomenon of civil society (in order to make the job of research manageable and tractable), as Putnam prefers to do, interpreting the findings will remain incomplete, and so can be misleading, without placing them—and the concept of social capital—in an adequate, encompassing theoretical and political context. This requires acknowledgment of the variable relationship between state and society.85 We have each separately emphasized that the nature and extent of the relationship between the state and its citizens is a critical factor in understanding how key outcomes are attained, even though the state is not itself part of the formal definition of social capital.86 This relationship is important, first, in the constitutional sense of the ways in which the state does or does not underwrite equally the entitlements and the capabilities of all citizens, regardless of gender, age, ethnic origins, and creed.87 Second, it is important in the moral sense of the historically contingent disposition, which citizens have towards the larger social

394

Health and Wealth

collective, of which they form a part, which motivates their actions.This disposition can range from outright rejection and hostility or studied indifference to patriotic fervor or blind obedience. Somewhere in the large space between these extremes lies the central range of more healthy, balanced, and mature dispositions, characterized by both informed commitment to a wider society, while retaining independence and liberty, corresponding to Evans’s88 and Woolcock’s89 notion of “embedded autonomy.”90 Third, there is the issue of the state as the appropriate public arbiter of the liberal polity’s collective resources. It is an absolutely essential role of the state in a liberal democratic society with a market economy that it act as the just arbitrator among all the different interest groups and parties who stake a claim to the commonwealth’s collective resources. This is quite simply because some form of redistribution of such resources is necessary to ensure that all, including the temporarily and permanently dependent, the marginal and the unfortunate, are permitted their equal chances to participate to the full in the community’s life; if this task is taken seriously and not performed in a merely token manner, it is an expensive collective undertaking and one that does not get any cheaper as societies become wealthier (and, usually, older). By now it should be clear that the sense in which “the state” is being used here is as much an idea (or set of principles) as a formal institution or agency.91 It is certainly not intended that “the state” be used to denote simply “the central government,” as in “Whitehall” or “Washington,” the bureaucratic caricature beloved of those libertarians who offer the simplistic doctrinaire dichotomies of “the state” versus “civil society” or “the market” in place of serious thought.92 In those societies where “the state” has come to mean only monolithic organs of the center, it has not, ultimately, played a constructive role in its citizens’ lives, as Soviet Moscow discovered to its cost.93 Thus, genuinely devolved and vigorous, elected, local self-government and regional self-government, with these bodies not acting as mere ciphers or transmission lines for centralist policies but as independent, democratic agencies with a high degree of local participation and autonomy, should be conceptualized as a vitally important component of the more complex concept of “the state.”94 This is the form of the state that is found in a society well-endowed with extensive social capital of all three kinds, and (importantly) in which social relations

Health by Association? Social Capital, Social Theory

395

between citizens and representatives of the state are well developed. Britain and America, but also Sweden, have been characterized by fairly well-devolved states of this kind for much of their respective histories.95 What, then, does all this mean for the debate among public health experts and comparative epidemiologists concerning the relationship of social capital to their interest in explaining and remedying inequalities of health? It means that social capital is in fact as much about highly tangible matters such as styles and forms of leadership and activism among public health workers and officials themselves—and structures of service delivery—as it is about the seemingly abstract properties of “social cohesion” among communities or social collectivities of various kinds. The practical payload for practitioners and for policy design, resulting from taking linking social capital seriously, and the implied policy ideal of an autonomous but embedded and devolved state, is in fact much more immediate than might at first be appreciated. Lynch, Kaplan, and Salonen96 asked, “Why do poor people behave poorly?” But what also of health professionals on the front line, and also those who set the overall tone and who design the facilities, the politicians and administrators, who “behave poorly” with respect to their fellow citizens? The importance of linking and bridging social capital would indicate that an equally compelling question to that of material provision of adequate resources (which undoubtedly is important, as Lynch et al. have correctly emphasized) is to examine all the aspects of health care provision that relate to relationships of mutual respect between citizens of different kinds and to their experience of the medical and social institutions, especially those provided by the devolved state. This inevitably relates to more general features of the national community in question, since it would be entirely unrealistic to expect such respectful relations to be observed uniquely in the health care sector if they are not congruent with a similar pattern of behavior in the wider society. The nature of the general argument being put here can be verified by examining the long-term modern history of British society. The following historical account illustrates the way in which the balance between bonding, bridging, and linking social capital changed in Britain during the period 1815–1914, and the very real implications this had for the nation’s population health patterns during that long period. It also demonstrates the way in which the evolution of social capital is closely related to the

396

Health and Wealth

practices and politics of the state, both as central and as local government, and to citizens’ varied relationships to this multifaceted “state.”

History Lessons: Social Capital, the State, and the Resolution of Public Health Crises in NineteenthCentury Britain By the beginning of the nineteenth century the British polity had established itself as the most prosperous, socially cohesive, and socially secure in Europe, proven through the capacity of its national social security system, the Poor Law, to protect its citizens from local famines since the seventeenth century,97 and its highly efficient fiscal-military regime guaranteeing external security by achieving the defeat of its principal European rival, Napoleonic France.98 Even the momentous loss of the American colonies to the home-grown principles of liberty had not precipitated the kind of constitutional crisis that had characterized the seventeenth “century of revolution.” Historians of Britain during the eighteenth century portray it as a “polite,” civil, commercial society, experiencing buoyant, if bumpy, economic growth, highly resilient in the face of internal stresses and external threats.99 This was both the era of the building of country houses and of the founding of subscription hospitals by the nation’s land-owning and aristocratic elite, and of the intensification of the coffee house society of the merchants of the City of London and the employing manufacturers and traders of the many fastgrowing provincial towns.There was abundant and burgeoning bridging and linking social capital, particularly in the towns, in an increasingly socially mobile nation. By 1750 already almost one-fifth of the population were urban-dwellers, twice the European average.100 For almost a century from the 1730s until the 1820s, while the population doubled in size, its average life expectancy also steadily improved, from under 35 years to reach just over 40 years.101 But then all this changed. For about half a century, from the 1820s until the 1870s, during the period when the British economy and national wealth was growing at unprecedented rates (historically analogous to the extremely high rates seen in East Asia during the last two decades), the health and welfare of its industrial workforce and the quality of its urban environments both

Health by Association? Social Capital, Social Theory

397

became endangered in a way that had not been allowed to happen over the previous century of growth. The booming market economy was undoubtedly generating great wealth decade after decade; there was massive surplus capital initially invested in railways and later overseas; and the real wages of the workers were definitely rising (albeit not as fast as the profits and dividends of employers and rentiers). Nevertheless, the health of the industrial urban workers and their families experienced a catastrophic crisis in the second quarter of the nineteenth century. From the evidence of death registration it is clear that in the central parishes of cities such as Manchester, Liverpool, and Glasgow, life expectancies dropped to about 25 years, lower than had been seen at any time in those places since the Black Death in the fourteenth century.102 The independent testimony of anthropometric evidence (heights) confirms such a severe urban health crisis in the second quarter of the nineteenth century, and that it took until the generation born just before World War I before average heights of the working classes had returned to the levels of the generation born a century earlier, immediately after the Napoleonic Wars.103 There is therefore a major puzzle concerning human resources and welfare during this period, when the world witnessed its first great economic success story and when British capital and trade rose to a position of global predominance. Changing patterns in the balance between bridging, bonding, and linking social capital within the domestic British polity are an important part of the explanation for this puzzle. Two examples, each crucial for the health of the urban population, can illustrate various dimension of the problem: the Poor Law; and water supply and sanitation. During the era of relatively gradual but sustained economic growth, migration, and urbanization throughout the eighteenth century to the end of the Napoleonic Wars, the nation’s social security system had been operated in an ever-more generous way, with national expenditure on poor relief rising tenfold between the 1750s and 1810s.104 However, with the end of the war for national survival the prescriptions of the laissez-faire, anti-welfare analysis of the new “dismal science” of classical political economy became increasingly influential with a propertied governing elite who believed they were now paying out far too much to the poor. A politics of distrust and suspicion towards the poor and the unemployed was replacing the more paternalistic attitudes

398

Health and Wealth

of the past in a society increasingly composed of large urban agglomerations teeming with immigrants, recently arrived strangers from the countryside.The three consecutive decades 1811–1840 saw peak growth rates for all medium and large provincial towns (of more than 10 000 inhabitants). As a category they grew on average by 40 percent in each ten-year period, representing a deluge of literally hundreds of thousands of new arrivals in each decade.105 Class divisions of interest were rapidly opening up between capitalowning “masters” and hired “men,” as the mechanization of successive branches of industry transformed labor relations, beginning with the mass redundancy of a quarter of a million handloom weaving families in Lancashire during the second quarter of the nineteenth century.106 Such families were forced to leave their rural hamlets and head for the smokestacks of Manchester where the new jobs were to be found in the factories. In this context, patterns of social capital were transformed. The linking and bridging social capital of a paternalistic society and a relatively generous Poor Law was formally repudiated with the enactment of the draconian New Poor Law of 1834, which slashed social security spending in half nationally and instituted a new deterrent regime, on the premise that in order to ensure efficiency of free markets in factors of production the unemployed should be strongly encouraged to offer their labor at whatever price was available to them. No longer were there to be cash handouts to the families of the unemployed. Now they were to be segregated by sex and compelled to repay their meager social security allowances by arduous labor inside work-houses.107 In the name of market efficiency, the propertied classes believed themselves justified in defaulting on a previous history of more humane treatment of the poor. In this harsh climate the principal source of social security for the working classes was to be found in the growth of two types of networks, which primarily represent defensive bonding social capital. These were, first, workingmen’s mutual insurance Friendly Societies,108 and second, denominational religious congregations and sects,109 both of which proliferated in numbers and memberships greatly at this time. Meanwhile the propertied middle-classes moved out to healthier, cleaner suburbs.110 Thus, the towns and cities of Britain during the half-century after 1815 became both socially divided and class-segregated entities. They were culturally riven by socially exclusive and ideologically separatist

Health by Association? Social Capital, Social Theory

399

sets of disparate social networks, each of them focused around a distinctive nonconformist congregation (dissenting from the Anglican Established Church), each with its own variant of Christian belief and its own pool of resources. Furthermore, much conflict of values and mutual political suspicion arose between the various factions of “new men” on the scene. Some were rapidly becoming large employers of other men, while many were only petty capitalists of very modest and precarious means exposed to the vagaries of the free market; both of these kinds of new men were in turn quite distinct from the traditional patrician power elite, the network of mainly Anglican landowners and gentry who also continued to be a presence. Class divisions were exacerbated by the 1832 “Great Reform Act,” a clever “divide and rule” move by the landed oligarchy who still dominated the British Parliament, which split the urban industrial interest, granting the vote only to about one in seven adult males, namely those with significant property. Britain’s towns and cities therefore became socially, culturally, and politically fissured by conflicting and cross-cutting networks of power and association for a whole generation before and after 1832, such that in general all that these different fractions of property—some large, some small; some Anglican, some dissenting—could agree upon, was to disagree! The net result was administrative stalemate. There was plenty of social capital in this society. The trouble was that there was very little bridging and even less linking social capital, due to a highly negative attitude towards both the central state and local government and suspicions of all kinds between different social groups (relatively few of whom were yet full citizens with voting rights). There was an abundance only of denominational, sect-based, and trade-associated social capital of a predominantly bonding kind, with insufficient interest in bridging social capital, between congregations, between social classes, between men and women, or between different industrial regions (which virtually formed into separate linguistic groups—the heavy regional accents which developed at this time still remain a marked cultural feature of Britain today).111 This state of affairs had profound implications for the second public health example of water and sanitation.112 The provision of sufficient clean water and sewerage systems to preserve human health in such rapidly expanding residential centers required the effective mobilization of political will in order to solve a classic collective action problem, since

400

Health and Wealth

the costs involved were far from trivial. Instead, the growing towns’ physical environments were simply allowed to deteriorate as ever more workers crowded in to work in the money-making factories, while the voting ratepayers could not agree to tax themselves to pay for the extremely expensive municipal water supply and sanitation schemes that were needed. The central government itself was also plagued by this paralyzing conflict between different ideologies and power networks of equal and opposing strength. A political ideology of laissez-faire and nonintervention by central government was most attractive to politicians and the executive in these circumstances because it legitimated the political line of least resistance in a situation where there were too many and too powerful complex, competing voices. An experiment with central fiat was tried in the late 1840s, in response to the official confirmation that death rates were unacceptably high in the big industrial cities. But the vitriolic popular reaction elicited by the nation’s first general Public Health Act of 1848, threatening to compel the urban bourgeoisie to spend heavily on their health infrastructure, was so powerful that central government was forced to withdraw from such direct interference in the sacrosanct field of local self-government (local ratepayers’ freedom not to tax themselves) for a further quarter century.113 During the next two decades private interests continued to dominate the pattern of water infrastructure in British industrial cities, with the result that while water supply did increase significantly because of its value as a cheap raw material for industry (now subsidized by government because of its recognized public health virtues), there was still no matching provision of domiciliary connection or of an integrated sewers system.114 In these circumstances urban death rates fell back from the catastrophic levels of the 1830s and 1840s but there was no absolute improvement over the unimpressive life expectancy levels of the 1820s.115 Bridging and linking social capital, in the form of trusting relations between the central state and the local communities, or among the fractions of property holders in the cities, therefore remained a rarity in the public health and social policy field in mid-Victorian Britain. The breakthrough did not come until the 1870s, or even later in some of the smaller towns. It was notably pioneered in the city of Birmingham through the political leadership of Joseph Chamberlain, scion of one of the city’s leading screw manufacturing dynasties, a member

Health by Association? Social Capital, Social Theory

401

of the extensive and well-connected Unitarian congregation and mayor for three consecutive years, 1873–1876.116 After a century’s rapid growth, the influence of the old landed families and their social superiority had finally all but disappeared in a city the size of Birmingham, so that by this time a man like Chamberlain, from a third-generation industrial magnate family, was indisputably part of the unchallenged natural leadership of his city. He was at the center of a large network of families of these leading local businessmen, joined together both by their commercial interests in the prosperity of their industrial district and through their nonconformist congregations. Chamberlain simultaneously spearheaded both an ideologically transformative social and moral movement, and a practically innovative program of political economy. Historians know the former as “the civic gospel,” which was literally preached from the pulpit of the Unitarian and Congregationalist chapels in central Birmingham by leading clerics. Chamberlain’s opponents christened the latter the policy of “gas and water socialism.”The former legitimized the moral and politically energizing imperative for the collective attack on squalor, poverty, and disease; the latter represented the fiscal magic needed to take away the financial pain from the city’s ratepayers, at least for long enough that the city achieved its environmental improvements. Some of the lessons that the British historical case may hold for relating social capital to public health practice appear to be as follows. Commercial and financial success and economic growth may not necessarily be associated with the flourishing of extensive bridging social capital or with linking social capital between agencies of the state and civil society. Instead, only socially exclusionary and sectional networks of primarily bonding social capital may proliferate in these circumstances, such as the Friendly societies and the worshipping congregations and the associated voluntary associational life of early and mid-Victorian Britain. This sectional and bonding social capital can particularly manifest itself in an incapacity or unwillingness to take expensive collective decisions on the part of the community as a whole. If the true purposes and characteristics of networks of association are not properly evaluated, there may be much confusion and conflicting results in studying the relationship between social capital, economic growth, and collective political action. Liberal, market-oriented societies may appear to be rich in voluntary associational life, a feature which has been emphasized by many

402

Health and Wealth

leading social capital exponents, such as both Robert Putnam and Francis Fukuyama. Yet if these associations are sectional in their goals and too exclusionary in their membership, this may remain primarily bonding social capital only, and thus may impede the articulation of collective interests and the development of extensive bridging and linking social capital. It was therefore crucial that Chamberlain’s social networks were wide-ranging and multifaceted.Within Birmingham, he benefited from a decade’s patient prior work by his loyal Liberal party lieutenants, who had for the first time in British history built up a matrix of permanent party political associations right down to ward-level all across the city. This was specifically an organizational response to the Second Reform Act of 1867, which doubled the proportion of working-class men who had the vote, making their votes critical to electoral success. Chamberlain was, thus, the leader of a thoroughly “embedded” set of networks, which crucially crossed social class and religious divides, representing a balance of bonding, bridging, and linking social capital all working together.A key element of his successful political strategy was his capacity to offer a genuine appeal to the increasingly empowered and selforganized working class. Meanwhile, his range of contacts also embraced all three key dimensions of power in his society: religion, scientific or technical knowledge, and wealth. The British historical example also indicates that explicitly moral rhetoric and values—which in the nineteenth century was popularly expressed in the language of religion, applied to economic and social relationships—must be successfully harnessed for the cause in question if bridging and linking social capital is to be mobilized in order to move an entire, complex community, such as a city the size of Birmingham, towards a collective goal. Science and technology alone is not enough. British water engineers and public health doctors technically knew how to construct a sanitary environment for a city with a domiciliary water supply and a mains sewers system since at least as early as the 1840s, but it took a religiously infused moral movement to motivate the mobilization of collective will. Furthermore, the precise details of language, rhetoric, and policy are extremely important in accounting for the success of Chamberlain’s program; and, closely related to this question of political presentation

Health by Association? Social Capital, Social Theory

403

skills, he took the fiscal sensitivities of his diverse audience extremely seriously and devoted a great deal of effective attention to those problems. He addressed directly the principal objection of small ratepayers, who had blocked collective spending throughout the mid-Victorian decades of death in British cities. He devised two extremely effective responses to the powerful objections of the petty bourgeoisie. First, in his political rhetoric, he ingeniously undercut and subverted the ratepayers’ perennial call for “economy” in municipal affairs by arguing that the ratepayers were mistakenly backing false economy and that “true economy” lay in investing in their city today so as to have healthier, more skilled, more educated, more productive, and more competitive workers and citizens tomorrow. As a practical man of business with a proven, enviable and unimpeachable track record, Chamberlain’s interpretation of “economy” commanded respect among the citizens of his town. Second, he used his financial genius and contacts in the City of London to innovate long-term, low-interest loans (on the security of the city’s rates) to buy up productive monopoly services in the city, such as gas supply and transport, thereby raising revenue from a form of indirect taxation to fund the city’s social and health services and various capital projects of improvement. Between them these novel ploys quietened the anxieties of the ratepayers for a generation—long enough to bring into being the crucial environmental improvements and a range of local preventive health and social services. By the end of the century all other cities of any size had followed the lead of Chamberlain, rebuilding and sanitizing their urban environments with the massive revenue flows generated by owning local monopoly services and utilities.117 Central government, meanwhile, had also become integrally involved, but primarily as a facilitator of local initiatives and energies, providing loans, and inspection services, and generalizing best practices, rather than attempting to direct developments from the center. The principal study of central-local government relations in this period has concluded that central government officials operated in a diplomatic mode in their relationships with local authorities, almost a model of linking social capital in practice, respecting the autonomy of the latter.118 What, then, are the valid, more general inferences of relevance to social capital and issues of health and welfare to be drawn from this episode in the history of the world’s first industrial society?

404

Health and Wealth

First, British economic history indicates that a nation that places too much emphasis on the accumulation of capital in private hands as its primary objective for economic growth while abdicating responsibility towards the less fortunate in society—a direct implication of “free market” growth models—may well be paying a high price in terms of bridging and linking social capital formation. Consequently both its environmental and its human capital may also suffer significantly (measured in the British historical case in the rather direct sense of the urban citizens’ deficient life expectancy and biological growth).Those studying in detail the relationship between social capital and economic success are now increasingly emphasizing the importance of “co-production” across the false dichotomies of the “public versus private” and “market versus state” divides. Research by Chalmers Johnson,119 Alice Amsden,120 Robert Bates,121 Robert Wade,122 Peter Evans,123 and Judith Tendler124 (among others) has shown that sustainable economic success is most likely to occur through cooperative, highly negotiated engagement between “the state” (often in the form of resource and infrastructureproviding local government agencies), and local businesses and representative bodies of local workers and residents.The British historical case confirms this, in that Britain’s industrial cities were fast becoming unworkable environments, until Chamberlain found a political means to cut the Gordian knot of social fragmentation and distrust and to implement forms of “co-production.” Second, the British case indicates that it is only when networks of association are as well-developed and as multifaceted as Chamberlain’s were, and are geared to comprehending the interests of the political majority in the community, as his were (which enabled him to know, understand, and respect—but also deal with—the fiscal sensitivities of the opponents to his schemes), that leaders and policy-makers will, indeed, have sufficiently detailed understanding and knowledge of the society with which they are negotiating, which will enable them to formulate effective programs that genuinely facilitate or persuade (rather than merely attempt to “lead” or coerce) the wishes and interest of the majority of the citizens.This is an example of bridging and linking social capital, of Woolcock’s125 emphasis on embedded autonomy, and the importance of democratically elected local government as the responsive and accountable “state” in action.

Health by Association? Social Capital, Social Theory

405

This leads on, naturally, to a third important issue: political participation. Chamberlain’s new politics was developed directly in response to the opportunities for a more democratic and participatory urban politics opened up by the British state’s belated enfranchisement between 1867 and 1884 of a large section of the working classes (two in three adult males had the vote by 1885; universal adult male franchise did not arrive until 1918 and female until 1928). Many contemporary developing societies and communities exhibit extremely poor resources in terms of civic political participation, with some important examples such as China formally channeling all political energy through the narrow nexus of the official Party apparatus, while others, such as India, too often making a mockery of their formally democratic constitutions because of the impoverished and socially excluded nature of vast tracts of their citizenry, notably rural peasants and, especially, females. Extensive bridging and linking social capital cannot possibly flourish in these circumstances, where the basic political and institutional ground-rules for citizen participation in the political processes are lacking. The state is at its most effective in both facilitating and benefiting from social capital when it is operating in a highly devolved form, something we principally associate with the institutions of elected local government. Chamberlain showed that increasingly democratic and vigorous local government, when sufficiently politically responsive to the interests of a wide range of groups in the local community, is the most obvious and effective ally of social capital. One danger in the social capital literature has been an overemphasis on voluntary associations alone as the key to healthy social capital, and a tendency to cast “the state” only in the negative terms of an impersonal and monolithic “big brother” figure. The British historical case indicates that voluntary associations of citizens alone can have ambiguous consequences for a community’s social capital and its public health, as in the early and mid-Victorian decades in Britain. There is a crucial facilitating role for the state, for elected, representative, and dynamic local government agencies, and for politics and ideas in the formation of the kind of balanced social capital required for promotion of population health under the dynamic conditions of continual economic growth. The recent example of the Brazilian city of Porto Alegre’s fifteen-year experiment with participatory budget-setting confirms the continuing relevance of the historical case of Birmingham and

406

Health and Wealth

of the bridging and linking social capital analysis presented here, which focuses on the salience of motivating moral ideals, cross-class political leadership, embedded but autonomous local government, and empowerment of inhabitants, resulting in major improvements to the city’s population health.126

Discussion The empirical base of the general social capital story—and the veritable explosion of interest accompanying it across the social and medical sciences—rests in no small part on applied research in the fields of public health and epidemiology. As such, the debates taking place within these fields deserve special attention, and are instructive for broader conceptual and policy deliberations.We have argued that while the current disagreements among the major protagonists in the field of social capital and public health manifest themselves as methodological differences regarding the efficacy of power (access to resources), inequality, or social support networks as the primary determinant of health outcomes, they are in fact better understood as products of an ill-specified (or at least less-than-comprehensive) theory of social capital. Indeed, closer attention to the current theoretical developments—themselves a product of close engagement with a range of empirical studies—reveals a conceptual framework that provides a basis for resolving the current debates, one that is also consistent with rich historical evidence regarding the emergence and resolution of major public health crises in nineteenth century Britain. This framework centers on an analytical distinction among three kinds of social relationships in which individuals are engaged, and, crucially, the nature of the state-society relations in which these individuals and their relationships are inherently embedded. It relies on the distinction between bonding, bridging, and linking forms of social capital. Of course many other things are also required for a “healthy society” to be capable of consistently using its material resources for the promotion of the population health of all its citizens.127 One necessary condition, however, will be a balanced distribution of a relatively rich endowment of all three of these forms of social capital. In these circumstances the polity

Health by Association? Social Capital, Social Theory

407

will be constituted by a vigorous, open, and politically conscious civic society of mutually respecting and (in terms of their social identities) highly varied citizens and their many associations. In such societies, individuals and the wide range of associations that represent their interests are in active dialogue and negotiation (since there are certain to be conflicts requiring negotiation) with both their elected local governments and their central state.Without such a health-promoting, balanced development of all three forms of social capital, however, social capital, in any of its three forms, may easily be used as a resource for exclusionary and sectional interests, which may have an ambivalent or even negative consequence for the overall population health of society. It is, then, an entirely contingent question of politics, public morality, ideology, and historical events as to whether or not the resources of social capital, which necessarily exist in any society, will take on health-promoting or health-degrading net effects. This question of negotiated political and ideological contingency is crucial. Social capital is not a magic wand for improving society, nor is it a self-contained comprehensive theory. It is a useful concept, which focuses our attention on an important set of resources, inhering in relationships, networks, associations, and norms that have previously been accorded insufficient priority in the social sciences and health literature. This is probably partly because they are not easy to categorize, study and measure in their effects.Advances are now being made, but this will continue to be a site for “work in progress” for some time to come. It is important to remember that it recently took several decades of patient methodological work for the concept of human capital to be accepted as tractable by most economists, as it is today. The theoretical formulation of social capital presented here may offer the basis for reconciling the three different positions on social capital and health outlined above. The oldest school of thought, the “social support” view of social relationships, tends to imply that, at least from an individual’s point of view, any kind of positive social support is good for your health—the classic case is that of family and friends to get you through a critical illness.This corresponds to an undifferentiated concept of social capital as simply all and any networks. Marmot and Wilkinson’s inequalities approach has significantly complicated the epidemiological picture by arguing that, at least in the relatively affluent societies they

408

Health and Wealth

have studied, the overall patterns of individuals’ social relations should be seen in a wider political and historical context in order to be able to evaluate whether, in the aggregate, they are of net benefit to their health. In societies characterized by steep or by growing inequalities, there will be a tendency for social relationships in general to become less egalitarian and mutually respectful and more hierarchical and unsympathetic.A general disposition of goodwill towards other citizens will be replaced by suspicion and distrust. A range of negative health implications follows, particularly for those lower down the social status hierarchy, whose perceptions of disrespect for themselves will be harmful to their health. Although their personal friendships may still be helpful to them in fighting ill health—the “social support” thesis—the overall pattern of the social relationships available to them in such an unequal society may be responsible for an extra burden of illness. This development in the epidemiological literature corresponds to the recognition of the importance of the distinction between bonding and bridging in the social capital literature—from a health point of view, not all social relationships are the same and have similar supportive effects. While Wilkinson’s “political economy” critics have been content to deny the thesis that the putative sociopsychological pathways of health damage are the most important, they agree that conditions of heightened inequality are harmful to health. They prefer, however, to emphasize the importance of the deficient material living conditions of the poor and the political and ideological factors, which result in some societies accepting conditions among some of their populace that other societies would find intolerable.This focus on the causal importance of the prior and ongoing history of the political and the ideological correspond, in social capital theory, to the acknowledgment of the significance of questions of relationships between citizens and the state, issues that are raised through a focus on linking social capital, as an additional category distinct from that of bonding and bridging social capital.This suggests that none of the three epidemiological schools of thought is wrong, in its own terms, about the relationship between social capital and health, but that, like the sequence of conceptual developments of social capital theory, they represent successively more comprehensive formulations of the scope of the causal factors involved in analyzing the relationship among health, citizens, society, and, ultimately, the polity and the state.

Health by Association? Social Capital, Social Theory

409

Policy Conclusions We stated earlier that we would attempt to outline the policy implications that such a revised theory of social capital would have for the public health field, particularly in addressing the issues of inequality and health in relatively affluent societies, issues that lie at the heart of the dispute between Wilkinson, Lynch, and others.We argue that taking seriously the concept of linking social capital problematizes in particular the quality of relationships whenever and wherever resources might flow across perceived power gradients. Potentially health-enhancing resources may be primarily material (a new hip replacement) or may be purely informational (where to go to get a hip replacement or the knowledge that one has a right to have a hip replacement), but they are most frequently an alloy of both (getting the hip replacement and the right advice about postoperative rehabilitation). Improving human health requires both the entitlement to appropriate “material” needs and the capability to benefit from it, which is so often mediated through social relationships. Lynch and the “neo-materialists” are right to continue to emphasize that even in the most affluent societies in the world, the poor can still suffer major material deprivations that directly cause their ill health. Wilkinson and Marmot are right to stress that the perception of living in an unequal and unjust society can be so corrosive of social relationships as to have tangible consequences for the health of the population.The concept of linking social capital makes the connection between these two through the issue of the quality of health-services information and delivery-influencing equality of access to health education and health knowledge.There can be little doubt that the maintenance of population health at historically high levels in affluent societies depends on a relatively high proficiency of health knowledge among citizens, both in the sense of knowing how to keep themselves healthy in the potentially highly toxic and dangerous urban environments we mostly inhabit, and having the expertise and confidence to access medical and other social services when they are needed.128 In affluent societies that allow themselves to become particularly unequal, not only will the underprivileged suffer substantial health-compromising material deprivations, but there will also arise problems of social distance and the likelihood of deteriorating mutual respect between the haves and have-nots if a sense of injustice develops.While Wilkinson and others have been exploring the possible

410

Health and Wealth

direct health consequences of this situation, the linking social capital concept indicates that in addition to such physiological impacts, if relationships of trust and respect deteriorate between the poor and the range of more privileged people in their lives who are involved in delivering the essential public services of education, health, and social security, then the capacity of the poor to acquire, utilize, and benefit from health-enhancing material goods will be seriously compromised. The interaction of all these factors has, for instance, been persuasively expounded in Klinenberg’s comprehensive analysis of the causes of the more than seven hundred fatalities due to the 1995 heat wave in Chicago.129 These were particularly concentrated among males aged over 65. Klinenberg’s comparison of two matched, poor districts showed that the disproportionately high death-rate in North Lawndale was indeed correlated with material deficits, notably such as lack of air-conditioning. However, there was also a strong correlation with living alone, and the strongest correlation of all was with absence of any social contacts, extending to many deceased males being found locked in their own apartments, reflecting the chronic state of fear of neighbors in this downwardly spiraling,“abandoned,” black immigrant part of town. By contrast, adjacent South Lawndale (also a poor area in which many homes lacked air-conditioning) benefited from a vibrant Latino community in which people felt relatively safe in public spaces. It exhibited starkly contrasting, disproportionately low mortality during the heat wave.Thus, social capital and Wilkinson’s emphasis on the social psychology of dynamic trends in inequality are clearly implicated as playing a major role, along with neo-material deficits. And finally, behind both of these factors lies the causal role of the changing political economy and public culture of the U.S.The society that only two decades earlier had responded in full to Lyndon Johnson’s call for an “unconditional war on poverty” to honor the wishes of their assassinated young president, had now, during the decades of the 1980s and 1990s, acquiesced in the abandonment of whole districts like North Lawndale. Heat waves as severe as 1995 had occurred in Chicago before; in 1964, for example, a comparable heat wave generated no death peak, as many without air-conditioning had felt safe enough to sleep outside at night in the parks. Where future policy is concerned, the social capital framework presented here indicates that in British society, which remains a strongly class-divided culture, a key problem with the universalist national health

Health by Association? Social Capital, Social Theory

411

service and welfare state has been that, while it delivered a reasonable amount of “material” inputs to the poor, this was done in the context of a relative deficit of sensitive linking social capital, whose most obvious and tangible, health-compromising results have been the profusion of poorly designed housing estates for the poor.130 In the U.S., during the last two decades there has been a failure to deliver even half-adequate material assistance to the very poor and while the society as a whole pays lipservice to the ideals of a citizen republic of equals, its bridging and linking social capital is in tatters.131 In Sweden, by contrast, there has been a record of adequate material assistance to the poor and much more effective linking social capital than in either of the other two cases.132 In view of these considerations, it is a particularly ironic misconception entertained in some quarters that the social capital approach to both the promotion of population health and also to the improvement of public services in general in a democratic society necessarily might represent a “cheap” option and might be lacking in political radicalism. It can be seen that social capital theory, embracing not only bonding and bridging but also linking social capital, places great emphasis on both the quality and the quantity of relationships among all citizens. It also places great emphasis on whether or not these relationships are founded on mutual respect between people, differentiated either horizontally by their varying social identities or vertically by their access to different levels of power and authority. Commitment to the goal of a society of mutually respecting citizens has the potential to motivate an extremely radical political economy, carrying strong redistributionist implications.133 The social capital perspective also informs us that if we normatively approve of the goal of enhancing population health, we cannot achieve this through material inputs alone, or simply through “technological fixes,” whether “imposed” or magnanimously “granted” by those with superior resources. Material assistance will almost certainly be necessary in most contexts; but equally important will be attention to the quality and quantity of relationships that carry and make interpretable any such material or technological transfers. In the public services and in developed societies in general it is in fact these precious resources of human relationships, effort, and care—or labor, to use an old fashioned word—that are crucial, rather than material inputs alone. Human expertise, time, and attention are also, inevitably,

412

Health and Wealth

increasingly expensive to deploy.Taking social capital seriously in the context of health promotion in rich or poor countries is, therefore, not in any sense a cheap option; it is an additional dimension—and one necessarily requiring additional costs—that too often has been neglected.

Notes 1. Berkman,Thomas, Brissette and Seeman (2000); Kawachi (2001). 2. Coburn (2000). 3. American Journal of Public Health (2003). 4. Putnam (1993); Putnam (2000). 5.Woolcock (1998);Woolcock and Narayan (2000). 6. Putnam (2000). 7. Lomas (1998); Morrow (1999); Hawe and Shiell (2000);Veenstra (2001); Macinko and Starfield (2001); Cattell (2001); Cullen and Whiteford (2001); Whitehead and Diderichsen (2001); Siegrist (2002); Leeder and Dominello (1999). 8. Fine (2000); Harriss (2002). 9. Putnam (2000). 10. House, Landis and Umberson (1988). 11. Berkman (1995). 12. Seeman (1996). 13. Lynch, Davey Smith, Kaplan and House (2000). 14. Navarro (2002); Muntaner, Lynch, Hillemeier, et al. (2002). 15. Coburn (2000); Seeman (1996); Davey Smith (1996); Muntaner and Lynch (1998); Kaplan (1999); Lynch (2000); Lynch, Due, Muntaner and Davey Smith (2000); Muntaner, Lynch and Davey Smith (2000); Muntaner, Lynch and Davey Smith (2001); Lynch, Davey Smith, Hillemeier, et al. (2001); Lynch and Davey Smith (2002); Pearce and Davey Smith (2003); Wilkinson (1999); Wilkinson (2000a); Marmot and Wilkinson (2001); Wilkinson (2002); Baum (1997); Baum (1999); Wilkinson (2000b); Kawachi and Berkman (2000). 16. Putnam (1993). 17.Wilkinson (1996). 18. Putnam (2000). 19.Wilkinson (1986). 20. Kawachi and Berkman (2000). 21. Berkman (2000); Cooper,Arber, et al. (1999); Gorski (2000); Lennartsson (1999). 22. Berkman (2000). 23. Baum (1997). 24. Brown and Harris (1978). 25. Berkman and Glass (2000); Berkman and Syme (1979).

Health by Association? Social Capital, Social Theory

413

26. Forbes and Wainwright (2001); Eckersley, Dixon and Douglas (2001). 27. Kawachi (1999). 28. Keating (2000). 29. Howard (2003). 30. Kawachi and Berkman (2001). 31. Hagan, Merkens and Boehnke (1995); Sampson, Morenhoff and Earls (1999). 32. Kawachi, Kennedy, Lochner, et al. (1997). 33.Weitzman and Kawachi (2000). 34. Lin,Ye and Ensel (1999); Bullers (2000). 35. Penninx, van Tilburg, Kriegsman, et al. (1999). 36. Lindstrom, Hanson, Ostergren and Berglund (2000). 37. Sevigny, Belanger and Sullivan (1999); Raphael, Renwick, Brown, et al. (2001); Helliwell (2002). 38. Kawachi, Kennedy and Glass (1999); Rose (2000); Ellaway and Macintyre (2000); Subramanian, Kawachi and Kennedy (2001). 39. Steptoe and Feldman (2001). 40. Duncan (1999). 41.Wakefield, Elliott, Cole and Eyles (2001). 42. Rosenheck, Morrissey, Lam, et al. (2001); Campbell (2000); Ong (2000); Murray (2000); Smith, Littlejohns and Thomson (2001); McCulloch (2001); Campbell and Aggleton (1999). 43. Davey Smith (1996); Muntaner and Lynch (1998); Kaplan (1999); Lynch (2000); Lynch, Due, Muntaner and Davey Smith (2000); Muntaner, Lynch and Davey Smith (2000); Lynch, Davey Smith, Hillemeier, et al. (2001); Lynch and Davey Smith (2002); Pearce and Davey Smith (2003); Wilkinson (1999); Wilkinson (2000a); Marmot and Wilkinson (2001); Wilkinson (2002); Galea, Karpati and Kennedy (2002); Kawachi and Kennedy (1999). 44. Portes (1998). 45. Kunitz (2001). 46. Pope (2000); Harpham, Grant and Thomas (2002). 47. Subramanian, Kim and Kawachi (2002); Subramanian, Blakely and Kawachi (2003); Subramanian, Lochner and Kawachi (2003). 48.Wilkinson (1996). 49. Omran (1971). 50.Wilkinson (1996); Putnam (1993);Wilkinson (1999);Wilkinson (2001). 51. Marmot, Rose, Shipley and Hamilton (1978); Marmot, Davey Smith, Stansfield, et al. (1991). 52. Brunner and Marmot (1999); Beaglehole and Magnus (2002). 53.Lynch, Davey Smith, Kaplan and House (2000); Muntaner, Lynch, Hillemeier, et al. (2002); Davey Smith (1996); Muntaner and Lynch (1998); Kaplan (1999); Lynch (2000); Lynch, Due, Muntaner and Davey Smith (2000); Muntaner, Lynch and Davey Smith (2000); Muntaner, Lynch and Davey Smith (2001); Lynch,

414

Health and Wealth

Davey Smith, Hillemeier, et al. (2001); Lynch and Davey Smith (2002); Pearce and Davey Smith (2003); Ross,Wolfson, Dunn, et al. (2000);Wolfson, Kaplan, Lynch, Ross and Backlund (1999). 54. Navarro and Shi (2001). 55.Wilkinson (2000b). 56. Putnam (1993). 57. Krugman (2002). 58. Alesina and La Ferrara (2001). 59. Dominguez and Watkins (2003). 60.Woolcock (1998);Woolcock (2001); Szreter (2000); Szreter (2002). 61. Bourdieu (1986). 62. Woolcock (1998); Coleman (1988); Coleman (1990); Loury (1977); Farr (2004); Jacobs (1961). 63. Woolcock (1998); Portes (1998); Foley and Edwards (1999); Schuller, Baron and Field (2001). 64. Glaeser, Laibson and Sacerdote (2002). 65. Fukuyama (1995). 66. Knack and Keefer (1995); Knack and Keefer (1997). 67. Evans (1996). 68.Woolcock (1998). 69. Szreter (2000); Szreter (2002). 70. Putnam (2000). 71. Portes (1998). 72. Putnam (2000). 73. Burt (1992); Burt (2000); Lin (2001). 74. Putnam (2000). 75. Gittell and Vidal (1998). 76. Portes (1998). 77. Putnam (1993). 78.Woolcock (2001); Szreter (2002);Woolcock (1999);World Bank (2000). 79. Pritchett and Woolcock (2004). 80. Lipsky (1980); Narayan (2000); Krishna (2002). 81. Grootaert and van Bastelaer (2002); Grootaert, Narayan, Nyhan Jones and Woolcock (forthcoming). 82. Durlauf (2002). 83.Wilson (1996). 84. Gittell and Thompson (2001); Noguera (2001). 85. Evans, Rueschemeyer and Skocpol (1985); Skocpol and Fiorina (1999). 86.Woolcock (1998);Woolcock (2001); Szreter (2000); Szreter (2002). 87. Sen (1999). 88. Evans (1995). 89.Woolcock (1998). 90. Granovetter (1985).

Health by Association? Social Capital, Social Theory 91. Dyson (1980). 92. On this, see Evans (1996). 93. Scott (1998); Bunce (1999). 94. Mann (1993). 95. Rothstein (1998); Esping-Andersen (1990). 96. Lynch, Kaplan and Salonen (1997). 97. Appleby (1978). 98. Brewer (1989). 99. Langford (1989). 100.Wrigley (1987). 101.Wrigley, Oeppen, Davies and Schofield (1997). 102. Chap. 6, this volume. 103. Floud,Wachter and Gregory (1990). 104. Slack (1990); Marshall (1985). 105. Garrett, Reid, Schurer and Szreter (2001). 106. Bythell (1969). 107. Rose (1986). 108. Neave (1996). 109. Gilbert (1976); Mason (1994). 110. Dyos and Reeder (1973). 111.Waller (1989). 112. Chap. 7, this volume. 113. Prest (1990). 114. Hassan (1985). 115. Chap. 6, this volume. 116. Hennock (1973). 117. Bell and Millward (1998). 118. Bellamy (1988). 119. Johnson (1982). 120. Amsden (1989). 121. Bates (1989). 122.Wade (1990). 123. Evans (1995). 124.Tendler (1997). 125.Woolcock (1998). 126. Abers (1998). 127. Szreter (2003). 128. Powles (2001). 129. Klinenberg (2002). 130. Szreter (2002); Power (1996). 131. Putnam (2000). 132. Rothstein (1998). 133. Szreter (2000).

415

12 PUBLIC HEALTH AND SECURITY IN AN AGE OF GLOBALIZING ECONOMIC GROWTH The Awkward Lessons of History1

Globalization and the Postwar Liberal Consensus Historians of globalization have identified two modern forms of global economic growth in history (following two premodern forms—archaic globalization and proto-globalization—antedating the emergence of nation-states and the onset of the first industrial revolution in the eighteenth century).2 Of the two modern forms, the first refers to the period from the late eighteenth to the early twentieth centuries, in which nation-states industrialized and colonized; while the second comprises the current postcolonial phase, following the period during which most colonies gained their independence between 1945 and 1975. Along with the ending of the Cold War and deregulation of international financial markets, this shift has formed the wider political context in which the 416

Public Health and Security in an Age of Globalizing Economic Growth

417

global communications and information technology revolution of the last quarter-century has occurred, concomitant with a phase of almost unprecedented rapid economic and cultural change in the social and economic relations of the entire world. The net effect of all this, so far, has been the much-commented-on liberation of the power of “the market,” “the consumer,” transnational corporations, and finance capital, at the expense of the incumbent power-holders of the previous century or more: nation-states and their elected governments, whose autonomy has putatively suffered a relative decline. In fact for many countries, certainly including Britain, the current era of globalization and the challenges it presents are not at all without historical precedent. I will argue here that careful attention to historians’ findings concerning the nature of the original historical episode of modern globalization, the eighteenth and nineteenth century industrialization with its epicenter in Britain, can provide important and unexpected perspectives on contemporary world problems of coping with transformative global economic change today. If the promotion of human security and the health of the population truly remain among our principal goals, history can give some guidance as to which policies should be prioritized today under these conditions of rapid economic change. The lessons of history are, however, awkward ones. They do not correspond in any straightforward way to the policy nostrums of the conventional liberal orthodoxies of the postwar era. An overlapping sequence of four influential general models of the relationship between economic growth and population health can be identified since 1945. Each in turn has assumed that history shows that population health improves with the advent of economic growth. The first and most insidiously influential of all of these postwar models, the theory of “demographic transition,” came to prominence in the aftermath of World War II and in the subsequent Cold War climate of economic rivalry between liberal and communist regimes.3 Transition theory was the demographic component of the more general liberal theory of modernization.4 Demographic transition theory posited that economic growth, in the form of industrialization, was a benevolent primum mobile. It produced a decline in mortality, which empowered the economy with a healthier and growing labor force. A compensatory fertilityreducing social response followed, dampening down population growth

418

Health and Wealth

and thereby ensuring that a trajectory of self-sustaining economic growth could be maintained through incremental rates of capital investment (avoiding the undesirable alternative of a rising dependency ratio and the diversion of too much output into current consumption, rather than capital investment).5 The second model followed a quarter of a century later. Omran’s concept of the epidemiological transition supplemented the plausibility of the transition approach by elaborating in a more detailed way the three types of epidemiological regime typical of the three stages of demographic transition.6 Famines and pestilence dominated the preindustrial high-mortality stage, followed by “receding pandemics” as transitional societies industrialized and became wealthier and their medical technology advanced. Finally, the most developed, high life expectancy societies of stage three were afflicted by a residual of “degenerative and man-made diseases.” The third in this sequence of four influential models was Thomas McKeown’s bestseller, The Modern Rise of Population, published in 1976. This work continued to champion an essentially nonproblematic relationship between economic growth and population health.7 McKeown argued—iconoclastically—that medical science and technology were not, after all, responsible for any significant proportion of the mortality decline consequent on industrialization. However, he still retained a primarily benevolent role for economic growth, consistent with the transition model. According to the McKeown thesis, it was a gradually rising per capita nutritional intake made possible by a better food supply and rising real incomes (purchasing power) that was mainly responsible for falling mortality and population growth during industrialization. Finally, in the aftermath of the political collapse in 1989 of the Soviet regime in Moscow, there emerged a triumphalist fourth phase of liberal orthodoxy, the so-called “Washington consensus,” trumpeting the untrammeled virtues of free trade, free markets, and deregulated economic growth.The 1991 World Development Report, setting out the World Bank’s agenda for international development for the forthcoming decade and compiled under the direction of Larry Summers (subsequently the U.S. Secretary of the Treasury) was a product of its times, reflecting this rather one-sided faith in liberal market economics to guide the world’s development policies. It cited McKeown’s Modern Rise and Robert Fogel

Public Health and Security in an Age of Globalizing Economic Growth

419

extensively on the importance of economic growth and nutrition for population health,8 while simply ignoring the research of other equally eminent analysts, notably S. H. Preston, whose work indicated the need for a rather different set of policies requiring strong government-led investment in public health infrastructure.9 All of these orthodox models have essentially been arguing what many in the developed world, from the rather complacent perspective of an uncritical hindsight, believed to be a self-evident truth, namely that economic growth has been the principal direct cause of improvements to the public’s health and to social security in modern history. This apparent lesson of history carries an obvious general policy implication: that economic growth should be maximized wherever possible and that economic growth, particularly the most rapid, “free market,” version can be viewed as an unalloyed good in itself. However, hindsight can be profoundly misleading. As with many commonsense, conventional wisdoms, more careful investigation of the historical evidence in fact shows a very different and more complex relationship between global economic growth, health, and human security.

Economic Advance as Challenge to Population Health Throughout History The long-term human record shows no necessary, direct relationship between economic advance and improvements in population health, but rather a highly ambivalent and contingent relationship. In fact, the most important general lesson of history regarding all known previous phases of transformative technological and economic change is that they have always been profoundly challenging to human health and security in their immediate consequences. The most general policy implication is that societies today experiencing rapid economic growth—especially those experiencing it for the first time—need to be very much on their guard to protect their populations from the disruptive corollaries of economic expansion. During the millennia of prehistory, the skeletal record indicates that each of the periods of transitional shift from hunter-gatherer to early settled agriculture, early to advanced agriculture, and then to ancient urban

420

Health and Wealth

civilization (the “archaic” form of globalization), while representing economic advance and increased human population density, were also accompanied by greater susceptibility to disease and decreased average population health. It seems most probable from the archeological and skeletal evidence that only with subsequent long-term adaptation, some time after each such phase of major economic advance, did population health recover somewhat.10 This reflects the powerful influence of two well-attested, negative epidemiological relationships between population health and increased economic activity: first, that trading contact between populations previously not exposed to each other’s disease ecologies results in enhanced morbidity and mortality on both sides;11 second, that the increasingly dense permanent settlement of populations, made possible by increased trade and material productivity, also results in enhanced communicable disease problems.Thus, the historical records of the early modern city-states of Italy demonstrate their governments’ preoccupations with a range of public health issues due to the sanitation problems of packed, urban living and the periodic threats of imported epidemics.12 Indeed, the gradual expansion of international and intercontinental trade throughout the early modern period (identified by historians as protoglobalization, the second form of premodern globalization) was characterized by a sequence of extraordinarily lethal epidemics of infectious disease, most tragic of all for the indigenous populations of the Americas.13 The eminent French historian, Emmanuel Le Roy Ladurie, was moved to christen this era of proto-globalization that of “l’unification microbienne du monde.”14 The first modern form of globalizing economic growth, the industrialization of the transatlantic economy, c.1750–1914, was no different. The immediate effect of industrialization was a negative impact on population health in each country that experienced the process.This is repeatedly confirmed in the “demographic footprint” of the “the four Ds” of disruption, deprivations, diseases, and death, which remains clearly visible in the national historical records in the form of a generation-long, negative discontinuity in the historical trends of life expectancy, infant mortality, or height attainments.15 And, of course, the global transformation in economic and political relations, which industrialization produced, meant that it was not necessarily only the populations of countries themselves undergoing industrialization that might find their livelihoods and

Public Health and Security in an Age of Globalizing Economic Growth

421

living conditions adversely affected, as, for instance, the Swedish agrarian workers in the early nineteenth century,16 the Irish peasantry at midcentury,17 and the Indian populace throughout the nineteenth and early twentieth centuries all discovered to their costs.18 In England and Wales average mortality rates failed to improve at all during the whole of the period when the economy experienced its historically unprecedented economic growth rates. While the steam-driven factories and railways powered the country’s economy to global trading predominance, c.1815–70, the health of the urban workers whose labor made this all possible languished. Although the population’s health had improved moderately during the initial phases of more gradual economic growth, c.1740–1815, thereafter there were no further gains in population health for two generations—this despite the fact that workers’ average real wages, which showed no definite overall improvement before 1811, now began definitely to rise throughout the rest of the nineteenth century.19 Thus, pace the McKeown and Fogel theses with their emphasis on food supplies and real wages, average health improved in the eighteenth century without the benefit of increased average purchasing power for food (the fluctuating cost of food was the major budgetary item influencing the reconstructed average real wage trend), while overall health then failed to improve further between 1811 and 1871, despite much enhanced average purchasing power, especially among the urban factory workers. Further research on an independent body of anthropometric evidence has confirmed that late eighteenth-century improvements in height attainments were curtailed and then even reversed during the second quarter of the nineteenth century.20 It is now clear from all the available evidence for a variety of towns of very different sizes, such as Carlisle, Wigan, West Bromwich, and Glasgow, that this discontinuity in national mortality trends was mainly due to sharply deteriorating health conditions in Britain’s industrializing towns and cities.21

The Historical Relationship Between Social Security and the Industrial Revolution From the overly schematic “transition” viewpoint, another seemingly obvious population health gain attributable to modern economic growth,

422

Health and Wealth

along with the claim of reduced mortality, has been the capacity of richer societies to offer a significantly increased degree of social security to their populace. However here, too, the historical evidence indicates something rather different. Far from being only a consequence of successful economic growth, historical research on early modern Britain has found that widespread institutions of social security were in existence for several centuries before the industrial revolution. England’s universalist social security system was unique in Europe in the seventeenth and eighteenth centuries and seems to have been crucially important in facilitating the enhanced agrarian and urban economic activity that ultimately led to Britain’s pioneering industrial revolution. In explaining how it was that the industrial revolution occurred first in Britain, there are many important factors involved. However, one recent general emphasis that has emerged among scholars of the British industrial revolution is an increasing attention to the longer-term sources of the high platform of productivity achieved in a predominantly agrarian economy by the start of the eighteenth century, eighty years before the beginnings of the steam mechanization of the cotton industry in Lancashire, which was to lead the world into its first industrial revolution.22 England’s “advanced organic economy” placed her in a leading position in Europe, such that already by 1700 the percentage of her population residing and working in towns was fully 50 percent higher than the European average, without the need for any net importation of foodstuffs.23 This British “urban advantage” over the rest of Europe was matched only by “golden age” Holland.24 But unlike Holland, Britain’s trend to increasing urbanization continued throughout the remainder of the eighteenth century. Britain’s agricultural economy still managed to feed a national population that had almost doubled in size by 1800, without any significant imports or rises in the real costs of food, while also managing to transfer a substantial labor surplus from the land to the town, providing ever more hands for manufacturing and services. Thus, it is increasingly being argued by the leading economic historians that a previously underestimated key to Britain’s precocious industrial revolution in fact lies in its prior agricultural revolution.The principal comparator here is with the immensely advanced Dutch agrarian and trading economy of the sixteenth and seventeenth centuries.25 Many of the most important technical innovations in British agriculture during

Public Health and Security in an Age of Globalizing Economic Growth

423

this period, such as land drainage engineering, new crop types and rotations, were directly borrowed from the Dutch.Yet it was the British agricultural and service economy that was increasingly outpacing the Dutch as the seventeenth and eighteenth centuries progressed. To explain this widening discrepancy between the two leading economies, Dutch historians have increasingly focused their attention on the potential economic significance of one major institutional difference between the two countries, namely the nationwide system of social security created in England by the Elizabethan Poor Laws. Although Holland and other European countries certainly had their Poor Laws, they were far from effectively enforced and frequently only really functioned in selected towns.26 By contrast there was nothing in Europe like the comprehensive system of poor relief established in England.27 It was funded by a local tax on the inhabitants of every parish, and administered by local officials but also rigorously enforced by local magistrates as representatives of the Crown and the law. From their comparative perspective Dutch historians have been particularly impressed by the research of British historians showing that by the middle of the seventeenth century, though by no means uniform in its procedures, the poor relief system was a genuine reality in full operational force throughout the land.28 It went side by side with a relatively efficient nationwide population registration system, the Church of England’s parish registers, instituted in 1538. This placed the English population and its labor market, both in town and countryside, on an entirely different basis, in terms of social security, from that of the rest of Europe. Consequently, England (but not Ireland, where there was no such Poor Law nor Anglican vital registration system) was the first nation in the world to cease to experience famine-related mortality (achieved by the mid-seventeenth century).29 Peter Solar has furthermore argued that the comprehensive social security system provided by the Poor Laws had a number of highly significant economic consequences, of relevance to England’s high levels of both agricultural productivity and urbanization.30 In particular, in combination with the very early establishment in English law of complete alienability of land (from the thirteenth century on),31 it had the potential to encourage labor mobility and emancipation from a peasant mentality of over-attachment to land-holding as the only form of security. Individuals had a relative certainty, within the rules governing settlement

424

Health and Wealth

rights and the associated system of certificates,32 of being provided for, wherever they moved to work in the economy, no matter what their property-ownership status. Landlords and farmers could reap the economic gains to be had from increased farm sizes, from enclosure, and from laying-off workers or changing their labor contracts to more efficient weekly or day labor, without this provoking the same fears and level of protests from those adversely affected, as such attempts elicited on the continent. But equally, such employers in England had a strong incentive only to do this if it really made economic sense because, through the Poor Law, they would also have to reckon with their liability for paying for the families of the laid-off workers, at least in the short term until they found new work.Thus, from the point of view of the smallholder or tenant, given such genuine social security, working for wages—whether in the countryside or in the town—was not necessarily any less secure than access to the land. There was no need to fetishize land ownership among the poor as their cherished symbol of family security, as happened among the peasantry on the continent, notably in France, whose agriculture was notoriously afflicted with the practice of “morcellement.”33 Thus, although in no way a voting democracy, the subjects of the British sovereign in the seventeenth and eighteenth centuries enjoyed, relative to the laboring poor in the rest of Europe at that time, “advanced,” state-guaranteed practical entitlements to security and health—functionings and capabilities in Sen’s terminology.34 Note that the argument here is not that the English Poor Law and its ubiquitous operation provided persons with their preferred means of social security. However, through its mandatory existence in every parish, it did provide a basis for the actual achievement of a state of personal social security, which was not merely a convention of traditional morality but an institutionally permanent and unavoidable social obligation.What the Poor Law created everywhere in England was a very public system of acknowledgment of collective responsibility for the subsistence of all, including, for instance, as the recent research of Tom Nutt has shown, a strikingly nonmoralistic and caring approach to the support of single mothers and their illegitimate children.35 This did not mean that those in need did not prefer, if they could, to draw support from a range of other, nonofficial, sources, such as kin, neighbours, individual philanthropists, and charities. But it does mean that those who lacked these sources of support did not

Public Health and Security in an Age of Globalizing Economic Growth

425

simply fall through this precious but frequently frayed network of informal, private acts of solidarity. Hence the compelling comparative evidence, at the aggregate level, of a relative lack of correspondence in England, alone in all of Europe, between fluctuations in the price of food and the death rate.36 For most of these other, nongovernmental forms of support existed throughout the rest of Europe. They worked for most people for most of the time, but crucially when the chips were really down for an entire community, as in times of dearth, they could fail.The Poor Law meant that in England and Wales social security functioned for all people all of the time. Given all the evidence that has been uncovered by historians of the poor in England of “an economy of makeshifts,” often involving kin and neighbors,37 and of much philanthropic and mutualist activity,38 it is also plausible that, far from crowding out alternative forms of social support, the existence of the locally devolved and entirely locally funded Poor Law in fact encouraged all citizens to think and act more purposefully about the problem of insecurity of income, health, and welfare, issuing in a wider range of private responses and behaviors than in most other societies. In other words, the state’s institutionalization of the fundamentals of social security, by bringing into reality a juridically contested practice in every town and village throughout the land, created the world’s first “welfare society,” a people for whom the issue of the livelihood and security of not only their own family and their neighbors but also of perfect strangers was now defined as their own problem, unless they could prove otherwise.39 The onus and the burden of proof was decisively shifted by the Elizabethan Poor Laws and their enforcement in the subsequent century, in favor of a collective responsibility of all for all. This consequently created a whole new discourse of welfare and an associated legal practice supervised by magistrates, both within parishes and between parishes, about where such responsibilities properly lay. This entirely reverses the direction of causation posited in transition theory and “Washington consensus” thinking on the relationship of economic growth, social security, and state-backed welfare. In British history, a unique, carefully negotiated and practically enforced act of statecraft in the form of the Poor Laws provided the English population with an unprecedented degree of social security. This thereby both reduced the death-rate from food shortages and substantially altered the nature of

426

Health and Wealth

social relationships between land-owning and capital-owning employers and laborers throughout the economy, facilitating an altogether greater degree of flexibility and efficiency in the allocation of labor and other factors of production across the agricultural, the manufacturing, and the service sectors of the economy. Thus, the state-supported institutional innovation of creating a nationwide but highly locally devolved social security system caused alterations both in population health and in the perception and reality of human security.This then facilitated crucial economic change of a form that placed the highly productive British agrarian economy in an excellent position to benefit from the labor-using demands of a new, urban technology of mechanized factory production when it finally emerged in the late eighteenth century. This is a very different causal sequence from that envisaged by transition thinking and the exclusive focus of an earlier generation on the primacy of capital accumulation as the key to achieving industrial “take-off.”40

The Disruptive Nature of Modern Globalizing Economic Growth In the absence of a democratic franchise to defend the securities represented by the early modern Poor Laws, this precocious acquisition of dependable individual rights to social security in England was, however, rudely interrupted—ironically by the industrial revolution itself, which the social security system had itself partly spawned. Part of the reason for this was very simple and has its exact parallel in virtually all of today’s developing countries. Decades of extremely rapid and chaotic urban growth through immigration from the countryside produced a situation, by the early nineteenth century, where large proportions of urban inhabitants were quite simply “unknown” to either the national government or the local authorities in most cities (it has been estimated that by the mid-nineteenth century, two out of every three adult inhabitants of Britain’s industrial towns had been born elsewhere).41 The established church’s registration system had broken-down in many towns, partly overwhelmed with the numbers flooding in, but also because rising proportions of the new urban residents were nonconformists of many kinds or Catholics from Ireland, all of whom fell outside the purview of

Public Health and Security in an Age of Globalizing Economic Growth

427

the Anglican Church registers. As today in the shanty towns and slums of India, Africa, or Latin America, many were of no recognized address. In the early nineteenth-century there was no constituted agency or recognized authority to make maps of the country’s administrative boundaries or maintain street directories of its towns.42 The situation began to be addressed only in the 1820s when the increasing commercial and manufacturing property-holders of the northern and midland cities, many of them nonconformists, intensified campaigns to have their civil and political rights recognized.With the repeal in 1828 of the seventeenth-century Test and Corporation Acts (excluding Protestant dissenters from holding civil office) followed by Catholic emancipation in 1829, religious minorities were given equal rights to civic and political participation.The Great Reform Act of 1832 established the principles of a representative, property-owning democracy on a nationally uniform and statutory basis, although votes were only as yet available to a property-holding minority of less than one in five males. Local government was similarly remade in 1835 as a representative democracy for property-holders. In 1836, responding to overtures from the newly enfranchised nonconformists, Parliament legislated for a state-organized civil registration system, establishing a novel bureaucracy of a national network of locally resident salaried registrars to keep full and accurate records of all births, deaths, and marriages in England and Wales, regardless of religion (Scotland and Ireland were not granted such systems for another two decades).43 The century-long interruption in the historical development of individual rights to official recognition, created by the rapid economic and demographic growth of the industrial revolution, was thus resolved through the self-assertive political activities of the previously excluded nonconformists, and the administrative response of the reforming liberal state. Furthermore, with the availability of this centrally collated vital registration data, the Victorian public health movement was now able to find its voice and began to publish authoritative statistics on the diseased state of the crowded cities, a necessary adjunct to devising effective remedial policies.44 Thus, an essential element of the administrative groundwork for the democratic recognition of individual rights to health and security had been put back in place by the end of the 1830s. But simultaneously during the 1830s, the other dimension of state infrastructure, even more crucial for guaranteeing individual security and

428

Health and Wealth

capabilities in practice—the local, parish-funded Poor Law system—was drastically altered. In a close parallel to views that gained credence in Anglo-Saxon liberal democracies during the 1980s, such state-backed systems of social security were now disparaged. The chief apologists of the moral and economic virtues of the free market contended that this welfare system was overly generous, laxly administered, and a self-defeating encouragement to a dependency culture. Reverend Thomas Malthus was the most (in)famous of a number of powerful advocates of this viewpoint, which included a substantial element of the aristocratic landowning class.45 National expenditure on the Poor Laws was slashed in half in 1834, cut from approximately 2 percent down to 1 percent of national income.46 The 1834 New Poor Law’s intention was to remove graft and shirking. Parishes were to be centrally monitored by the new Poor Law Board in London, to excise local corruption. All those without work were now to enter workhouses, where they would perform tedious and arduous labor in return for their daily bread and soup, in the belief that this experience would return them to the labor market as soon as possible.47 The putting asunder of man and wife in the new workhouses (the sexes were to be separated on Malthusian grounds) represented a significant constitutional victory for the new morality of the “dismal science” of political economy over that of the Christian religion.This was bitterly resented in some quarters and a vigorous anti-Poor Law guerrilla campaign of civil disobedience erupted, particularly in the industrial north where some parishes refused to build workhouses, since much unemployment was recognized to be cyclical, not voluntary.48 There would seem to be more than a passing similarity between the centrally devised “one size fits all” Whitehall policy of 1834, the compound of moral and economic rationale, the grudging compliance, particularly where the one size patently did not fit, and the recent history of the structural adjustment programs handed down by the International Monetary Fund (IMF) to the world’s less developed countries during the last two decades of the twentieth century, with the IMF insisting that the borrowers radically reduce public expenditure on collectively provided public services on the argument that they cannot be afforded, distort the operation of the market, and are in any case conducive to corruption in their administration.49 The New Poor Law in effect replaced the post-Reformation principle of exclusion of individuals from the polity on doctrinal, religious grounds

Public Health and Security in an Age of Globalizing Economic Growth

429

with a new principle of exclusion on market economic grounds.This transformation in the statutorily sanctioned principles of social exclusion illustrates the breadth and depth of ideological, cultural, and social disruption that rapid economic growth entails. Even long-standing and powerful elite groups, such as the Church of England and the nation’s landowning oligarchy, found their own moral values and economic interests threatened and overturned. In the case of the landowners the great symbol of their political defeat at the hands of the rising commercial bourgeoisie was not the New Poor Law, which many of the more substantial landowners had supported,50 but the repeal of the Corn Laws in 1846, a protectionist statute that had kept agricultural prices high, benefiting the pockets of landholders at the expense of urban employers and their workers.51 Multiple dimensions of disruption are an inevitable concomitant of economic change on such a scale as occurred in Britain during its initial phase of widespread industrial mechanization and urban growth through rural immigration.52 At times like these there are undoubtedly great private opportunities to make fortunes for those with the wit and personal resources to take them, but at the same time this disruption threatens the security of all concerned, rich, middling, and poor. Established social and economic relations, ways of doing business, even ways of thinking, and recognized moral claims on others (kin, neighbors) and institutional sources of assistance (the Poor Law) are thrown into question. Population mobility and migration means that kin may no longer be accessible, neighbors may be strangers.53 As in Third World cities today, do-it-yourself forms of trust and mutual assistance come into being, born of necessity. In Britain, due to its long-term historical inheritance of the nuclear family household, extensive family and kinship links did not tend to provide the major support network in the towns. Instead it was often provided by small, even single-chapel congregations led by a local charismatic figure, or certain of the local business leaders themselves, endeavoring to look after their workforces as well as they could.54 Trade-based Friendly Societies of mutual insurance (and rudimentary trade unions) were also popular among those who could make regular payments to insure themselves against sickness or disability.55 These were primarily forms of bonding social capital.56 Thus, when in 1834 the state withdrew its support for the poor (as has happened in many developing countries today under structural

430

Health and Wealth

adjustment programs and also in the U.S. with welfare cuts), access to support in these circumstances became closely tied to membership of exclusive groups, such as religious congregations, workingmen’s associations, or the workforces of a suitably paternalist company.The plight of Silas Marner in George Eliot’s novel of that name (published in 1861) is a celebrated literary example of the dire social consequences for the individual of exclusion from such sects and their support networks at this time. In the absence of collective local government or state provision of adequate social security for all, reliance on these islands of support necessarily creates around them a sea of potential deprivation, engulfing all those who cannot gain access because they do not qualify for membership. If the sea of deprivation is too deep and if too many of the deprived are too weak, they may drown in large numbers, particularly of course the most dependent groups—women, children, migrants, the aged, and any others with insufficient social supports. This certainly happened in Britain’s industrial towns during two long decades of economic fluctuations and ferocious epidemic, endemic, and sanitary diseases in the 1830s and 1840s. And her sister island, Ireland, administered by the same laissez-faire ideology of government in Whitehall,57 was of course engulfed during this same period in the tragedy of the Great Famine.

The Institutional Basis for Securing Population Health under Conditions of Economic Growth Contrary to the transition myths and the dominant postwar models, not only has the initial process of industrialization usually been a costly one in terms of human health and security, but the subsequent, continuing pursuit of economic growth also entails continuing disruptive challenges, as both the physical and the social environment are continually transformed. The British historical record indicates that British society, in common with most other successfully “developed” countries, has evolved three categories of state-backed protective institutions to accommodate such continuous change.These have been vital in ensuring that the disruptive tendencies of economic growth have been harnessed so that economic change has, in general, been associated with rising, not deteriorating public health and human security. The popular notion that

Public Health and Security in an Age of Globalizing Economic Growth

431

economic growth itself automatically delivers these benefits if given enough time is an illusionary view that overlooks the crucial mediating role played by these three state-supported institutions. The first of these three institutions is a system of universal registration of all individuals from birth, guaranteeing legal acknowledgment of their civic existence and rights in all their diversity of social, religious, and ethnic identities.The second is a legal system that provides the conditions for a flourishing civic society: a free press, elected and independent local government, and freedom of association.58 The third is some form of comprehensive welfare, insurance, or social security system: that is, the securing, with the sanction of the central state, of locally effective collective provision for citizens’ legitimate aspirations for their own personal security and mental and physical health. In British history, the evolution of these three essential institutional provisions took centuries to accomplish and was profoundly disrupted—not simply spurred on—by the process of industrialization, as the previous section’s account of the history of the Poor Law and vital registration has shown. Indeed, the first century after Britain’s industrial revolution, from c.1815 until c.1914, was characterized by a very slow, hesitant, and conflict-ridden process, full of reverses, of building up the second of these three institutional forms, a legal system that permitted the civic associations—the bridging and linking social capital so essential for a liberal society’s capacity to cope with the conflicts and challenges of economic growth—to flourish. Elected, representative local government was reformed in response to popular pressure in 1835. However, this produced not a fully democratic electorate but a narrow, petty bourgeois “shopocracy” until further reforms in 1869 for municipalities and 1889 for counties. Trade unions, the litmus test of freedom of association in a market economy, had existed in the eighteenth century but had to contend with the restrictive legislation of the Combination Acts, 1799–1824.The unions did not become more securely established until the 1850s and were still embroiled in critical legislative appeals over their practical rights and powers during the first decade of the twentieth century.59 Professional associations, too, struggled to reform themselves from 1815 onwards, but by the last third of the nineteenth century were increasingly taking the form of accountable organizations, licensed by the state through public examination to provide a range of commercially valuable intellectual services.60

432

Health and Wealth

The many other, more informal types of civic association also increasingly flourished, while undergoing something of a shift in character from the predominantly bonding forms of denominational, paternalistic, or mutualist forms of social capital formed for self-protection purposes in the precarious early industrial society, c.1780–1850, to the more consumerist and leisure-oriented bridging social capital of associational activities, such as soccer-playing and spectating, mother’s unions, or music halls, all of which characterized the more affluent and stable urban communities of the later Victorian and Edwardian eras.61 The checkered history of press freedom, a crucial legal foundation to release the powers of civic association, also tracked this process. Britain in the mid-eighteenth century was endowed with a comparatively literate and highly urbanized population informed by a range of provincial weekly newspapers.62 However, the British state sought increasingly to restrain the press through taxes on paper and advertisements, and a heavy “stamp duty” (per printed sheet!). At times of difficulty for the national government the duty was successively raised—in 1776, 1789, and 1797—with the intention of dampening popular protest. Not until 1836 was there a significant relaxation in this regime of discouragement, with all taxes on the press finally repealed in the period 1853–61.63 During the subsequent four decades of the nineteenth century, armed with a genuinely free press and also an increasingly more democratic electorate following the important national and local franchise reforms 1867–89, and led by certain of the larger municipal authorities, the public health movement, their allies in the emerging public service professions, and sections of the labor and feminist movements, the nation’s civil institutions began to renegotiate further expansion in the third vital protective institution: collective provision of effective health and social security systems, which had languished since the repeal of the old Poor Law in 1834. For several decades in late Victorian Britain this proudly provincial social movement put into practice ideals of municipal self-government. From the 1870s through to the 1900s, in return for the urban middle classes agreeing to greater taxes on their wealth and property, while the working classes often incurred increased indirect taxes (e.g., through their use of monopoly municipal services such as gas, electricity, and tramways), Britain’s cities and towns were at last able to make the necessary hefty collective investments to maintain and even promote population health in

Public Health and Security in an Age of Globalizing Economic Growth

433

the urban environment.This included sanitary systems and public housing, paved and cleansed roads, and health promotion services, from food inspectors to universal education, maternity services to public baths.64 This movement for urban social reform metamorphosed through a sequence of rhetorical forms focusing on local government as the appropriate executive agency. The pioneering 1860s civic gospel became in the 1870s “gas and water socialism” and by the 1890s was being promoted as the “Progressive” program of the London County Council (LCC, formed in 1889).65 The ideas and policies innovated and developed over these decades in local government practice eventually fed into national government thinking and policies following the galvanizing Edwardian call to “National Efficiency.”66 This movement was a protracted moral panic in response to the growing uneasiness of public opinion at the imperial rivalry to Britain’s military and commercial might represented by the new industrial powers of Germany, United States, and Japan.The state of health and physical efficiency of Britain’s industrial and military manpower became of serious concern. Under the “New Liberal” government, which was continuously in power from December 1905 until the outbreak of World War I, there emerged an entirely new preparedness on the part of public opinion to support a wide range of ambitious and expensive insurance-based pension and social security schemes and public health measures for infant, child, and maternal health and for adult male workers.Though still far from universalist in their remit, the novel degree of central funding and organization required to deliver these various initiatives to restore “national efficiency” required a transformation in the nation’s fiscal regime, with the introduction by Lloyd George of a progressive national income tax. It was coincident with these radical new departures in municipal and, eventually, in central government activism, from the 1870s onwards that, with cumulative expenditure on urban infrastructure and a wide range of public health services at last beginning to rise significantly on an ever-increasing trajectory, the health conditions of Britain’s wealthproducing towns and cities finally began to experience substantial improvements. In the 1870s urban expectation of life at birth lifted for the first time above the levels of the 1810s and 1820s, and then experienced sustained improvement in each subsequent decade.67 These improvements, along with the increased voting power of both working-class men and all women, consolidated by the final democratic

434

Health and Wealth

extensions of the franchise in 1918 and 1928, resulted in Labour-controlled local government authorities being elected in the interwar period and, eventually, in the return of a majority Labour administration in central government, 1945–51. This national administration then enacted a centrally funded, comprehensive health and social security system in the form of the Beveridge welfare state (in fact a compromise of an insurance-based but universalist system).68 State-guaranteed protection for individuals had been significantly enhanced between 1908 (the old age pensions act) and 1911 (the National Insurance Acts) but only now, symbolized by the passing of the National Health Act in 1946, was the nonstigmatizing, universalist principle of social security—obtaining for two centuries prior to 1834—once more reasserted in British society. Britain was now fully in possession of all three of the institutional resources necessary for ensuring that population health is not unduly threatened by continuing economic growth.

The Historical Creation of Global Institutional Def icits When we consider today’s less developed countries and regions— notably in Africa, much of Asia, Latin America and the Caribbean—there are clear and massive deficits in terms of all three of the institutions identified here as crucial for the preservation of population health and social security under conditions of global economic growth.This is because the histories of the countries in these regions since the eighteenth century (themselves very diverse, of course) have been extremely different from Britain’s. As emphasized in the review of British history, the emergence of the three state-sanctioned institutions has taken considerable time.The histories of today’s less developed countries have been so different in this respect partly because of their colonial relationships with the “successful” industrializers of the northern hemisphere. The mercantile and industrial revolutions of western Europe and North America also affected and transformed these other continental areas of the globe and their indigenous polities and peoples (and could not have happened without the trade and raw materials drawn from them). But the relationship between the capital-accumulating North American and European imperial metropoles and these southern and eastern trading partners was, as is well known, highly unequal. Many of

Public Health and Security in an Age of Globalizing Economic Growth

435

the populations of these vast areas were subject to formal, colonial, or imperial domination (for instance, India) or to practical dependency status (for instance, China) throughout much of the period from 1750 to 1945 or even until the 1960s. The main apparent exceptions were the several independent countries of Latin America. However, having precociously flung off their Spanish and Portuguese colonial rulers in the early nineteenth century, most Latin American states then fell prey to vicious, nepotistic, postcolonial, neo-aristocratic elites, who relied on primitive rather than industrial capital accumulation, often through slave-labor, to exploit their enormous continent’s rich natural resources and its agricultural potential for their own private and dynastic interests.69 Consequently, the three constitutional and institutional developments identified above as crucial in order that societies, faced with the challenges and disruptions of global economic change, can evolve the political and civic capacity to pursue their own health and security agendas, never occurred in most parts of these three, continent-scale regions of “underdevelopment.” Whereas these legislative and constitutional innovations—and associated changes in the social relations between citizens and their agencies of both local and national government—took decades or even centuries to negotiate in the histories of today’s most developed nations, they were blocked at source in Africa, in large tracts of Asia, and in much of Latin America and the Caribbean—often by the self-same colonizing states whose domestic societies were gradually evolving these institutions for themselves those countries that make up most of today’s OECD nations.70 The possibility for the creation of such a set of legal institutions in a dependent society was inimical to the political requirements of the dominant, colonial (usually European) power; and also to the interests of the neocolonial plantation and ranch elites of Latin America. Individuals were not granted meaningful voting rights if at all possible; they were to be permitted at best only carefully policed rights of civic association.The central state (the colonial government) mainly wished to use local rulers or authorities as transmission mechanisms for its own centrally administered policies and was not interested in endowing them with the status of elected authority.71 The census enumeration, rather than the civil registration of individuals, was the favored method for demographic intelligence-gathering. Such censuses were not taken to ensure a diverse citizenry’s individual

436

Health and Wealth

property rights, nor were they used to inform an expensive strategy of effective public health measures, the two principal uses of the civil registration system in Britain.72 The colonial census was principally a tool for acquiring economic knowledge of where resources were located and a surveillance exercise for law and order purposes to keep the costs of policing under control.73 Hence, the efficient registration of deaths in order to analyze their causes and to prevent their incidence was of much less pressing interest to the authorities in India than it was in England, where the relevant census official,William Farr, became the world’s leading expert on the subject.74 In India, the geographical distribution of religions and castes was of much greater interest to the census authorities, especially following the trauma of the Indian mutiny in 1857, after which the British believed that specific Indian castes had to be monitored carefully.75 A convenient, evolutionary, racist ideology explained and justified the absence of civic rights for the colonized peoples, who were considered to be not yet ready for the responsibilities of self-government.76 The governing interests of the imperial states firmly committed them to maintaining these dependent societies and their citizens in a limbo of constitutional underdevelopment. Thus, during the period from 1770 to 1950 citizenship, civil society, and state relationships gradually evolved in western Europe and in those parts of the globe in which migrants from these states had settled permanently after suppressing the indigenous peoples (principally North America and Australia). These societies gradually adapted to the challenges of rapid economic growth in a manner that broadly resembled the British historical course, in that the three essential institutions emerged. But, through the direct and indirect influence of the formal and informal trading empires that these same states and their wealth-owning classes established throughout the globe, they simultaneously prevented virtually all other societies under their control from adapting in similar ways so as to be able to develop the three categories of essential state and civil institutions required to cope with the disruptive character of world economic growth during these two centuries. When decolonization and independence came to these parts of the world rather suddenly in the three decades after 1945, world economic development did not stop to enable these societies—lacking a history of the development of state-recognized individual citizenship, civic associations, elected local self-government, and collective welfare and social

Public Health and Security in an Age of Globalizing Economic Growth

437

security provision—to catch-up with a century and a half of suppressed historical adaptation. These societies, having a long tutelage in dependence as the worst possible preparation, were immediately subjected to all the disruptions and demands of ongoing globalizing economic growth after 1945. In fact, in many ways, the period of tutelage was prolonged for most of these countries for a further three to four decades because of the clientalist relationships eagerly sought by the two nuclear superpowers, the U.S. and the U.S.S.R.Thus, the tendency, already marked under formal colonial regimes, for small, trusted (by the foreigners), subaltern elite groups and families to garner most of the power and economic resources through their personal contacts at the very center of the colonial state’s administrative apparatus was further emphasized in these initial decades of independence. At least this protracted period of Cold War clientage permitted the independent governments of many poor countries to enjoy a reasonably dependable flow of resources from their patrons. Although much money went into private bank accounts, in most countries enough of it found its way into the young state’s investment programs so that roads, schools, and hospitals were built between the 1950s and the 1970s. And more importantly, precious human capital to staff the schools and hospitals was increasingly forthcoming, much of it initially trained through exchange programs set up by the nations of the rival liberal and communist ideological blocs of the First and Second Worlds. There were also, of course, substantial UNESCO educational and WHOsponsored health programs during this period, such as the celebrated smallpox eradication program and a range of other significant initiatives.77 When we calibrate the experience of many Third World countries in the 1945–89 era against the historical model that has been set out here of the three crucial institutional developments that most First World countries had achieved by 1950, it is clear that their most obvious weakness has been in the civic institutions of elected local government, freedom of association, and a free press providing the essential legal framework for civil associations giving voice to the interests of diverse social groups. Individual citizens certainly have had a reasonable range of formal democratic rights conferred upon them in most postcolonial states, including universal suffrage.There were also promising incipient signs of collective provision by the state in terms of education, health, and social security between the 1950s and the 1970s. But now we can see, given the

438

Health and Wealth

relatively rapid way in which many of these societies and their infrastructural systems have buckled—and some have virtually collapsed—during the 1980s and 1990s, how fragile and unviable these formal individual rights and a relatively proactive central state are—without the vital third institutional support of civic freedoms and independent associations as well.These institutions took a long time to evolve, deepen, and multiply in the history of the developed nations.They are vitally important to making merely formal individual rights substantial and useful in practice. In order supposedly to boost the vigor and scope of competitive free markets and liberal democracy, the Washington consensus waged a messianic war throughout the 1980s and 1990s on state capacity in the First World, the Second World of the ex-Comecon transition countries, and the Third World. This policy simply ignored the intimate historical relationship of interdependence between strong states and strong markets. For, as Hernando de Soto’s historical reconstruction of the emergence of capital itself in the West demonstrates, only states strong enough to provide a universally available system of sanctions to guarantee individuals’ legal titles to their diverse property holdings could provide the basis for effective markets in capital within civil society to develop in the first place.78 This is an amplification of a theme that also emerges from the earlier Nobel prize-winning work of D. C. North, who emphasized the importance of the rule of law in sustaining the property rights that underpin the incentives for individuals to engage in market activity.79

Lessons From History, and a Very Different Set of Development Policy Priorities If there is one single foundational policy that the world’s poorest states should be encouraged to undertake in pursuit of their citizens’ long-term health and wealth, it is to start at the legal and civic ground level by establishing a comprehensive, reliable, and secure civil registration system for all their individual citizens.The World Bank should provide the necessary financial grants and technical expertise to launch such civil registration systems to empower citizens with their own identities. For, without an accessible legal identity, most positive civil, social, and economic rights are difficult to assert or deploy, while the individual’s ability to function

Public Health and Security in an Age of Globalizing Economic Growth

439

economically is severely constrained to a local context or a network of familiars. Correspondingly, in a fast-changing economy, the capacity of central or local governments (or NGOs) to devote scarce resources to effective promotion of social security and public health measures is extremely limited without accurate, locally precise intelligence, derived from individual-level data, on demographic trends and epidemiological patterns.80 This important data must, however, also be securely protected from improper use, either by the state or by private organizations.While domestic laws are probably an adequate safeguard against the latter, binding international human rights treaties and sanctions are necessary to ensure against the former threat. Indeed, the crucial importance of all people’s right to legal recognition of their identities and official acknowledgment of their existence only underlines the equally crucial need for powerful constitutional laws and international agreements to prevent the abuse of such information systems. In his path-breaking analysis, Hernando de Soto identifies the failure of an appropriate system of formal property law to develop in many countries, such as his native Peru, as a gross institutional disability preventing capital formation among the poor.81 This failure restricts the commercial usage to which all but the richest in society (who alone can afford the costs, bribes, and delays of the tortuous legal processes) can assign their assets— homes, land, businesses. For the rest, their inability to gain legal formal title to their assets means that these cannot be used as capital in the conventional economic sense, as a security to generate credit or funds for investment. But de Soto’s policy prescription is radically incomplete in practical terms. He focuses on only one half of the problem of creating fixity and security of legal title, and omits the question of the legal personhood of agents themselves in many poor countries.As we have seen, from the sixteenth century onwards in British history the two aspects worked together, in the form of the common law’s rules of property ownership and the Henrician parish register system.Thomas Cromwell, the crown servant who introduced the nationwide registration of all births, deaths, and marriages saw its utility “for the avoiding of sundry strifes and processes and contentions arising from age, lineal descent, title of inheritance, legitimation of bastardy, and for knowledge, whether any person is our subject or no.”82 Cromwell’s register system created a state-backed institutional framework enabling individuals to establish their secure title to property

440

Health and Wealth

ownership and so facilitated the development of mobile British capital markets sufficiently to facilitate the mercantile and industrial revolutions.As we have seen, this institutional structure was jeopardized by its own success in the disrupted era of the world’s first industrial revolution, but was then brought back into full working order with the creation in 1836 of the modern civil (secular) registration system, which was finally much improved, from a human rights point of view, through the legal reforms from 1870 onwards, which recognized married women’s property rights.83 In addition to this new level of legal recognition for every individual person, international organizations such as the World Bank should be providing every incentive possible for the governments of poor countries to invest in and build up these human resources, whose existence and rights should be formally acknowledged by the state through registration, and to provide them with the social security institutions to enable persons to move within the economy without this being such a drastic option as it is in many of today’s poorest countries, where places like the Nairobi slum are the necessary destination of economic migrants.Again, this policy prescription is consistent with the historical evidence that Britain, on the eve of its industrialization in, say, 1750, was a society characterized by one of the highest levels of literacy and physical mobility within Europe, as well as by a relatively high level of average health, and that these factors, along with a well-developed social security system, were important facilitators of the high level of economic productivity then being achieved. This picture also corresponds with a significant strain of new econometric research, which is increasingly examining the hypothesis that the much-observed and debated statistical association between enhanced economic productivity and improvements in population health and the quality of human resources may, in fact, represent predominantly an outcome whose line of causation runs from human health to economic growth, rather than vice-versa.84 This hypothesis would, of course, indicate the importance of a set of policies heretical for the Washington consensus, emphasizing investment in the public goods of health, security, and education of all citizens as a top priority in place of the gospel of opening up the economy to the market forces of individualist enterprise while reducing government interventions. Indeed, other econometric historians have published work directly contradicting the policy-implications of the Washington consensus, that “Wealthier is healthier” (the title of an

Public Health and Security in an Age of Globalizing Economic Growth

441

influential article co-authored by Larry Summers in 1996, whose analysis has now been directly questioned85). Easterlin, for example, with respect to health, has answered the question “How beneficent is the market?” predominantly in the negative.86 Most importantly from a policy point of view, the recent review of the evidence by the Commission on Macroeconomics and Health, chaired by Jeffrey Sachs and published by WHO, came out strongly in favor of the proposition that the evidence it has reviewed indicated that investment in health and social services should most correctly be seen as an important input to economic productivity, not simply as a possible output from it.87 It also needs to be recognized that only in a gradual and organic manner can poor countries build the all-important civic institutions and voluntary associations (such as trade unions and professional associations) that are necessarily intimately related to their capacity to develop a wide range of economic activities and social services to supply their own needs. The world’s international organizations—such as the UN, WHO, ILO,World Bank, and even the IMF and WTO—must call for and work toward a new era of contingent protectionism. Only a self-denying ordinance from the world’s wealthiest nations, corporations, and the WTO will allow poor countries the breathing space to develop their industries and economies at their own pace and follow their own domestic population’s gradually rising demand levels for goods and services, rather than to focus on servicing the demand for a narrow range of goods that Western consumers want at the lowest prices and for which the poor countries happen to have a comparative advantage. Indeed, this comparative advantage often amounts to little more than very low labor costs because of the absence of trade unions and practical capacities to exercise freedoms of speech and association, which are among the very institutions that the World Bank and most “Western” organizations claim they wish to promote in less developed countries. However, paradoxically, the globalizing forces of free market economics are rewarding the world’s poorest countries if they keep their workers and citizens in a state of institutional impoverishment, reproducing the patterns of the colonial era. As this chapter has argued it is because of a radically flawed understanding of the historical relationship between economic advance and the three sets of civic and legal institutions discussed here that these self-contradictory policies continue to be pursued.

442

Health and Wealth

The historical analysis offered here indicates that only the most developed economies with the most comprehensive social security protections in place should be exposed to the full competitive rigors of global free markets, since they alone have the institutional and governmental machinery—their legally empowered citizenry, their civic associations, and their welfare or insurance states—to stand up to its disruptive effects. All the world’s poorest societies should be granted general exemptions from free trade. In fact selective protectionism has an impeccable historical pedigree, in that it was the primary policy that the governments of the U.K., U.S., France, Germany, and Japan, for instance, all followed at earlier points in their own economic development when it suited them to nurture their nascent industrial economies.88 Restrictions on exposure to free trade should only gradually be lifted, as the three vital state and civic institutions identified here (and not simply a country’s per capita GDP) develop in strength and depth.89 This process is almost the opposite of the policies pursued throughout the 1990s by the WTO and especially the IMF, which have instead imposed open exposure to international capitalism and trade only on the poorest countries, unable to resist the insistence on conditionality clauses in return for life-saving loans. By contrast, the WTO and IMF have often remained relatively impotent to force the richest countries, with the entrenched lobbying power of the producer interests, to drop their favored protection for large sectors of the economy, such as agriculture in both Europe and the U.S.90 Indeed, the IMF represents probably the single most important and egregious case for its own reform, among all the international institutions, since it is so patently undemocratic in its constitution, with most countries having so little voice at its decision-making table. Finally, it must be noted that the lessons of history are not simply that once they have been developed, the three sets of vital civic institutions discussed in this essay can be considered established for all time and their benevolent and protective effects henceforth be taken for granted. Given the intrinsically disruptive global search for new kinds of markets and profits under conditions of economic growth, citizens must practice eternal vigilance, continually exercising these important institutional tools for their own civic empowerment, while seeking to extend their remit to all countries who seek to engage with the global economy, lest they atrophy or become subverted.

Public Health and Security in an Age of Globalizing Economic Growth

443

Notes 1.This essay is a revised version of an address, bearing this title, given on 27 November 2003 as the launch lecture for the Centre for History in Public Health of the London School of Hygiene and Tropical Health. I am grateful to Professor Andy Haines, the Dean of the School, and to Professor Virginia Berridge, the Director of the Centre, for the invitation to deliver the lecture. This essay reintegrates much material that has been published separately in three places but, that was, in fact, originally drafted as a single text. I am grateful to audiences at LSHTM and at UCL’s seminar in Social Epidemiology for their comments on an earlier version. 2. Archaic globalization refers to the intercontinental, city-based trade, migration and universalist belief systems of the great premodern empires, such as Byzantium, Tang China, and the Islamic Arab umma. Proto-globalization relates to the period from c.1500 until c.1800, when world fiscal and financial systems were transformed under the pressure of globally competing Muslim and numerous Christian state-empires (Ottoman, Austrian, Polish, Swedish, Russian, Portuguese, Spanish, Dutch, French, and British), along with Qing and Ming China: Hopkins (2002). 3. See this volume, chapter 3. 4. See Burke (1992), chap. 5, esp. 130–41; and Szreter (1996), 21–24. 5. Notestein (1945); Davis (1945); Coale and Hoover (1958). See this volume, chapter 3. 6. Omran (1971). 7. McKeown (1976). For critique of McKeown’s work, see this volume, chapters 4 and 5. 8. See Johansson (1994) for a critical review of the links between Fogel’s project and McKeown’s interpretation: Fogel (1986); Fogel (1991); Fogel (1992). 9. World Development Report 1991, chap. 3, “Investing in People.” Sam Preston’s important cross-national statistical research was published at the same time as McKeown’s bestseller. Preston’s research indicated that during the course of the twentieth century rises in societies’ and states’ overall investments in health-promoting technology and services were in fact a more significant source of gains in average life expectancy than economic growth per se, as measured by rising per capita incomes: Preston (1975; 1976). Having simply excluded any mention of Preston’s work from consideration in the World Bank’s flagship policy document of 1991, several years later Summers coauthored with Lant Pritchett an article that did at least acknowledge some of Preston’s work. Pritchett and Summers deployed a cross-national comparative statistical methodology, which, it was claimed, demonstrated different conclusions from Preston’s, showing that “Wealthier is healthier,” as its title proclaimed. However, the validity of the Pritchett and Summers approach has now been directly challenged by Case and Deaton (2004) and by Jamison, Sanbu, and Wang (2004), who have applied a technically superior methodology.Also see notes 84 and 86 below for references to other subsequent econometric studies,

444

Health and Wealth

which have produced results whose policy implications are more in line with those of Preston’s analysis. 10. Cohen (1989), chap. 7; Steckel and Rose (2002). 11. Burnet and White (1972); McNeill (1976); Crosby (1986). 12. Cipolla (1976). 13. Crosby (1972). 14. Le Roy Ladurie (1973). 15. See this volume, chapter 7, note 3; and chapter 1, note 75 on the Swedish “exception” that proves the rule. See also: Bourdelais and Demonet (1996). 16. Bengtsson and Dribe (2000). 17. Neal (1998). 18.Watts (1997); Davis (2001). 19. Feinstein (1998). 20. Floud,Wachter and Gregory (1990). 21. See this volume, chapter 6. 22. Harley (1999);Wrigley (2000). 23.Wrigley (1987), table 7.6. In 1700 13.4 percent of England’s population was urban and in 1800 24.0 percent. Meanwhile the average for the rest Europe had remained almost constant, rising from 9.2 to 9.5 percent.The term “advanced organic economy” comes from E. A. Wrigley’s important reinterpretation of the industrial revolution:Wrigley (1988). 24. Israel (1995). 25.Wrigley (2004). 26. Lis and Soly (1979); de Swaan (1988); van Leeuwen (1994). 27. Solar (1995). 28. Slack (1990). 29. Outhwaite (1991), chap. 2. 30. Solar (1995). Note that Steve King has disputed Solar’s interpretation, pointing out that the practices of the Poor Law in England varied substantially in different regions, counties, and even adjacent parishes: King (1997b). Solar responded that, despite such variation in practices, the force of the comparative perspective was precisely the point that there were relief practices occurring everywhere throughout England—albeit in their profusion of local differences— whereas on the continent they simply didn’t exist at all across extensive tracts of the country: Solar (1997). In his most recent contribution King uses evidence for the eighteenth century to argue for two different regional Poor Law regimes, accepting Solar’s depiction for the more populous south and east, where about two-thirds of the population resided in 1701 (see this volume, chapter 10, 356, and discussion Table 10.3), while claiming that in the north poor relief was often operated in a much more stringent and parsimonious fashion, pushing poor people’s survival capacities to the limits: King (2000), esp. chap. 7. However, this would still leave substantially intact Solar’s main point concerning the role of the Poor Law as an important contributory explanation for the exceptional productivity of

Public Health and Security in an Age of Globalizing Economic Growth

445

England’s agrarian economy since it was predominantly located in the south and east, c.1550–1750. 31. Macfarlane (1978), 82–83, citing F. W. Maitland, the eminent historian of English law. 32. From the late seventeenth century individuals could be issued with portable certificates from their parish of settlement acknowledging its responsibility for their relief: Solar and Smith (2003), 472. 33. Solar (1995). 34. Sen (1999). 35. Nutt (2005). 36. Galloway (1988). 37. King and Tomkins (2003). 38. Feldman (2003). 39. See the interpretation along these lines of Lyn Hollen Lees (1998). 40. Rostow (1960). 41. Feldman (2000), 185. 42. Fletcher (1999). 43. Glass (1973b); Eyler (1979), chap. 3; Higgs (2004b), 9. 44. See this volume chapter 8. 45. Brundage (1978). 46. Lindert (1994), 385–86. 47. Crowther (1981). 48. Rose (1970). 49. Stiglitz (2002). 50. Mandler (1987). 51. Pickering and Tyrrell (2000). 52.Taylor (1989); Pooley and D’Cruze (1994). 53. Hitchcock et al. (1997); King (1997a); Sokoll (2001). 54. Gilbert (1976); Roberts (1979). On the plethora of small, nonconformist congregations and their charismatics, see Mason (1994), 15–43. 55. Gosden (1993); Neave (1996). 56. See this volume, chapter 11, on social capital and its different forms. 57. Brundage (2002), 84–85. 58. For an excellent historiographical survey, see Trentman (2000), esp. “Introduction.” 59. Clegg, Fox and Thompson (1964); Reid (2004), parts 1 and 2. 60. Reader (1966); Perkin (1989). 61. Cunningham (1990); Benson (1994). 62. Read (1961), 59. 63. Koss (1991), chaps. 1–2. 64. See this volume, chapters 4, 7. Wohl (1983); Bell and Millward (1988). 65. See this volume, chapter 7. 66. See this volume, chapter 9.

446

Health and Wealth

67. Bell and Millward (1998). Note that the important research of Bell and Millward can be misread as appearing to suggest that little significant sanitary investment was made by British cities until the 1890s, partly because the authors’ own summary of their findings encourages such a reading.While Bell and Millward’s data confirms that substantial increases in such expenditure occurred in both the 1890s and the 1900s, they themselves acknowledge that their evidence source does not cover the period before 1882 in such a way as to enable them to draw detailed conclusions about the trends of such investment during those decades. However, they do note that the scale of urban indebtedness recorded in their evidence strongly implies that substantial investments must have been made in many towns in the 1870s and 1880s. In fact we know from a different source of evidence—the central government records of the Local Government Board—that the amount of subsidized loans from the Exchequer made to local authorities for sanitary purposes rocketed after 1872, averaging over 2.5 million pounds each year thereafter, through to the end of the 1880s, compared to less than 0.5 million per year between 1848 and 1872: Wohl (1983), 162–63. Although the sums involved were much less than the total of municipal expenditure subsequently entertained in the 1890s (when such loans, incidentally, also rose to over 5.0 million per annum), the crucial point is that this hike in sanitary investment in the 1870s represented a turning point and a departure from the previous practice of very low levels of such expenditure.This is surely the key issue of historical substance, rather than merely to dwell on its modest scale relative to subsequent investments. Indeed, the fact that the increased investment in the 1870s represented the start of a cumulative trend, which thereafter gathered momentum, renders the initial phase of investments more, not less significant, as the marker of an important historical turning-point and the beginning of this process of continually increasing investment.The recent survey by Harris (2004) does not take this consideration sufficiently into account. 68. However, as chapter 10 points out, time has since proved that a flaw in this bold initiative was an over-commitment to central direction, a problem that has been compounded by each subsequent national government, of both parties, consistently attempting to resolve problems by taking ever more central control to themselves and reducing the financial independence and discretionary powers of elected local authorities, replacing them with centrally appointed bodies or private businesses.This has been a self-defeating attempt to guarantee geographical uniformity of treatment, which has dangerously undermined the vigor of elected local government, one of the crucial institutional elements for a healthy democracy. See Lowe (1998); Glennerster and Hills (1998); Johnson.(2004). 69. Engerman and Sokoloff (1997); Haber (1997). 70. Acemoglu, Johnson, and Robinson (2001). 71. This is not to say that the colonial state always achieved its aims. For a nuanced account of the complex and changing relationship between official information needs and forms of “intelligence” and the indigenous networks of knowledge and communication in the important case of India, see Bayly (1996).

Public Health and Security in an Age of Globalizing Economic Growth

447

72. See chapter 8, this volume. 73. Anderson B (1991), chap. 10. 74. Eyler (1979) and this volume, ch. 8. 75. Cohn B (1987). 76. Stocking (1987). 77. See for example Amrith (2004) on the joint WHO and Indian government investigation into of the value of issuing antituberculosis drugs in south India. 78. De Soto (2000). 79. North (1981). 80. For two contrasting examples of deficiencies in this respect, see Vilaveces (2004) and Greenhalgh (2004). 81. De Soto (2000). 82. Higgs (2004a), 39. 83. Holcombe (1983). 84. Ramirez, Ranis, and Stewart (1998); Arora (2001); López-Casasnovas et al. (2005). 85. See above note 9. 86. Easterlin (1999); and for important contemporary case-studies, see Homedes and Ugalde (2005). 87.WHO/WTO Commission on Macroeconomics and Health (2001). 88. Chang (2003). 89. It should be noted, incidentally, that the acknowledgment of such a new international policy principal of contingent protectionism for poor countries will in fact have almost no aggregate negative impact whatsoever on international investment, for the simple reason that almost all international investment capital flows between developed nations only. 90. Note that it was not the IMF but carefully targeted counter sanctions by the EU that persuaded President Bush in 2003 to abandon support for illegal tariffs to protect the ailing U.S. steel industry.

CONSOLIDATED BIBLIOGRAPHY

Reference Volumes Munk’s Roll of the Royal College of Physicians Plarr’s Lives of the Royal College of Surgeons of England. Annual Reports of the Registrar-General of England and Wales (ARRG): 1st to 83rd Annual Reports, (1837–1920). [In chapters 4, 6, and 8, numerous endnotes refer to these reports. They were originally issued in two series, one printed in Parliamentary Papers and another sent out from the GRO, including to copyright libraries. From the 18th ARRG (for 1855) onward the two series were identical but before that they varied in content. References here all relate to the series held in Cambridge University Copyright Library and therefore they may not correspond exactly to the Parliamentary Papers Series, where references are to the 1st–17th ARRGs.]

Abbreviations ARRG PP PDC R-G RC on PT

Annual Report of the Registrar-General of England and Wales Parliamentary Papers Interdepartmental Committee on Physical Deterioration Registrar-General of England and Wales Royal Commission on Physical Training

448

Consolidated Bibliography AJPH BHM BMJ CSSH EcHR HTR JECH JEcH JIH JRSS JSSL PDR PS SHM

449

American Journal of Public Health Bulletin of the History Medicine British Medical Journal Comparative Studies in Society and History Economic History Review Health Transition Review Journal of Epidemiology and Community Health Journal of Economic History Journal of Interdisciplinary History Journal of the Royal Statistical Society Journal of the Statistical Society of London Population and Development Review Population Studies Social History of Medicine

Official Publications and Documents Cabinet Office (1998) Bringing Britain Together:A National Strategy for Neighbourhood Renewal. Interdepartmental Committee on Physical Deterioration PP 1904 XXXII, Cd2175 (Report); Cd2210 (Evidence). Report on Public Health and Social Conditions PP 1909, CII. Report of the Committee Appointed by the Treasury to Inquire into Certain Questions Connected with the Taking of the Census PP 1890 LVIII, Cd.6071. Royal Commission on Physical Training (Scotland) PP 1903 XXX, Cd 1507 (Report); Cd 1508 (Evidence). R-G (1884–85): see Supplement to 45th A.R.R.G. R-G (1897) Supplement to 55th Annual Report of the Registrar-General Pt.2 (PP 1897, XXI). R-G (1905): see Supplement to 65th A.R.R.G. Supplement to 25th A.R.R.G., PP 1865, XIII. Supplement to 35th A.R.R.G., PP 1875, XVIII, pt. II. Supplement to 45th A.R.R.G., PP 1884–85, XVII. Supplement to 55th A.R.R.G., PP 1895, XXIII, pt. I. Supplement to 65th A.R.R.G., PP 1905, XVIII.

Published Sources Aberle, D. (1987) “What kind of science is anthropology?” American Anthropologist 89, 551–66. Abers, R. (1998) “From clientalism to cooperation: local government, participatory policy, and civic organising in Porto Alegre, Brazil” Politics and Society 26, 511–37.

450

Consolidated Bibliography

Abramovitz, M. (1989) Thinking About Growth: And Other Essays on Economic Growth and Welfare, Cambridge: Cambridge University Press. Abrams, P. (1968) The Origins of British Sociology 1834–1914, Chicago: Chicago University Press. Acemoglu, D., S. Johnson, and J. Robinson (2001) “The colonial origins of comparative development: an empirical investigation” American Economic Review 91, 1369–1401. Acheson, D. (1998) Independent Inquiry into Inequalities in Health Report, London: Stationery Office. Ackerknecht, E. H. (1953) Rudolf Virchow: Doctor, Statesman, Anthropologist, Madison: University of Wisconsin Press. ——— (1967) Medicine at the Paris Hospital, 1794–1848, Baltimore: The Johns Hopkins Press. ——— (1948) “Anticontagionism between 1821 and 1867” BHM 22, 562–93. ——— (1948) “Hygiene in France, 1815–48” BHM 22, 117–55. Adonis, A., and S. Pollard (1997) A Class Act. The Myth of Britain’s Classless Society, London: Hamish Hamilton. Alchon, G. (1985) The Invisible Hand of Planning: Capitalism, Social Science and the State in the 1920s, Princeton, NJ: Princeton University Press. Aldrich, R., and P. Gordon (1989) eds. Dictionary of British Educationists, London: Woburn Press. Allen, G. A. (1978) Thomas Hunt Morgan: the Man and his Science, Princeton, NJ: Princeton University Press. American Journal of Public Health (2003) Special section on “Population Health”, AJPH 93, 371–96. Amrith, S. (2004) “In search of a ‘magic bullet’ for tuberculosis: south India and beyond, 1955–1965” SHM 17, 113–30. Amsden, A. (1989) Asia’s Next Giant: South Korea and Late Industrialization, Oxford: Oxford University Press. Anderson, B. (1991) Imagined Communities. Reflections on the Origin and Spread of Nationalism (revised edn.), London:Verso. Anderson, M. (1988) The American Census: A Social History, New Haven:Yale University Press. ——— (1991) “The US Bureau of the Census in the nineteenth century” SHM 4, 497–513. Anderson, M. A. (1971) Family Structure in Nineteenth-Century Lancashire, Cambridge: Cambridge University Press. Appleby, A. (1978) Famine in Tudor and Stuart England, Liverpool: Liverpool University Press. Armstrong,W.A. (1981) “The trend of mortality in Carlisle between the 1780s and the 1840s: a demographic contribution to the standard of living debate” EcHR 34, 94–114. Arora, S. (2001) “Health, human productivity, and long-term economic growth” JEcH 61, 699–749.

Consolidated Bibliography

451

Balfour, M. C., R. F. Evans, F.W. Notestein, and I. B.Taueber (1950) Public Health and Demography in the Far East: Report of a Survey Trip September 13–December 13, 1948, New York:The Rockefeller Foundation. Ball, S. (1896) The Moral Aspects of Socialism, Fabian Tract 72, London: Fabian Society. Banks, J. A. (1954) Prosperity and Parenthood.A Study of Family Planning among theVictorian Middle Classes, London: Routledge and Kegan Paul. Banks, J. A., and O. Banks (1964) Feminism and Family Planning in Victorian England, Liverpool: Liverpool University Press. Banks, O. (1955) Parity and Prestige in English Secondary Schools. A Study in Educational Sociology, London: Routledge and Kegan Paul. Bannister, R. C. (1987) Sociology and Scientism: The American Quest for Objectivity, 1880–1940, Chapel Hill, NC: University of North Carolina Press. Bartrip, P. (1988) “Expertise and the dangerous trades, 1875–1900” in MacLeod R, ed, Government and Expertise. Specialists, Administrators and Professionals 1860–1919, Cambridge: Cambridge University Press, 89–109. Bates, R. H. (1989) Beyond the Miracle of the Market: The Political Economy of Agrarian Development in Kenya, Cambridge: Cambridge University Press. Baum, F. (1997) “Public health and civil society: understanding and valuing the connection” Aust N Z J Public Health 21, 673–75. ——— (1999) “Social capital: is it good for your health? Issues for a public health agenda” JECH 53, 195–96. ——— (2000) “Social capital, economic capital and power: further issues for a public health agenda” JECH 54, 409–10. ——— (2001) “Health, equity, justice and globalization: some lessons from the People’s Health Assembly” JECH 55, 613–16. Bayly, C. A. (1996) Empire and Information: Intelligence Gathering and Social Communication in India, 1780–1870, Cambridge: Cambridge University Press. Beaglehole, R., and R. Bonita (1997) Public Health at the Crossroads: Achievements and Prospects, Cambridge: Cambridge University Press. Beaglehole, R., and P. Magnus (2002) “The search for new risk factors for coronary heart disease: occupational therapy for epidemiologists?” Int J Epidemiol 31, 1117–22. Bean, L. L., G. P. Mineau, and D. L. Anderton (1990) Fertility Change on the American Frontier:Adaptation and Innovation, Berkeley: University of California Press. Behlmer, G. K. (1982) Child Abuse and Moral Reform in England, 1870–1908, Stanford: Stanford University Press. Bell, F., and R. Millward (1998) “Public health expenditures and mortality in England and Wales, 1870–1914” Continuity and Change 13, 221–50. Bellamy, C. (1988) Administering Local-Central Relations 1871–1919:The Local Government Board in Its Fiscal and Cultural Context, Manchester: Manchester University Press. Benson, J. (1994) The Rise of Consumer Society in Britain 1880–1980, London: Longman. Berg, M., and P. Hudson (1992) “Rehabilitating the industrial revolution” EcHR 45, 24–50.

452

Consolidated Bibliography

Berkman, L. (1995) “The role of social relations in health promotion” Psychosomatic Medicine 57, 245–54. ——— (2000) “Social support, social networks, social cohesion and health” Soc Work Health Care 31, 3–14. Berkman, L., and T. Glass (2000) “Social integration, social networks, social support and health” in Social Epidemiology, edited by L. Berkman and I. Kawachi, Oxford: Oxford University Press, 137–73. Berkman, L., and S. L. Syme (1979) “Social networks, host resistance and mortality: a nine year follow-up study of Alameda County residents” Am J Epidemiol 109, 186–204. Berkman, L., G.Thomas, I. Brissette, and T. E. Seeman (2000) “From social integration to health: Durkheim in the new millennium” Soc Sci Med 51, 843–57. Berkman, L. F., and I. Kawachi (2000) “A historical framework for social epidemiology” in Social Epidemiology, edited by L. F. Berkman and I. Kawachi, Oxford: Oxford University Press, 3–12. Berlinguer, G. (2002) Everyday Bioethics: Reflections on Bioethical Choices in Daily Life, New York: Baywood Pub. Berridge, V., and S. Blume (2003), eds. Poor Health: Social Inequality before and after the Black Report, London: Frank Cass. Bettcher, D., and K. Lee (2002) “Globalization and public health” JECH 56, 817. Bhaskar, R. (1978) A Realist Theory of Science, 2nd edn., Hassocks: Harvester Press. ——— (1979) The Possibility of Naturalism, Brighton: Harvester Press. Biagini, E. (1992) Liberty, Retrenchment and Reform: Popular Liberalism in the Age of Gladstone 1860–80, Cambridge: Cambridge University Press. Black, D. (1992) Inequalities in Health, edited by Townsend, P., and Davidson, N., (and including Whitehead, M., The Health Divide) London: Penguin. Blake, J. (1985) “The fertility of transition: Continuity or discontinuity with the past?” IUSSP International Population Conference, Florence,Vol. 4, Liège: IUSSP, 393–405. Booth, C. (1894), The Aged Poor in England and Wales, London: Macmillan. ——— (1899) Old Age pensions and the Aged Poor: a Proposal, London: Macmillan. Bourdelais, P., and M. Demonet (1996) “The evolution of mortality in an industrial town: Le Creusot in the nineteenth century” History of the Family 1, 183–204. Bourdieu, P. (1973) “Cultural reproduction and social reproduction” in Knowledge, Education and Cultural Change edited by R. Brown, London: Tavistock Publications, 71–112. ——— (1986) “The forms of capital” in Handbook of Theory and Research for the Sociology of Education, edited by J. Richardson,Westport, CT: Greenwood Press, 241–58. Bourgeois-Pichat, J. (1965) “The general development of the population of France since the eighteenth century” in Population in History: Essays in Historical Demography, edited by D.V. Glass and D. E. C. Eversley, London: Edward Arnold, 474–506. Bowler, P. J. (1989) Evolution. The History of an Idea, Berkeley (rev. edn.). Berkeley: University of California Press.

Consolidated Bibliography

453

Brand, J. L. (1965) Doctors and the State: the British Medical Profession and Government Action in Public Health, 1870–1912, Baltimore:The Johns Hopkins Press. Brentano, L. (1910) “The doctrine of Malthus and the increase of population during the last decades” The Economic Journal 20, reproduced in PDR 18 (1992), 147–66. Breslow, L. (1999) “From disease prevention to health promotion” Journal of the American Medical Association 281, 1030–33. Brewer, J. (1989) The Sinews of Power: War, Money and the English State, 1688–1783, London: Unwin Hyman. Briggs, A. (1961) Social Thought and Social Action: a Study of the Work of Seebohm Rowntree, London: Longmans. ——— (1968) Victorian Cities, (first published 1963) London: Penguin. Brown, G. W., and T. Harris (1978) Social Origins of Depression. A Study of Psychiatric Disorder in Women, London:Tavistock Publications. Brown, J. E., and P. D. Reagan, eds. (1989) Voluntarism, Planning and the State: The American Planning Experience 1914–46, New York: Greenwood Press. Brundage, A. (1978) The Making of the New Poor Law: the Politics of Inquiry, Enactment and Implementation 1832–39, London: Hutchinson. ——— (2002) The English Poor Laws, 1700–1930, Basingstoke: Palgrave. Brunner, E., and M. Marmot (1999) “Social organization, stress, and health” in Social Determinants of Health, edited by M. Marmot, R. Wilkinson, Oxford: Oxford University Press, 17–43. Bryder, L. (1988) Below the Magic Mountain. A social history of tuberculosis in twentiethcentury Britain, Oxford: Clarendon Press. Buer, M. C. (1926), Health, Wealth and Population in the Early Days of the Industrial Revolution, London: G. Routledge and Sons, Ltd. Bullers, S. (2000) “The mediating role of perceived control in the relationship between social ties and depressive symptoms” Women and Health 31, 97–116. Bulmer, M. (1984) The Chicago School of Sociology, Chicago: Chicago University Press. Bunce, V. (1999) Subversive Institutions:The Design and Destruction of Socialism and State, Cambridge: Cambridge University Press. Burawoy, M. (1979) Manufacturing Consent: Changes in the Labor Process under Monopoly Capitalism, Chicago: Chicago University Press. ——— (1985) The Politics of Production: Factory Regimes under Capitalism and Socialism, London:Verso. Burke, P. (1992) History and Social Theory, Cambridge: Polity Press. Burnet, M., and D. O. White (1972) Natural History of Infectious Disease 4th edn., Cambridge: Cambridge University Press. Burnett, J. (1983) Plenty and Want. A Social History of Diet in England from 1815 to the Present Day, (rev. edn.) London: Methuen. ——— (1991) “Housing and the decline of mortality” in Schofield R et al., eds. The Decline of Mortality in Europe, Oxford: Clarendon Press, 158–76. Burrow, J. W. (1966) Evolution and Society. A study in Victorian Social Theory, Cambridge: Cambridge University Press.

454

Consolidated Bibliography

Burt, R. (1992) Structural Holes: the Social Structure of Competition, Cambridge, MA: Harvard University Press. ——— (2000) “The network structure of social capital” in Sutton R, Staw B, eds. Research in Organizational Behavior, Amsterdam: JAI, 345–423. Bynum, W. F. (1983) “Darwin and the doctors: evolution, diathesis, and germs in nineteenth-century Britain” Gesnerus 40, 43–53. ——— (1994) Science and the Practice of Medicine in the Nineteenth Century, Cambridge: Cambridge University Press. Bynum W. F., E. J. Browne, and R. Porter, eds. (1981) Macmillan Dictionary of the History of Science, Basingstoke: Macmillan. Bythell, D. (1969) The Handloom Weavers. A study in the English Cotton Industry during the Industrial Revolution, Cambridge: Cambridge University Press. Cain, L. P., and E. J.Rotella (2001) “Death and spending: urban mortality and municipal expenditure on sanitation” Annales de Démographie Historique, 139–54. Caldwell, J. C. (1986) “Routes to low mortality in poor countries” PDR 12, 171–220. Caldwell, J. C. and P. Caldwell (1986) Limiting Population Growth and the Ford Foundation Contribution, London and Dover, NH: Pinter. Caldwell, J. C., A. G. Hill, and V. J. Hull, eds. (1988) Micro-Approaches to Demographic Research, London: Kegan Paul in association with Australian International Development Assistance Bureau and International Union for the Scientific Study of Population. Campbell, C. (2000) “Social capital and health: contextualizing health promotion within local community networks” in Social Capital: Critical Perspectives, edited by S. Baron, J. Field, and T. Schuller, Oxford: Oxford University Press, 182–96. Campbell, C., and P. Aggleton (1999) “Young people’s sexual health: a framework for policy debate” Canadian Journal Human Sex 8, 249–62. Carr-Saunders, A. M. (1922) The Population Problem, Oxford: Clarendon Press. Case, R. A. M., C. Coghill, J. L. Harley, and J. T. Pearson (1962) The Chester Beatty Research Institute Serial Abridged Life Tables (England and Wales, 1841–1960), London: The Chester Beatty Research Institute. Cashdollar, C. D. (1989) The Transformation of Theology,1830–1890:Positivism and Protestant Thought in Britain and America, Princeton, NJ: Princeton University Press. Cattell, V. (2001) “Poor people, poor places, and poor health: the mediating role of social networks and social capital” Soc Sci Med 52, 1501–16. Chadwick, E. (1965) Report on the Sanitary Condition of the Labouring Population of Great Britain (edited with an Introduction by M. Flinn), Edinburgh: Edinburgh University Press. Chalke, H. D. (1959) “Some historical aspects of tuberculosis” Public Health 74, 83–95. Chang, H-J (2001) Joseph Stiglitz and the World Bank:The Rebel Within, London: Anthem Press. ——— (2003) “The real lesson for developing countries from the history of the developed world: freedom to choose” last accessed January 2005 at: http://www. historyandpolicy.org/main/policy-paper-09.html.

Consolidated Bibliography

455

Chaplin, S. E. (1999) “Cities, sewers and poverty: India’s politics of sanitation” Environment and Urbanisation 11, 145–58. Chapman, S. D. (1987) The Cotton Industry in the Industrial Revolution, 2nd edn., Basingstoke: Macmillan. Chen, J.,T. C. Campbell, J. Li, and R. Peto (1990) Diet, Lifestyle and Mortality in China: A Study of the Characteristics of 65 Chinese Counties, Oxford: Oxford University Press. Cherry, S. (1980) “The hospitals and population growth: the voluntary general hospitals, mortality and local populations in the English provinces in the eighteenth and nineteenth centuries”, Parts 1 and 2, PS 34, 59–75 and 251–66. Chesnais, J. C. (1986) La Transition Démographique, Paris : Presses Universitaires de France. Cipolla, C. M. (1976) Public Health and the Medical Profession in the Renaissance, Cambridge: Cambridge University Press. Clark,A. (1992) “The rhetoric of Chartist domesticity: gender, language and class in the 1830s and 1840s” Jnl. Brit. Stud, 31, 62–88. ——— (1995) The Struggle for the Breeches: Gender and the Making of the British Working Class, London: Rivers Oram. Clayson, G. (1957) “Sir Robert Philip and the conquest of tuberculosis” BMJ 2, 1503–8. Clegg, H. A., A. Fox, and A. F. Thompson (1964), A History of British Trade Unions since 1889.Vol.I 1889–1910, Oxford: Clarendon Press. Cleland, J. (1832) Enumeration of the Inhabitants of the City of Glasgow and County of Lanark, for the Government Census of 1831 with Population and Statistical Tables Relative to England and Scotland, 2nd edn., Glasgow, Edinburgh, and London: Smith. Cleland, J., and C.Wilson (1987) “Demand theories of the fertility transition: an iconoclastic view” PS 41, 5–30. Coale, A. J. (1973) “The demographic transition reconsidered” in IUSSP, International Population Conference, Liège,Vol. 1, Liège: International Union for the Scientific Study of Population, 53–72. Coale,A. J., and E. M. Hoover (1958) Population Growth and Economic Development in LowIncome Countries, Princeton, NJ: Princeton University Press. Coale, A. J., and S. C.Watkins, eds. (1986) The Decline of Fertility in Europe, Princeton, NJ: Princeton University Press. Coburn, D. (2000) “Income inequality, social cohesion and the health status of populations: the role of neo-liberalism” Soc Sci Med. 51, 139–50. Cochrane, A. (1972) Effectiveness and Efficiency: Random Reflections on Health Services, London: Nuffield Provincial Hospitals Trust. Cohen, M. N. (1989) Health and the Rise of Civilisation, London:Yale University Press. Cohn, B. S. (1987) “The census, social structure, and objectification in South Asia” in Cohn B. S. An Anthropologist Among the Historians and other Essays, Oxford: Oxford University Press, 224–54. Coleman, J. (1988) “Social capital in the creation of human capital” Am J Sociol 94, S95–120.

456

Consolidated Bibliography

Coleman, J. (1990) Foundations of Social Theory, Cambridge, MA: Harvard University Press. Coleman, W. (1964) Georges Cuvier, Zoologist: a Study in the History of Evolution Theory, Cambridge, MA: Harvard University Press. ——— (1974) “Health and hygiene in the Encyclopédie: A medical doctrine for the bourgeoisie” Journal of the History of Medicine 29, 399–421. ——— (1982) Death Is a Social Disease: Public Health and Political Economy in Early Industrial France, Madison: University of Wisconsin Press. Colley, L. (1992) Britons. Forging the nation 1707–1837, London:Yale University Press. Collier, P., and D. Horowitz (1976) The Rockefellers:An American Dynasty, London: Cape. Collini, S. (1979) Liberalism and Sociology, Cambridge: Cambridge University Press. Condran, G., H. Williams, and R. A. Cheney (1985) “The decline of mortality in Philadelphia from 1870 to 1930: the role of municipal services” in Sickness and Health in America 2nd edn., edited by J.W. Leavitt, and R. L. Numbers, Madison: University of Wisconsin Press, 422–36. Cooper, H., S. Arber, et al. (1999) The Influence of Social Support and Social Capital, London: Health Education Authority. Cooter, R., ed. (1992) In the Name of the Child. Health and Welfare 1880–1940, London: Routledge. Corfield, P. J. (1982) The Impact of English Towns, 1700–1800, Oxford: Oxford University Press. Crafts, N., and C. K. Harley (1992) “Output growth and the British industrial revolution: a restatement of the Crafts-Harley view” EcHR 45, 703–30. Crafts, N. F. R. (1995) “The golden age of economic growth in Western Europe, 1950–1973” EcHR 48, 429–47. Craig, F. W. S. (1989) British Electoral Facts 1832–1987, Dartmouth: Parliamentary Research Services. Cronjé, G. (1984) “Tuberculosis and mortality decline in England and Wales 1851–1910” in Urban Disease and Mortality in Nineteenth Century England, edited by R. I.Woods, and J.Woodward, London: Batsford Academic and Educational, 79–101. Crosby,A.W. (1972) The Columbian Exchange:Biological and Cultural Consequences of 1492, Westport, CT: Greenwood Press. ——— (1986) Ecological Imperialism: the biological expansion of Europe 900–1900, Cambridge: Cambridge University Press. Crowther, M. A. (1981) The Workhouse System 1834–1929: the History of an English Social Institution, London: Batsford Academic and Educational. Crowther, M. A., and B. M. White (1988) “Medicine, property and the law in Britain 1800–1914” Historical Journal 31, 853–70. Cullen, M. J. (1975) The Statistical Movement in Early Victorian Britain:The Foundation of Empirical Social Research, Hassocks: Harvester Press. Cunningham, H. (1990) “Leisure and culture”, ch.6 in F. M. L. Thompson, ed. The Cambridge Social History of Britain 1750–1950,Volume 2, Cambridge: Cambridge University Press, 279–339.

Consolidated Bibliography

457

Curtin, P. (1989) Death by Migration: Europe’s Encounter with the Tropical World in the Nineteenth Century, Cambridge: Cambridge University Press. Darley, G. (1990) Octavia Hill, London: Constable. Darwin, C. (1859) The Origin of Species by Means of Natural Selection, London: John Murray. ——— (1871) The Descent of Man, and Selection in Relation to Sex, London: John Murray. Dasgupta, P. (1993) An Inquiry Into Well-Being and Destitution, Oxford: Oxford University Press. ——— (2001) Human Well-Being and the Natural Environment, Oxford: Oxford University Press. Dasgupta, P., and I. Serageldin, eds. (2000) Social Capital: A Multifaceted Perspective, Washington, DC:World Bank. Daunton, M. J. (1983) House and Home in the Victorian City. Working-class Housing 1850–1914, London: Edward Arnold. Davenport-Hines, R. (1990) Sex, Death and Punishment. Attitudes to Sex and Sexuality in Britain since the Renaissance, London: Collins. Davey Smith, G. (1996) “Income inequality and mortality: why are they related? Income inequality goes hand in hand with underinvestment in human resources” BMJ 312, 987–88. Davey Smith, G., and D. Dorling (1996) “‘I’m all right, John’:Voting patterns and mortality in England and Wales, 1981–92” BMJ 313, 1573–77. Davey Smith, G., D. Dorling, and D. Gordon (1999) The Widening Gap: Health Inequalities and Policy in Britain, Bristol: Policy Press. Davidoff, L., and C. Hall (1987) Family Fortunes. Men and Women of the English Middle Class 1780–1850, London: Hutchinson. Davidson, R. (1985) Whitehall and the Labour Problem in late-Victorian and Edwardian Britain.A Study in Official Statistics and Social Control, London: Croom Helm. Davies, N. (1997) Dark Heart.The Shocking Truth About Hidden Britain, London: Chatto & Windus. Davin, A. (1978) “Imperialism and motherhood” History Workshop Journal 5, 9–65. Davis, J. (1988) Reforming London.The London Government Problem 1855–1900, Oxford: Clarendon Press. Davis, J., and D. Tanner (1996) “The borough franchise after 1867” Historical Research 69, 306–27. Davis, J. (2001) LateVictorian Holocausts. El Nino Famines and the Making of the ThirdWorld, London:Verso. Davis, K. (1945) “The world demographic transition” Annals of the American Academy of Political and Social Science 237, 1–11. ——— (1950)“Population and the further spread of industrial society” Proceedings of the American Philosophical Society 95, 8–19. ——— (1963) “The theory of change and response in modern demographic history” Population Index 29, 345–64. ——— (1967) “Population policy: Will current programs succeed?” Science 158, No. 3802, 730–39.

458

Consolidated Bibliography

De Soto, H. (2000) The Mystery of Capital:Why Capitalism Triumphs in the West and Fails Everywhere Else, New York: Basic Books. De Swaan, A. (1988) In Care of the State: health care, education and welfare in Europe and America, Cambridge: Polity Press. Deane, P., and W. A. Cole (1969) British Economic Growth 1688–1959, 2nd edn., Cambridge: Cambridge University Press. Degler, C. N. (1980) At Odds:Women and the Family in America from the Revolution to the Present, Oxford: Oxford University Press. Demeny, P. (1988) “Social science and population policy” PDR 14, 451–79. Desrosières, A. (1991) “Official statistics and medicine in nineteenth-century France: the SGF as a case study” SHM 4, 515–37. Devine, T. M., and G. Jackson, eds. (1995) Glasgow, I: Beginnings to 1830, Manchester: Manchester University Press. Dicey, A. V. (1905) Lectures on the Relation between Law and Public Opinion in England During the Nineteenth Century, London: Macmillan. Dobson, M. J. (1989) “Mortality gradients and disease exchanges: Comparisons from old England and colonial America” SHM 2, 259–97. ——— (1997) Contours of Death, Contours of Health. Death and Disease in Early Modern Southeast England, Cambridge: Cambridge University Press. Dominguez, S., and C. Watkins (2003) “Creating networks for survival and mobility: social capital among African-American and Latin-American low-income mothers” Social Problems 50, 111–35. Donaldson, P. J. (1988) “American Catholicism and the international family planning movement” PS 2, 367–73. ——— (1990a) “On the origins of the United States government’s international population policy” PS 44, 385–400. ——— (1990b) Nature Against Us: The United States and the World Population Crisis, 1965–1980, Chapel Hill, NC: University of North Carolina Press. Dorfman, R. (1991) “Review article: economic development from the beginning to Rostow” Journal of Economic Literature 29, 573–91. Drever, F., and M. Whitehead, eds. (1997) Health inequalities: Decennial Supplement DS Series 15, London: Stationery Office. Drèze, J., and A. Sen (1989) Hunger and Public Action, Oxford: Clarendon Press. Duffy, J. (1990) The Sanitarians: A History of American Public Health, Urbana: University of Illinois Press. Duncan, C. (1999) Worlds Apart:Why Poverty Persists in Rural America, New Haven: Yale University Press. Durlauf, S. (2002) “On the empirics of social capital” Economic Journal 112, 459–79. Dwork, D. (1986) War is Good for Babies and Other Young Children: A History of the Infant Welfare Movement in England, 1898–1918, London:Tavistock Publications. ——— (1987) “The milk option: an aspect of the history of the infant welfare movement in England 1898–1918” Medical History 31, 151–69.

Consolidated Bibliography

459

Dyhouse, C. (1978) “Working class mothers and infant mortality in England 1895–1914” Journal of Social History 12, 248–67. Dyos, H. J., and D.A. Reeder (1973) “Slums and suburbs” in TheVictorian city: Images and Realities,Vol. I, edited by J. H. Dyos, and M.Wolff, London: Routledge and Kegan Paul, 359–86. Dyson, K. H. F. (1980) The State Tradition in Western Europe: A Study of an Idea and Institution, Oxford: Robertson. Easterlin, R. A. (1999) “How beneficent is the market? A look at the modern history of mortality” European Review of Economic History 3, 257–94. Eckersley, R., and J. Dixon, eds. (2001) The Social Origins of Health and Well-Being: From the Planetary to the Molecular, Cambridge: Cambridge University Press. Ellaway, A., and S. Macintyre (2000) “Social capital and self-rated health: support for a contextual mechanism” AJPH 90, 988. Engerman, S. L., and K. L. Sokoloff (1997) “Factor endowments, institutions, and differential paths among New World economies: a view from economic historians of the United States” in How Latin America Fell Behind: Essays in the Economic Histories of Brazil and Mexico, 1800–1914, edited by S. Haber, Stanford: Stanford University Press, 260–304. Englander, D. (1983) Landlord and Tenant in Urban Britain 1838–1918, Oxford: Clarendon Press. Ensor, R. C. K. (1936) England 1870–1914, Oxford: Clarendon Press. Evans, P. (1995) Embedded Autonomy: States and Industrial Transformation, Princeton, NJ: Princeton University Press. ——— (1996) “Government action, social capital and development: reviewing the evidence on synergy” World Development 24, 1119–32. Evans, P., D. Rueschemeyer, and T. Skocpol (1985) Bringing the State Back In, Cambridge: Cambridge University Press. Evans, R. (1987) Death in Hamburg: Society and Politics in the Cholera Years 1830–1910, Oxford: Clarendon Press. Evans, R. G., and G. L. Stoddart (1990) “Producing health, consuming health care” Soc Sci Med. 31, 1347–63. Evans, R. G., M. L. Barer, and T. R. Marmor (1994) Why Are Some People Healthy and Others Not? The Determinants of Health of Populations, New York: Aldine de Gruyter. Ewbank, D. C., and S. H. Preston (1990) “Personal health behaviour and the decline in infant and child mortality: the United States 1900–1939” in What we Know about the Health Transition.The Cultural, Social and Behavioural Determinants of Health, 2 vols, edited by J. C. Caldwell, et al., Canberra: Health Transition Centre, Australian National University, 116–49. Eyler, J. M. (1976) “Mortality statistics and Victorian health policy: program and criticism” BHM 50, 335–55. ——— (1979) Victorian Social Medicine: The Ideas and Methods of William Farr, Baltimore: The Johns Hopkins University Press.

460

Consolidated Bibliography

Eyler, J. M. (1989) “Poverty, disease, responsibility: Arthur Newsholme and the public health dilemmas of British Liberalism” The Milbank Quarterly 67, Supplement 1, 109–26. ——— (1993) “The sick poor and the State: Arthur Newsholme on poverty, disease and responsibility” in Porter D and Porter R, eds. Doctors, Politics and Society: Historical Essays, Amsterdam: Rodopi, 188–211. ——— (1997) Sir Arthur Newsholme and State Medicine, 1885–1935, Cambridge: Cambridge University Press. Fabian, J. (1983) Time and the Other: How Anthropology Makes its Object, New York: Columbia University Press. Farmer, P. (1996) “Social inequalities and emerging infectious diseases” Emerging Infectious Diseases 2, 259–69. ——— (1999) Infections and Inequalities: The Modern Plagues, Berkeley: University of California Press. Farr, J. (2004) “Social capital: a conceptual history” Political Theory 32, 6–33. Farr,W. (1859) “On the construction of life-tables, illustrated by a new life-table of the healthy districts of England” Philosophical Transactions 149, 837–78. ——— (1865) “On Infant Mortality and on alleged inaccuracies of the Census”, JSSL 28 (1865), 125–49. Farrow, S. C. (1987) “McKeown Reassessed” BMJ 294, 1631–32. Feldman, D. (2000), “Migration”, ch.6 in Daunton MJ, ed. The Cambridge Urban History of Britain.Volume III 1840–1950, Cambridge: Cambridge University Press, 185–206. ——— (2003) “Migrants, immigrants and welfare from the old Poor Law to the welfare state” Trans Roy Hist Society 13, 79–104. Feinstein, C. H. (1972, 1976) National Income, Expenditure and Output of the U.K. 1855–1965, 2 vols, Cambridge: Cambridge University Press. ——— (1995) “Changes in nominal wages, the cost of living and real wages in the United Kingdom over two centuries, 1780–1990” in Labour’s Reward: Real Wages and Economic Change in Nineteenth- and Twentieth-Century Europe, edited by P. Scholliers, and V. Zamagni, eds., Aldershot: Ashgate Press, 3–36. ——— (1998) “Pessimism perpetuated: Real wages and the standard of living in Britain during and after the Industrial Revolution” JEcH 58, 625–58. Fine, B. (2000) Social Capital Versus Social Theory: Political Economy and Social Science at the Turn of the Millennium, London: Routledge. Fine, P. E. M. (1994) “Immunities in and to Tuberculosis: Implications for pathogenesis and vaccination” in Tuberculosis: Back to the Future, edited by J. D. H. Porter, and K. P.W. J. McAdam, Chichester:Wiley, 53–74. Finer, S. E. (1952) The Life and Times of Sir Edwin Chadwick, London: Methuen. Fletcher, D. (1999) “The Ordnance Survey’s nineteenth-century boundary survey: context, characteristics and impact” Imago Mundi 51, 131–46. Flinn, M.W. (1969), “Introduction” to the reprint of A. P. Stewart, and E. Jenkins, The medical and legal aspects of sanitary reform (first published 1866), Leicester: Leicester University Press.

Consolidated Bibliography

461

Flinn, M.W. (1974) “Trends in Real Wages 1750–1850” EcHR 27, 395–413. ——— (1984) “English workers” living standards during the industrial revolution: a comment’ EcHR 37, 88–92. ——— (1965) “Introduction” and edition of Report on the Sanitary Condition of the Labouring Population of Great Britain by Edwin Chadwick 1842, Edinburgh: Edinburgh University Press. ——— ed.(1977) Scottish Population History from the Seventeenth Century to the 1930s, Cambridge: Cambridge University Press. Floud, R., and B. Harris (1997) “Health, height and welfare: Britain 1700–1980”, ch. 3 in Health and Welfare During Industrialization, edited by R. H. Steckel, and R. Floud, Chicago: Chicago University Press, 91–126. Floud, R., K.Wachter, and A. Gregory (1990) Height,Health and History.Nutritional Status in the United Kingdom 1750–1980, Cambridge: Cambridge University Press. Fogel, R. (1986) “Nutrition and the decline in mortality since 1700: some additional preliminary findings” Studies in Income and Wealth 51, 439–555. ——— (1991) “The historical conquest of high mortality and hunger in Europe and America: timing and mechanisms” in Favourites of Fortune.Technology, Growth and Economic Development since the Industrial Revolution, edited by P. Higonnet, D. Landes, and H. Rosovsky, Cambridge, MA: Harvard University Press, 33–71. ——— (1992) “Second thoughts on the European escape from hunger: famines, chronic malnutrition and mortality” in Osmani S, ed. Nutrition and Poverty, Oxford: Clarendon Press, 243–81. Foley, M., and R. Edwards (1999) “Is it time to disinvest in social capital?” Jnl Public Policy 19, 141–73. Forbes, A., and S. P.Wainwright (2001) “On the methodological, theoretical and philosophical context of health inequalities research: a critique” Soc Sci Med 53, 801–16. Foucault, M. (1971) Madness and Civilisation: A History of Insanity in the Age of Reason, London (first published in English 1967): Tavistock Publications. ——— (1973) The Birth of the Clinic. An Archaeology of Medical Perception, London: Tavistock Publications. Fraser, D. (1976) Urban Politics in Victorian England: The Structure of Politics in Victorian Cities, Leicester: Leicester University Press. ——— (1984) The Evolution of the British Welfare State: A History of Social Policy since the Industrial Revolution (2nd edn), Basingstoke : Macmillan. Fraser, H. (1993) “Municipal socialism and social policy” in TheVictorian City:A Reader in British Urban History, 1820–1914, edited by R. J. Morris, and R. Rodger, London: Longman, 258–80. Frazer,W. M. (1947) Duncan of Liverpool: Being an Account of the Work of Dr.W. H. Duncan, Medical Officer of Health of Liverpool, 1847–63, London: H. Hamilton Medical Books. Freeden, M. (1978) The New Liberalism: An Ideology of Social Reform, Oxford: Clarendon Press.

462

Consolidated Bibliography

Friedlander, D., J. Schellekens, E. Ben-Moshe, and K. Keysar (1985) “Socio-economic characteristics and life expectancies in nineteenth-century England: a district analysis” PS 39, 137–51. Fukuyama, F. (1995) Trust:The Social Virtues and the Creation of Prosperity, New York: Free Press. Furner, M. O. (1975) Advocacy and Objectivity:A Crisis in the Professionalization of American Social Science, 1865–1905, Lexington:The University Press of Kentucky. Galbraith, J. K. (2002) “A perfect crime: global inequality” Daedalus. 131, 11–25. Galea, S., A. Karpati, and B. Kennedy (2002) “Social capital and violence in the United States, 1974–1993” Soc Sci Med 55, 1373–83. Galloway, P. (1988) “Basic patterns in annual variations in fertility, nuptiality, mortality, and prices in pre-industrial Europe” PS 42, 275–303. Garrett, E., A. Reid, K. Schurer, and S. Szreter (2001) Changing Family Size in England and Wales 1891–1911: Place, Class and Demography, Cambridge: Cambridge University Press. Gatrell, V. A. C. (1980) “The decline of theft and violence in Victorian and Edwardian England and Wales” in Crime and the Law:The Social History of Crime inWestern Europe Since 1500, edited by V. A. C. Gatrell et al., London: Europa, 238–370. Gautier, E., and L. Henry (1958) La Population du Crulai, Paroîsse Normande, Paris: Presses Universitaires de France. Gayer, A. D., W. W. Rostow, and A. J. Schwartz (1953) Growth and Fluctuations of the British Economy, 1790–1850: an Historical, Statistical and Theoretical Study of Britain’s Economic Development, 2 vols, Oxford: Clarendon Press. Gilbert, A. D. (1976) Religion and Society in Industrial England: Church, Chapel and Social Change 1740–1914, London: Longman. Gilbert, B. B. (1965) “Health and politics: the British physical deterioration report of 1904” BHM 39, 143–48. ——— (1966) The Evolution of National Insurance in Great Britain; the Origins of the Welfare State, London: Joseph. Gillis, J. R., L.A.Tilly, and D. Levine, eds. (1992) The European Experience of Declining Fertility. 1850–1970:The Quiet Revolution, Cambridge, MA: Harvard University Press. Gittell, R., and J. P. Thompson (2001) “Making social capital work: social capital and community Economic development” in Social Capital and Poor Communities, edited by S. Saegert, J. P. Thompson, and M. R. Warren, New York: Russell Sage Foundation, 115–35. Gittell, R., and A. C. Vidal (1998) Community Organizing: Building Social Capital as a Development Strategy, Thousand Oaks, CA: Sage Publications. Glaeser, E., D. Laibson, and B. Sacerdote (2002) “An economic approach to social capital” Economic Journal 112, 437–58. Glass, D. V. (1964) “Some indicators of differences between urban and rural mortality in England and Wales and Scotland” PS 17, 263–67. ——— (1973a) Numbering the People: The Eighteenth-century Population Controversy and the Development of Census and Vital Statistics in Britain, Farnborough: D.C. Heath.

Consolidated Bibliography

463

Glass, D.V. (1973b) The Development of Population Statistics:A Collective Reprint of Materials Concerning the History of Census Taking and Vital Registration in England and Wales, Farnborough: Gregg. Glennerster, H., and J. Hills, eds. (1998) The State of Welfare. The Economics of Social Spending, 2nd edn, Oxford: Oxford University Press. Goldstone, J. A. (1986) “The demographic revolution in England: a re-examination” PS 40, 5–34. Goldthorpe, J. H., D. Lockwood, F. Bechofer, and J. Platt (1968–69) The AffluentWorker in the Class Structure, 3 vols, Cambridge: Cambridge University Press. Gordon D, Adelman L, et al. (2000) Poverty and Social Exclusion in Britain,York: Joseph Rowntree. Gorski, P. A. (2000) “Caring relationships: An investment in health?” Public Health Rep 115, 144–50. Gosden, P. H. J. H. (1993) The Friendly Societies in England, 1815–1875, Aldershot: Ashgate Press. Goubert, P. (1960) Beauvais el les Beauvaisis 1600 à 1730 : Contribution à l’histoire sociale de la France du XVIIe Siècle, Paris : S. E.V. P. E. N. Gould, S. J. (1977) Ontogeny and Phylogeny, Cambridge, MA: Harvard University Press. Gouldner, A. (1970) The Coming Crisis of Western Sociology, New York: Basic Books. Gowdridge, C.,A. S.Williams, and M.Wynn, eds. (1997) Mother Courage.Letters from Poverty at the End of the Century, London: Penguin in association with the Maternity Alliance. Granovetter, M. (1985) “Economic action and social structure: the problem of embeddedness” Am Jnl Sociology 91, 481–510. Gray, B. Kirkman (1908), Philanthropy and the State, or Social Politics, London: P. S. King. Greenhalgh, S. (1996) “The social construction of population science: an intellectual, institutional and political history of twentieth-century demography” CSSH 38, 26–66. ——— (2004) “Making up China’s ‘Black Population’” in Szreter S, Sholkamy H and Dharmalingam A, eds. Categories and Contexts.Anthropological and Historical Studies in Critical Demography, Oxford: Oxford University Press, 148–72. Griffith, G. T. (1926) Population Problems of the Age of Malthus, Cambridge: Cambridge University Press. Grootaert, C., and T. van Bastelaer, eds. (2002) Understanding and Measuring Social Capital: A Multidisciplinary Tool for Practitioners,Washington, DC:World Bank. Guha, S. (1993) “Nutrition, sanitation, hygiene and the likelihood of death: the British army in India” PS 47, 385–401. ——— (1994) “The importance of social intervention in England’s mortality decline: the evidence reviewed” SHM 7, 89–113. Guy, J. (1923) Pulmonary Tuberculosis, its Diagnosis and Treatment: A Handbook for Students and General Practitioners, Edinburgh and London: Oliver and Boyd. Haber, S., ed. (1997) How Latin America Fell Behind:Essays in the Economic Histories of Brazil and Mexico, 1800–1914, Stanford: Stanford University Press.

464

Consolidated Bibliography

Hagan, J., H. Merkens, and K. Boehnke (1995) “Delinquency and disdain: social capital and the control of right-wing extremism among east and west Berlin youth” Am J Sociol 100, 1028–52. Hagen, E. E. (1964) On the Theory of Social Change: How Economic Growth Begins, London: Tavistock Publications. Haines, M. R. (1998) “Health, height, nutrition and mortality: Evidence on the antebellum puzzle from Union Army recruits for New York State and the United States” in The Biological Standard of Living in Comparative Perspective,Vol. 1: The Americas,Asia and Australia, edited by J. Komlos, and J. Baten, Stuttgart: Steiner, 155–80. ——— (2001) “The urban mortality transition in the United States, 1800–1940” Annales de Démographie Historique, 33–64. Haines, R., R. Shlomowitz, and L. Brennan (1996) “Maritime mortality revisited” International Journal of Maritime History 7, 133–72. Hajnal, J. (1965) “European marriage patterns in perspective” in Glass DV and Eversley DEC, eds. Population in History: essays in Historical Demography, London: Edward Arnold, 101–43. Halliday, R. J. (1968) “The sociological movement, the sociological society and the genesis of academic sociology in Britain” Sociological Review 16, 377–98. Halstead, S. B., J. A.Walsh, and K. S.Warren, eds. (1985) Good Health at Low Cost, New York:The Rockefeller Foundation. Hamlin, C. (1988) “Muddling in Bumbledon: on the enormity of large sanitary improvements in four British towns, 1855–1885” Victorian Studies 32, 55–83. ——— (1990) A Science of Impurity:Water Analysis in Nineteenth-Century Britain, Bristol: Hilger. ——— (1998) Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854, Cambridge: Cambridge University Press. Hanham, H. J. (1969) The Nineteenth Century Constitution 1815–1914, Cambridge: Cambridge University Press. Hanley, J. G. (2002) “Edwin Chadwick and the poverty of statistics” Medical History 46, 21–40. Hansen, A. H. (1939) “Economic progress and declining population growth” American Economic Review 29, 1–15. Hardy, A. (1983) “Smallpox in London: factors in the decline of the disease in the nineteenth century” Medical History 27, 111–38. ——— (1984) “Water and the search for public health in London in the eighteenth and nineteenth centuries” Medical History 28, 250–82. ——— (1988a) “Diagnosis, death and diet: the case of London” JIH 18, 387–401. ——— (1988b) “Public health and the expert: the London Medical Officers of Health, 1856–1900” in MacLeod R, ed. Government and Expertise. Specialists,Administrators, and Professionals, 1860–1919, Cambridge: Cambridge University Press, 128–42. ——— (1993) The Epidemic Streets. Infectious Disease and the Rise of Preventive Medicine 1856–1900, Oxford: Clarendon Press. ——— (2001) Health and Medicine in Britain since 1860, Basingstoke: Palgrave.

Consolidated Bibliography

465

Harley, C. K. (1982) “British industrialisation before 1841: Evidence of slower growth during the industrial revolution” JEcH 42, 267–89. ——— (1999) “Reassessing the industrial revolution”, ch. 3 in The British Industrial Revolution: An Economic Perspective, 2nd edn., edited by J. Mokyr, Boulder CO: Westview Press, 171–226. Harpham, T., E. Grant, and E. Thomas (2002) “Measuring social capital within health surveys: key issues” Health Policy Plan 17, 106–11. Harris, B. (2004) “Public health, nutrition and the decline of mortality:The McKeown thesis revisited” SHM 17 (2004), 379–407. Harris, J. (1972) Unemployment and Politics: A Study in English Social Policy, 1886–1914, Oxford: Clarendon Press. ——— (1988) “William Beveridge in Whitehall: maverick of mandarin?” in Government and Expertise. Specialists, Administrators and Professionals 1860–1919, edited by R. MacLeod, Cambridge: Cambridge University Press, 224–41 ——— (1989) “The Webbs, the C.O.S. and the Ratan Tata Foundation: social policy from the perspective of 1912” in The Goals of Social Policy, edited by M. Bulmer et al., London: Unwin Hyman, 27–63. Harriss, J. (2002) De-politicizing Development:The World Bank and Social Capital, London: Anthem. Harvie, C. T. (1976) The Lights of Liberalism: University Liberals and the Challenge of Democracy 1860–86, London: Allen Lane. Hassan, J. A. (1985) “The growth and impact of the British water industry in the nineteenth century” EcHR 38, 531–47. Hatton,T. J., and R. E. Bailey (2000) “Seebohm Rowntree and the postwar poverty puzzle” EcHR 53, 517–43. Hauser, P. M. (1967) “Family planning and population programs” Demography 4, 397–414. Hawe, P., and A. Shiell (2000) “Social capital and health promotion: a review” Soc Sci Med 51, 871–85. Hay, J. R. (1983) The Origins of the Liberal Welfare Reforms 1906–14, rev. edn., Basingstoke: Macmillan. Helliwell, J. (2002) “How’s life? Combining individual and national variables to explain subjective well-being” Economic Modeling 20, 331–60. Hennock, E. P. (1963) “Finance and politics in urban local government in England, 1835–1900” Historical Journal 6, 212–25. ——— (1973) Fit and Proper Persons: Ideal and Reality in Nineteenth Century Urban Government, London: Edward Arnold. ——— (1976) “Poverty and social theory in England: the experience of the 1880s” Social History 1, 67–91. ——— (1982) “Central/local government relations in England: an outline 1800–1950”, Urban HistoryYearbook, 38–49. ——— (1987a) British Social Reform and German Precedents:The Case of Social Insurance 1880–1914, Oxford: Clarendon Press.

466

Consolidated Bibliography

Hennock, E. P. (1987b) “The measurement of urban poverty; from the metropolis to the nation, 1880–1920” EcHR. 40, 208–27. ——— (1991) “Concepts of poverty in the British social surveys from Charles Booth to Arthur Bowley” in The Social Survey in Historical Perspective 1880–1940, edited by M. Bulmer, K. Bales, and K. Kish Sklar, Cambridge: Cambridge University Press, 189–216. Henry, L. (1956) Anciennes Familles Genevoises : étude démographique: XVIe-XXe siècle, Paris: Presses universitaires de France. Herf, J. (1984) Reactionary Modernism: Technology, Culture, and Politics in Weimar and the Third Reich, Cambridge: Cambridge University Press. Hertz, N. (2001) The Silent Takeover: Global Capitalism and the Death of Democracy, London: Heinemann. Higgs, E. (1988) “The struggle for the occupational census, 1841–1911” in Government and Expertise. Specialists, Administrators and Professionals, 1860–1919, edited by R. MacLeod, Cambridge: Cambridge University Press, 73–86. ——— (1991) “Disease, febrile poisons, and statistics:The census as a medical survey, 1841–1911” Social History of Medicine 4, 465–78. ——— (2004a) The Information State in England:The Central Collection of Information on Citizens since 1500, London: Basingstoke: Palgrave Macmillan. ——— (2004b) Life, death and statistics. Civil registration, censuses and the work of the General Register Office, 1836–1952, Hatfield, Herts: Local Population Studies Supplement. Hills, J. (1996) “Tax policy: are there still choices?” in Options for Britain.A Strategic Policy Review, edited by D. Halpern, S. Wood, S. White, and G. Cameron, Aldershot: Ashgate Press, 71–98. Hilton, B. (1988) The Age of Atonement: The Influence of Evangelicalism on Social and Economic Thought 1785–1865, Oxford: Clarendon Press. Himes, N. E. (1970) A Medical History of Contraception (first published 1936), New York: Schocken Books. Hirschman, A. O. (1945) National Power and the Structure of Foreign Trade, Berkeley: University of California Press. ——— (1970) Exit,Voice and Loyalty, Cambridge: Cambridge University Press. Hirschman, C. (1981) “The uses of demography and development planning” Economic Development and Cultural Change 30, 561–75. Hitchcock, T., et al., ed. (1997) Chronicling Poverty: the Voices and Strategies of the Poor 1640–1840, Basingstoke: Macmillan. Hobsbawm, E., and G. F. E. Rudé (1969) Captain Swing, London: Lawrence and Wishart. Hobsbawm, E. J. (1975) “The British standard of living, 1790–1850” in The Standard of Living Debate in the Industrial Revolution, edited by A. J.Taylor, London: Methuen, 58–92. Hodgson, D. (1983) “Demography as social science and policy science” PDR 9, 1–34. ——— (1988) “Orthodoxy and revisionism in American demography” PDR 14, 541–69. ——— (1991) “The ideological origins of the Population Association of America” PDR 17, 1–34.

Consolidated Bibliography

467

Hogg, J. (1860) Observations on the Prevention of Consumption:With Statistical Tables of the Prevalence of the Disease and of the Comparative Salubrity of Various Places at Home and Abroad, London: Robert Hardwicke. Holcombe, L. (1983) Wives and Property. Reform of the Married Women’s Property Law in Nineteenth-Century England, Toronto:Toronto University Press. Hollis, P. (1987) Ladies Elect.Women in English Local Government 1865–1914, Oxford: Clarendon Press. Homedes, N. and Ugalde,A. (2005) “Why neoliberal health reforms have failed in Latin America” Health Policy 71: 83–96. Honigsbaum, F. (1979) The Division in British Medicine. A History of the Separation of General Practice from Hospital Care 1911–68, London: Kogan Page. Hopkins, A. G. (2002) “Introduction: globalisation—an agenda for historians” in Globalisation in World History, edited by A. G. Hopkins, London: Pimlico, 1–10. Horlings, E., and J-P Smit (1998) “The quality of life in the Netherlands 1800–1913” in The Biological Standard of Living in Comparative Perspective, edited by J. Komlos, and J. Baten, Stuttgart: Steiner, 321–43. Horrell, S., and J. Humphries (1992) “Old questions, new data, and alternative perspectives: families’ living standards in the industrial revolution” JEcH 52, 849–80. ——— (1995) “Women’s labour force participation and the transition to the malebreadwinner family, 1790–1865” EcHR 48, 89–117. House, J. S., K. R. Landis, and D. Umberson (1988) “Social relationships and health” Science 241, 540–45. Huck, P. (1994) “Infant mortality in nine industrial parishes in northern England, 1813–36” PS 48, 513–26. ——— (1995) “Infant mortality and living standards of English workers during the industrial revolution” JEcH 55, 528–50. Hudson, P. (1992) The Industrial Revolution, London: Edward Arnold. Humphreys, N. A. (1874) “The value of death-rates as a test of sanitary condition”, JSSL 37, 437–77. Humphries, J. (1977) “Class struggle and the persistence of the working-class family” Cam. J. Econ. 1, 241–58. Hunt, E. H. (1981) British Labour History 1815–1914, London: Weidenfeld and Nicolson. ——— (1986) “Industrialisation and regional inequality: Wages in Britain, 1760–1914” JEcH 44, 935–66. Hunt, E. W., and F. W. Botham (1987) “Wages in Britain during the industrial revolution” EcHR 40, 380–99. Hunt, T. (2004) Building Jerusalem. The Rise and Fall of the Victorian City, London: Weidenfeld and Nicolson. Hurt, J. S. (1979) Elementary Schooling and the Working Classes 1860–1918, London: Routledge and Kegan Paul. Hutton,W. (1995) The State We’re In, London: Jonathan Cape.

468

Consolidated Bibliography

Illich, I. (1975) Medical Nemesis: the Expropriation of Health, London: Calder and Boyars. Israel, J. (1995) The Dutch Republic. Its Rise, Greatness, and Fall 1477–1806, Oxford: Clarendon Press. Jacobs, J. (1961) The Life and Death of Great American Cities, New York:Vintage Books. Jenkins, E. (1969) “The Legal aspects of sanitary reform” in The Medical and Legal Aspects of Sanitary Reform (first published 1866; 1969 reprint ed. M. Flinn), edited by A. P. Stewart, and E. Jenkins, Leicester: Leicester University Press. Johansson, S. R. (1991a) “‘Implicit’ policy and fertility during development” PDR 17, 377–414. ——— (1991b) “The Health transition: the cultural inflation of morbidity during the decline of mortality” HTR 1, 39–68. ——— (1991c) “Welfare, mortality, and gender. Continuity and change in explanations for male/female mortality dfferences over three centuries” Continuity and Change 6, 135–77. ——— (1992) “Measuring the cultural inflation of morbidity during the decline in mortality” HTR 2, 78–89. ——— (1994) “Food for thought: rhetoric and reality in modern mortality history” Hist Methods 27, 101–25. Johansson, S. R., and C. Mosk (1987) “Exposure, resistance and life expectancy: disease, and death during the economic development of Japan, 1900–60” PS 41, 207–35. Johnson, C. (1982) MITI and the Japanese Miracle: The Growth of Industrial Policy, 1925–1975, Stanford: Stanford University Press. Johnson, P. (1994) “The welfare state” in The Economic History of Britain Since 1700,Vol.3: 1939–1992, edited by R. Floud, and D. N. McCloskey, Cambridge: Cambridge University Press, 284–317. ——— (2004) “The welfare state” in The Economic History of Britain since 1700, 3rd edn., edited by R. Floud, and P. Johnson, Cambridge: Cambridge University Press, 213–37. Johnson, P., and S. Nicholas (1995) “Male and female living standards in England and Wales, 1812–1857: evidence from criminal height records” EcHR 48, 470–81. ——— (1997) “Health and welfare of women in the United Kingdom, 1785–1920” in Health and Welfare During Industrialization, R. H. Steckel, and R. Floud, Chicago: Chicago University Press, 201–50. Jones, G. (1980) Social Darwinism and English Thought:The Interaction between Biological and Social Theory, Brighton: Harvester Press. ——— (1986) Social Hygiene in Twentieth-Century Britain, London: Croom Helm. Kaplan, G. (1999) “Part III Summary: What is the role of the social environment in understanding inequalities in health?” Annals of the NewYork Academy of Science 896, 116–20. Kawachi, I. (1999) “Social capital and community effects on population and individual health” Annals of the NewYork Academy of Sciences 896, 120–30. ——— (2001) “Social capital for health and human development” Development 44, 31–35.

Consolidated Bibliography

469

Kawachi I. and Berkman L (2000) “Social cohesion, social capital, and health” in Social Epidemiology, edited by L. Berkman, and I. Kawachi, Oxford: Oxford University Press, 174–90. ——— (2001) “Social ties and mental health” Journal Urban Health 78, 458–67. Kawachi, I., and B. Kennedy (1999) “Income inequality and health: pathways and mechanisms” Health Serv Res 34, 215–27. Kawachi I., B. P. Kennedy, and R. G. Wilkinson, eds. (1999) The Society and Population Health Reader: Income Inequality and Health, New York: New Press. Kawachi I., B. Kennedy, and R. Glass (1999) “Social capital and self-rated health: a contextual analysis” AJPH 89, 1187–93. Kawachi, I., B. Kennedy, K. Lochner, et al. (1997) “Social capital, income inequality, and mortality” AJPH 87, 1491–98. Kearns, G. (1988) “The urban penalty and the population history of England” in Society, Health and Population during the Demographic Transition, edited by A. Brandstrom, and L. G.Tedebrand, Stockholm: Almqvist and Wiksell International, 213–36. ——— (2000) “Town hall and Whitehall: sanitary intelligence in Liverpool 1840–63” in Body and City: Histories of Urban Public Health, edited by S. Sheard, and H. Power, Aldershot: Ashgate Press, 89–108. Keating, D. P. (2000) “Social capital and developmental health: making the connection” Jnl Dev Behav Pediatr 21, 50–52. Keating, D. P., and C. Hertzman, eds. (1999) Developmental Health and the Wealth of Nations, New York: Guilford Press. Keith-Lucas, B. (1952) The English Local Government Franchise: A Short History, Oxford: Blackwell. Kellett, J. R. (1993) “The railway as an agent of internal change in Victorian cities” in The Victorian City: A Reader in British Urban History, 1820–1914, edited by R. J. Morris, and R. Rodger, London: Longman, 181–208. Kertzer, D. I., and D. P. Hogan (1989) Family, Political Economy, and Demographic Change: The Transformation of Life in Casalecchio, Italy, 1861–1921, Madison: University of Wisconsin Press. Kevles, D. J. (1985) In the Name of Eugenics: Genetics and the Uses of Human Heredity, New York: Knopf. Keynes, J. M. (1937) “Some economic consequences of a declining population” Eugenics Review 29, 13–17, reprinted in PDR 4 (1978), 517–23. Kickbusch, I. (2000) “The development of international health policies—accountability intact?” Soc Sci Med. 51, 979–89. King, G., and C. Murray (2002) “Rethinking human security” Polit Sci Q. 116, 585–610. King, S. (1997a) “Dying with style: infant death and its context in a rural industrial township 1650–1830” SHM 10, 3–24. ——— (1997b) “Poor relief and English economic development reappraised” EcHR 50, 360–68. ——— (2000) Poverty and Welfare in England 1700–1850. A Regional Perspective, Manchester: Manchester University Press.

470

Consolidated Bibliography

King, S., and A. Tomkins, eds. (2003), The Poor in England, 1700–1850: an Economy of Makeshifts, Manchester: Manchester University Press. Kirk, D. (1944) “Population changes and the postwar world” American Sociological Review 9, 28–35. Klein, N. (2000) No Logo: No Space, No Choice, No Jobs. Taking Aim at the Brand Bullies, London: Flamingo. Klinenberg, E. (2002) HeatWave. A Social Autopsy of Disaster in Chicago, Chicago: Chicago University Press. Knack, S., and P. Keefer (1995) “Institutions and economic performance: crosscountry tests using alternative institutional measures” Economics and Politics 7, 207–27. ——— (1997) “Does social capital have an economic pay off? A cross-country investigation” Quarterly Journal of Economics 112, 1251–88. Knodel, J. E. (1988) Demographic Behavior in the Past: A Study of Fourteen German Village Populations in the Eighteenth and Nineteenth Centuries, Cambridge: Cambridge University Press. Komlos, J. (1993) “The secular trend in the biological standard of living in the United Kingdom, 1730–1860” EcHR 46, 115–44. Koss, S. (1991) The Rise and Fall of the Political Press in Britain.Vol. I The Nineteenth Century, London: Hamish Hamilton. Krause, J. T. (1965) “The changing adequacy of English registration, 1690–1837” in Glass DV and Eversley DEC, eds. Population in History, 379–93. Kreager, E., and P. Kreager (1992) The Demographic Transition:Stages,Patterns and Economic Implications, translation of Chesnais (1986), Oxford: Clarendon Press. Krieger, N. (2000) “Epidemiology and social sciences: towards a critical reengagement in the 21st century” Epidemiological Review 11, 155–63. Krishna, A. (2002) Active Social Capital: Tracing the Roots of Development and Democracy, New York. Krugman, P. (2002) “For richer” NewYork Times Magazine, 20 Oct. Kuklick, H. (1991) The Savage Within. The Social History of British Anthropology, 1885–1945, Cambridge: Cambridge University Press. Kula, W. (2001) The Problems and Methods of Economic History, trans. R. Szreter, Aldershot: Ashgate Press. Kunitz, S. (2001) “Accounts of social capital: the mixed health effects of personal communities and voluntary groups” in Poverty, Inequality and Health: An International Perspective, edited by D. A. Leon, G.Walt, Oxford: Oxford University Press, 159–74. Kunitz, S. J. (2000) “Globalisation, states, and the health of indigenous peoples” AJPH 90, 1531–39. La Berge, A. F. (1984) “The early nineteenth-century French public health movement: the disciplinary development and institutionalization of Hygiène Publique” BHM 58, 363–79. ——— (1988) “Edwin Chadwick and the French connection” BHM 62, 23–41. ——— (1992) Mission and Method: The Early Nineteenth-Century French Public Health Movement, Cambridge: Cambridge University Press.

Consolidated Bibliography

471

Labonte, R. (1998) “Healthy policy and the World Trade Organisation: a proposal for an international health presence in future world trade/investment talks” Health Promotion International 13, 245–56. Lalonde, M. (1974) A New Perspective on the Health of Canadians: A Working Document, Ottawa:The Dept of Health and Welfare. Lambert, R. (1962–63) “Central and local relations in mid–Victorian England: the Local Government Act Office, 1858–71”, Victorian Studies 6, 121–50. ——— (1963) Sir John Simon 1816–1904 and English Social Administration, London: MacGibbon and Kee. Landers, J. (1990) “Age patterns of mortality in London during the ‘long eighteenth century’: a test of the ‘high potential’ method of metropolitan mortality”, SHM 3, 27–60. ——— (1993) Death and the Metropolis. Studies in the Demographic History of London 1670–1830, Cambridge: Cambridge University Press. Landers, J., ed. (1992) “Historical epidemiology and the health transition”, Supplement to Health Transition Review II. Landry, A. (1909) “Les trois théories principales de la population” Scientia. ——— (1934) La Révolution Démographique: études et essais sur les problèmes de la population, Paris: Librairie du Recueil Sirey. Langford, C. (1989) A Polite and Commercial People: England 1727–83, Oxford: Oxford University Press. Laslett, P. (1965) The World We Have Lost, London: Methuen. Laslett, P., and K. Oostereven (1973) “Long-term trends in bastardy in England” PS 27, 255–86. Law, C. M. (1967) “The growth of urban population in England and Wales, 1801–1911” Trans. Inst. Brit. Geog. 41, 125–43. Laxton, P. (2000) “Fighting for public health: Dr Duncan and his adversaries, 1847–63” in Sheard S and Power H, eds. Body and City: Histories of Urban Public Health, Aldershot: Ashgate Press, 59–88. Laxton, P., and N. Williams (1989) “Urbanisation and infant mortality in England: a long-term perspective and review” in Urbanisation and Epidemiologic Transition, edited by M. C. Nelson, and J. Rogers, Uppsala: Historiska institutionen, Uppsala universitet, 109–35. Le Roy, E. Ladurie (1973) “Un concept: l’unification microbienne du monde (XIVe–XVIIe siècles)” Revue Suisse d’Histoire 2, 627–96. Leavitt, J. W. (1982) The Healthiest City: Milwaukee and the Politics of Health Reform, Princeton, NJ: Princeton University Press. Lee, R., and D. Lam (1983) “Age distribution adjustments for English censuses, 1821–1931” PS 37, 445–64. Leeder, S., and A. Dominello (1999) “Social capital and its relevance to health and family policy” Aust N Z J Public Health 23, 424–29. Lees, L. H. (1998) The Solidarities of Strangers. The English Poor Laws and the People, 1700–1948, Cambridge: Cambridge University Press.

472

Consolidated Bibliography

Leibenstein, H. (1954) A Theory of Economic-Demographic Development, Princeton, NJ: Princeton University Press. ——— (1957) Economic Backwardness and Economic Growth: Studies in the Theory of Economic Development, New York:Wiley. Lennartsson, C. (1999) “Social ties and health among the very old in Sweden” Res Ageing 21, 657–81. Leon, D. A., and G. Walt, eds. (2000) Poverty, Inequality and Health: An International Perspective, Oxford: Oxford University Press. Levy, M. (1949) The Family Revolution in Modern China, Cambridge, MA: Harvard University Press. Lewes, F. (1991) “The GRO and the provinces in the nineteenth century” SHM 4, 479–96. Lewis, J. (1980) The Politics of Motherhood: Child and Maternal Welfare in England, 1900–1939, London: Croom Helm. ——— (1982) “Parents, school fees and the London School Board 1870–1890” History of Education 11, 291–312. Lewis, W. A. (1949) The Principles of Economic Planning: A Study Prepared for the Fabian Society, London: D. Dobson. Lin, N. (2001) Social Capital: A Theory of Social Structure and Action, Cambridge: Cambridge University Press. Lin, N., X.Ye, and W. M. Ensel (1999) “Social support and depressed mood: a structural analysis” Jnl Health Soc Behav 40, 344–59. Lindert, P. (1994) “Unequal living standards” in The Economic History of Britain Since 1700 vol. 1, 1700–1860, 2nd edn., edited by R. Floud, and D. McCloskey, Cambridge: Cambridge University Press, 357–86. Lindert, P. H. (2004) Growing Public. Social Spending and Economic Growth since the Eighteenth Century, 2 vols, Cambridge: Cambridge University Press. Lindert, P. H., and J. G. Williamson (1983) “English Workers” Living Standards’ EcHR 36, 1–25. Lindstrom, M., B. S. Hanson, P. O. Ostergren, and G. Berglund (2000) “Socio-economic differences in smoking cessation: the role of social participation” Scand J Public Health 28, 200–208. Lipsky, M. (1980) Street-level Bureaucracy: Dilemmas of the Individual in Public, New York: Russell Sage Foundation. Lis, C., and H. Soly (1979) Poverty and Capitalism in Pre-industrial Europe, Hassocks: Harvester Press. Lister, R. (1997) Citizenship: Feminist Perspectives, Basingstoke: Macmillan. ——— (1998) “Citizenship on the margins: citizenship, social work and social action” European Journal of Social Work 1, 5–18. Llewellyn Davies, M. (1915; 1984), ed. Maternity. Letters from Working Women, London: G. Bell and Sons. Lomas, J. (1998) “Social capital and health: implications for public health and epidemiology” Soc Sci Med 47, 1181–88.

Consolidated Bibliography

473

Loomis, D., and S.Wing (1990) “Is molecular epidemiology a germ theory for the end of the twentieth century?” International Journal of Epidemiology 19, 1–3. López-Casanovas, G., Rivera, B., and Currais, L. (2005) eds. Health and Economic Growth. Findings and Policy Implications, Cambridge, Mass:The MIT Press. Loury, G. (1977) “A dynamic theory of racial income differences” in Women, Minorities, and Employment Discrimination, edited by P.A.Wallace, and A. LeMund, Lexington, MA: Lexington Books, 153–86. Lowe, R. (1979) “Eugenicists, doctors and the quest for national efficiency: an educational crusade 1900–39” History of Education 8, 293–306. ——— (1980) “Eugenics and education; a note on the origins of the intelligence testing movement” Educational Studies 6, 1–8. ——— (1998), TheWelfare State in Britain since 1945, 2nd edn, Basingstoke: Macmillan. Luckin, B. (1986) Pollution and Control. A Social History of the Thames in the Nineteenth Century, Bristol: Hilger. Luckin, B., and G. Mooney (1997) “Urban history and historical epidemiology: the case of London between 1860 and 1920” Urban Hist. 14, 37–55. Lukes, S. (1973) Individualism, Oxford: Basil Blackwell. Lynch, J. (2000) “Income inequality and health: expanding the debate” Soc Sci Med 51, 1001–5. Lynch, J., G. Davey Smith (2002) “Commentary: income inequality and health: the end of the story?” Int J Epidemiol 31, 549–51. Lynch, J., G. Davey Smith, M. Hillemeier et al. (2001) “Income inequality, the psychosocial environment, and health: comparisons of wealthy nations” Lancet 358, 194–200. Lynch, J., G. Davey Smith, G. Kaplan, and J. House (2000) “Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions” BMJ 320, 1200–1204. Lynch, J., P. Due, C. Muntaner, and G. Davey Smith (2000) “Social capital—is it a good investment strategy for public health?” JECH 54, 404–8. Lynch, J. W., G. A. Kaplan, and J. T. Salonen (1997) “Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse” Soc Sci Med 44, 809–19. Macfarlane, A. (1978) The Origins of English Individualism:The Family, Property and Social Transition, Oxford: Blackwell. Macinko, J., and B. Starfield (2001) “The utility of social capital in research on health determinants” Milbank Q 79, 387–427. Mackenzie, D. A. (1981) Statistics in Britain 1865–1930: The Social Construction of Scientific Knowledge, Edinburgh: Edinburgh University Press. Macleod, R. M. (1967) “The frustration of state medicine” Medical History 11, 15–40. ——— (1968a) Treasury Control and Social Administration:A Study of Establishment Growth at the Local Government Board 1871–1905, London: Bell. ——— (1968b) “The anatomy of state medicine: concept and application” in Medicine and Science in the 1860s, edited by F. N. L. Poynter, London:Wellcome Institute of the History of Medicine, 199–227.

474

Consolidated Bibliography

Macleod, R. M. (1988) “Introduction” in Government and Expertise. Specialists,Administrators and Professionals 1860–1919, edited by R. M. Macleod, Cambridge: Cambridge University Press, 1–24. Macmahon, R. J. (1988) “U.S. Cold War strategy in S. Asia: making a military commitment to Pakistan” Journal of American History 75, 812–40. Mandler, P. (1987) “The making of the New Poor Law redivivus” Past and Present 117, 131–57. Mann, M. (1993) The Sources of Social Power.Vol II. The Rise of Classes and Nation-States, 1760–1914, Cambridge: Cambridge University Press. Marmot, M., and R. G. Wilkinson (2001) “Psychosocial and material pathways in the relation between income and health: a response to Lynch et al.” BMJ 322, 1233–36. ——— eds. (1999) Social Determinants of Health, Oxford: Oxford University Press. Marmot, M., G. Davey Smith, S. Stansfield, et al. (1991) “Health inequalities among British civil servants: the Whitehall II study” Lancet 337, 1387–93. Marmot, M., G. Rose, M. Shipley, and P. J. Hamilton (1978) “Employment grade and coronary heart disease in British civil servants” JECH 32, 244–49. Marmot, M. G. (1986) “Social Inequalities in Mortality: The Social Environment” in Class and Health. Research and Longitudinal Data, edited by R. G. Wilkinson, London:Tavistock Publications, 21–33. Marsh, P. T. (1994) Joseph Chamberlain. Entrepreneur in Politics, London:Yale University Press. Marshall, J. D. (1985) The Old Poor Law, 1795–1834, Basingstoke: Macmillan. Mason, M. (1994) The Making of Victorian Sexual Attitudes, Oxford: Oxford University Press. Maurice, (J). F. (1902) (pseud. “Miles”) “Where to get men” Contemporary Review, 78–86. ——— (1903) “National health: a soldier’s study” Contemporary Review, 41–56. McBriar, A. M. (1966) Fabian Socialism and English Politics 1884–1918, Cambridge: Cambridge University Press. ——— (1987) An Edwardian Mixed Doubles. The Bosanquets versus the Webbs. A Study in Social Policy 1890–1929, Oxford: Clarendon Press. McCormack, C. P. (1982), ed. Ethnography of Fertility and Birth, London:Academic Press. McCulloch, A. (2001) “Social environments and health: cross sectional national survey” BMJ 323, 208–9. McKeown, T. (1979) The Role of Medicine: Dream, Mirage or Nemesis (first published, Nuffield Provincial Hospitals Trust 1976), Oxford: Blackwell. ——— (1976) The Modern Rise of Population, London: Edward Arnold. McKeown,T., and R. G. Brown (1955) “Medical evidence related to English population changes in the eighteenth Century” PS 9, 119–41. McKeown, T., and R. G. Record (1962) “Reasons for the decline of mortality in England and Wales during the nineteenth century” PS 16, 94–122.

Consolidated Bibliography

475

McKeown,T., R. G. Record, and R. D.Turner (1975) “An Interpretation of the decline of mortality in England and Wales during the twentieth century” PS 29, 391–422. McKibbin, R. (1998) Classes and Cultures: England 1918–1951, Oxford: Oxford University Press. McMichael, A. J. (2001) Human Frontiers, Environments and Disease. Past Patterns, Uncertain Futures, Cambridge: Cambridge University Press. McMichael, A. J., and R. Beaglehole (2000) “The changing global context of public health” Lancet 356, 495–99. McNeill,W. H. (1976) Plagues and Peoples, Garden City, NY: Anchor Press. Meacham, S. (1987) Toynbee Hall and Social Reform, 1880–1914: the Search for Community, New Haven:Yale University Press. Meller, H. (1997) Towns, Plans and Society in Modern Britain, Cambridge: Cambridge University Press. Melosi, M.V. (2000) The Sanitary City: Urban Infrastructure in America From Colonial Times to the Present, Baltimore:The Johns Hopkins University Press. Mercer, A. (1990) Disease Mortality and Population in Transition, Leicester: Leicester University Press. Mill, J. S. (1912) ‘Considerations on Representative Government’ in On Liberty, Representative Government,The Subjection of Women:Three Essays by John Stuart Mill. London: Oxford University Press. Millward, R., and S. Sheard (1995) “The urban fiscal problem, 1870–1914: government expenditure and finance in England and Wales” EcHR 48, 501–35. Milne, J. (1815), Treatise on the Valuation of Annuities and Assurances on Lives and Survivorships, London: Longmans. Miringoff, M., and M. Miringoff (1999) The Social Health of the Nation: How America Is Really Doing, Oxford: Oxford University Press. Mitchell, B. R., and P. Deane (1962) Abstract of British Historical Statistics, Cambridge: Cambridge University Press. Moore, G. E. (1903) Principia Ethica, Cambridge: Cambridge University Press. Morris, J. N., and R. M.Titmuss (1942) “Epidemiology of juvenile rheumatism” Lancet (July 13), 59–65 ——— (1944a) “Health and social change, I: the recent history of rheumatic heart disease Medical Officer 2 (August 26, September 2 and 9), 69–71, 77–79, 85–87. ——— (1944b) “Epidemiology of peptic ulcer: vital statistics” Lancet, December 30, 841–56. Morrow,V. (1999) “Conceptualising social capital in relation to the well-being of children and young people: a critical review” Sociol Rev 47, 744–65. Muntaner, C., and J. Lynch (1998) “Income inequality and social cohesion versus class relations: a critique of Wilkinson’s neo-Durkheimian research program” Int J Health Serv 29, 59–81.

476

Consolidated Bibliography

Muntaner, C., J. Lynch, and G. Davey Smith (2000) “Social capital and the third way in public health” Crit Public Health 10, 107–24. ——— (2001) “Social capital, disorganized communities, and the third way: understanding the retreat from structural inequalities in epidemiology and public health” Int J Health Serv 31, 213–37. Muntaner, C., J.W. Lynch, M. Hillemeier et al. (2002) “Economic inequality, workingclass power, social capital, and cause-specific mortality in wealthy countries” Int J Health Serv 32, 629–56. Murray, M. (2000) “Social capital formation and healthy communities: insights from the Colorado Healthy Communities Initiative” Community Development Journal 35, 99–108 Narayan, D., et al. (2000) Voices of the Poor: Can Anyone Hear Us, Oxford: Oxford University Press for the World Bank. Nathanson, C. A. (1996) “Disease prevention as social change: toward a theory of public health” PDR 22, 609–37. Navarro,V. (2002) “A critique of social capital” Int J Health Serv 32, 423–32. Navarro, V., and L. Shi (2001) “The political context of social inequalities and health” Int J Health Serv 31, 1–21. Neal, F. (1998) Black ’47: Britain and the Irish Famine. Basingstoke: Macmillan. Neave, D. (1996) “Friendly Societies in Great Britain” in Social Security Mutualism:The Comparative History of Mutual Benefit Societies, edited by M. van der Linden, M. Dreyfus, B. Gibaud, and J. Lucassen, Berne: Peter Lang, 41–64. Nelson, M. C., and J. Rogers (1994) “Cleaning up the cities: application of the first comprehensive public health law in Sweden” Scand J Hist. 19, 17–39. Nelson, R. R. (1956) “A theory of the low-level equilibrium trap in under-developed economies” American Economic Review 46, 894–908. Newsholme, A. (1896) “A national system of notification and regulation of sickness” J.R.S.S. 59, 1–28. Newsholme, A. (1935) FiftyYears in Public Health, London: Allen and Unwin. Newsholme, A. (1936) The Last ThirtyYears in Public Health, London: Allen and Unwin. Nicholas, S., and D. Oxley (1993) “The living standards of women during the industrial revolution, 1795–1820” EcHR 46, 723–49. Nisbet, R. A. (1969) Social Change and History:Aspects of theWestern Theory of Development, New York: Oxford University Press. Noguera, P. A. (2001) “Transforming urban schools through investment in the social capital of parents” in Social Capital and Poor Communities, edited by S. Saegert, J. P. Thompson, and M. R. Warren, New York: Russell Sage Foundation, 189–212. North, D. C. (1981) Structure and Change in Economic History, New York: Norton. Norton, B. (1981) “Psychologists and class” in Webster C, ed. Biology, Medicine, and Society 1840–1940, Cambridge: Cambridge University Press, 289–314. Notestein, F. W. (1939a) “Some implications of current demographic trends for birth control and eugenics” Journal of Heredity 30, 121–26.

Consolidated Bibliography

477

Notestein, F. W. (1939b) “Intrinsic factors in population growth” Proceedings of the American Philosophical Society 80, 499–511. ——— (1944) “Problems of policy in relation to areas of heavy population pressure” Milbank Memorial Fund Quarterly 22, 424–44. ——— (1945) “Population—the long view” in Food for the World, edited by T. W. Schultz, Chicago: Chicago University Press, 36–57. ——— (1946) “The facts of life” Population, 615–22. ——— (1948) “Summary of the demographic background of problems of un-developed areas” Milbank Memorial Fund Quarterly 26, 249–55. ——— (1950) “The reduction of human fertility as an aid to programs of economic development in densely settled agrarian regions” in Milbank Memorial Fund, Modernization Programs in Relation to Human Resources and Population Problems, New York: Milbank Memorial Fund, 89–100. ——— (1953) “Economic problems of population change” in Proceedings of the Eighth International Conference of Agricultural Economists, London: Oxford University Press, 3–31. ——— (1971) “Reminiscences” Milbank Memorial Fund Quarterly 49, No. 4, part 2, 67–85. ——— (1982) “Demography in the United States: A partial account of the development of the field” PDR 8, 651–87. Notestein, F. W., and C. Chiao (1937) “Population” in Land Utilization in China, edited by J. L. Buck, Nanking: University of Nanking, 358–99. Nutt, T. (2005) “The paradox and problems of illegitimate paternity in Old Poor Law Essex” in Illegitimacy in Britain 1700–1920, edited by A. S. Levene, T. W. Nutt, and S. K.Williams, Basingstoke: Macmillan, 101–21. Oakley, A. (1991) “Eugenics, social medicine and the career of Richard Titmuss in Britain 1935–50” British Journal of Sociology 42: 165–94. ——— (1996) Man and Wife: Richard and Kay Titmuss: My Parents’ Early Years, London: Harper Collins. O’Day, R., and D. Englander (1993) Charles Booth’s Inquiry. Life and Labour reconsidered, London: Hambledon Press. Oddy, D. J. (1970) “Working class diets in late nineteenth century Britain” EcHR 23, 314–23. ——— (1990) “Food, Drink and Nutrition” in Cambridge Social History of Britain 1750–1950.Vol.2 People and Their Environment, edited by F. M. L. Thompson, Cambridge: Cambridge University Press, 251–78. Offer, A. (1981) Property and Politics 1870–1914: Landownership, Law, Ideology, and Urban Development in England, Cambridge: Cambridge University Press. Olby, R. (1979) “Mendel no Mendelian” History of Science 17, 53–73. Omran, A. R. (1971) “The epidemiologic transition: a theory of the epidemiology of population change” Milbank Memorial Fund Quarterly 49, 509–38. Ong, B. N. (2000) “Assessing the context for partnerships between communities and the National Health Service in England” Critical Public Health 10, 343–51.

478

Consolidated Bibliography

Oppenheim, C., and Harker, L., (1996) Poverty:The Facts, London: Child Poverty Action Group. Outhwaite, R. B. (1991) Dearth, Public Policy and Social Disturbance in England, 1550–1800, Basingstoke: Macmillan. Pamuk, E. R. (1985) “Social class inequality in mortality from 1921 to 1972 in England and Wales” PS 39, 17–31. Parton, C. (1983) “The infant welfare movement in early twentieth century Huddersfield” Journal of Regional and Local Studies 3, 69–77. P. D. C. (Interdepartmental Committee on Physical Deterioration)—see under “Official Publications.” Peacock, A.T., and J.Wiseman (1967) (and J.Veverka), The Growth of Public Expenditure in the United Kingdom (rev. edn.; first published 1961), London:Allen and Unwin. Pearce, N., and G. Davey Smith (2003) “Is social capital the key to inequalities in health?” AJPH 93, 122–29. Pelletier, F., J. Légaré, and R. Bourbeau (1997) “Mortality in Quebec during the nineteenth century: from state to the cities” PS 51, 93–103. Pelling, M. (1978) Cholera, Fever and English Medicine 1825–65, Oxford: Oxford University Press. Pember Reeves, M. (1913) Round About a Pound a Week, London: G. Bell. Penninx, B. W. J. H., T. G. van Tilburg, D. M. W. Kriegsman et al. (1999) “Social network, social support, and loneliness in older persons with different chronic diseases” J Aging Health 11, 151–68. Pennybacker, S. (1995) A Vision for London, 1889–1914: Labour, Everyday Life and the LCC Experiment, London: Routledge. Perkin, H. G. (1969) Origins of Modern English Society, 1780–1880, London: Routledge and Kegan Paul. ——— (1989) The Rise of Professional Society. England since 1880, London: Routledge. Phelps Brown, H. (1988) Egalitarianism and the Generation of Inequality, Oxford: Clarendon Press. Pickering, P. A., and A. Tyrrell (2000) The People’s Bread. A History of the Anti-Corn Law League, Leicester: Leicester University Press. Pickstone, J.V. (1985) Medicine and Industrial Society: a History of Hospital Development in Manchester and its Region, 1752–1946, Manchester: Manchester University Press. Pigou, A. C. (1920) The Economics of Welfare, London: Macmillan. Polanyi, K. (1957) The Great Transformation, Boston, Mass.: Beacon Press. Pollak, M. (1979) “Paul F. Lazarsfeld, fondateur d’une multinationale scientifique” Actes de la Recherche en Science Sociales No. 25, 45–59. Pollard, S. (1992) The Development of the British Economy 1914–90, 4th edn, London: Edward Arnold. Pooley, C., and S. D’Cruze (1994) “Migration and urbanisation in north-west England circa 1760–1830” Social History 19, 339–58. Pooley, C., and J. Turnbull (1998) Migration and Mobility in Britain Since the Eighteenth Century, London: UCL Press.

Consolidated Bibliography

479

Pope, J. (2000) “Social capital should not be incorporated into surveys designed to monitor population health” Aust N Z J Public Health 24, 341. Porter, D. (1991) “‘Enemies of the race’: biologism, environmentalism, and public health in Edwardian England” Victorian Studies 35, 159–78. Porter, D., ed. (1997) Social Medicine and Medical Sociology in the Twentieth Century, Amsterdam: Rodopi. Porter, D., and R. Porter (1988) “What was social medicine? An historiographical essay” Journal of Historical Sociology 1, 90–106. Porter, T. M. (1986) The Rise of Statistical Thinking, 1820–1900, Princeton, NJ: Princeton University Press. Portes, A. (1998) “Social capital: its origins and applications in modern sociology” Ann Rev Sociol 24, 1–24. Power, A. (1996) “Area-based poverty and resident empowerment” Urban Studies 33, 1535–64. Powles, J. (2001) “Healthier progress: historical perspectives on the social and economic determinants of health” in The Social Origins of Health and Well-Being: From the Planetary to the Molecular, edited by R. Eckersley, J. Dixon, Melbourne: Oxford University Press, 3–24. Powles, J., and N. Day (1995) “The East Europeans dying before their time” European Brief 2, 50–51. Prest, J. (1990) Liberty and Locality: Parliament, Permissive Legislation, and Ratepayers’ Democracies in the Mid-Nineteenth Century, Oxford: Clarendon Press. Preston, S. H. (1975) “The changing relation between mortality and level of economic development” PS 34, 231–48. ——— (1976) Mortality Patterns in National Populations:With Special Reference to Recorded Causes of Death, New York: Academic Press. Preston, S. H., and V. E. Nelson (1974) “Structure and change in causes of death: an international summary” PS 28, 19–51. Preston, S. H., and E.Van de Walle (1978) “Urban French mortality in the nineteenth century” PS 32, 275–97. Pritchett, L., and M. Woolcock (2004) “Solutions when the solution is the problem: arraying the disarray in development” World Development 32, 192–212. Prochaska, F. (1980) Women and Philanthropy in Nineteenth-Century England, Oxford: Clarendon Press. Provine, W. B. (1971) The Origins of Theoretical Population Genetics, Chicago: Chicago University Press. ——— (1986) SewallWright and Evolutionary Biology, Chicago: Chicago University Press. Putnam, R. (1993) Making DemocracyWork: Civic Traditions in Modern Italy, Princeton, NJ: Princeton University Press. ——— (2000) Bowling Alone: The Collapse and Revival of American Community, New York: Simon and Schuster. Rabinowicz, L. (1929) Le Problème de la Population en France : précédé d’une histoire générale de al population : étude sociologie de la population, Paris : M.Rivière.

480

Consolidated Bibliography

Raphael, D., R. Renwick, Brown et al. (2001) “Making the links between community structure and individual wellbeing: community quality of life in Riverdale, Toronto, Canada” Health Place 7, 179–96. Razzell, P. (1977) The Conquest of Smallpox: the Impact of Inoculation on Smallpox Mortality in Eighteenth-Century Britain, Firle: Caliban Books. Razzell, P. E. (1965) “Population change in eighteenth century England: a re-appraisal” EcHR 18, 312–32. ——— (1974) “An Interpretation of the modern rise of population in Europe: a critique” PS 28, 5–17. R. C. on P.T. (Royal Commission on Physical Training)—see under “Official Publications.” Read, D. (1961) Press and People 1790–1850: Opinion in Three English Cities, London: Edward Arnold. ——— (1994) The Age of Urban Democracy. England 1868–1914 (rev. edn), London: Longman. Reader, W. J. (1966) Professional Men. The Rise of the Professional Classes in NineteenthCentury England, London:Weidenfeld and Nicolson. Reddaway, W. B. (1939) The Economics of a Declining Population, London: Allen and Unwin. Reed, J. (1978) From Private Vice to Public Virtue:The Birth Control Movement and American Society Since 1830, New York: Basic Books. Reid, A. J. (2004) United we stand.A History of Britain’s Trade Unions, London: Allen Lane. R-G—see under “Official Publications.” Rice,T. (1997) “Can markets give us the health we want?” J Health Politics, Policy and Law 22, 383–426. Rich, A. R. (1951) The Pathogenesis of Tuberculosis, 2nd edn., Oxford: Blackwell. Richardson, B.W. (1876) Hygiea: a City of Health, London: Macmillan. ——— (1879) A Ministry of Health, and Other Essays, London: Chatto & Windus. Riggs, P. (1994) “The standard of living in Scotland, 1800–50” in Stature,Living Standards and Economic Development. Essays in Anthropometric History, edited by J. Komlos, Chicago: Chicago University Press, 60–75. Riley, J. C. (1987) The Eighteenth Century Campaign to Avoid Disease, Basingstoke: Macmillan. ——— (1992) “From a high mortality regime to a high morbidity regime: is culture everything in sickness?” HTR 2, 71–78. ——— (1989) Sickness, Recovery and Death: A History and Forecast of Ill-health, Iowa City: University of Iowa Press. ——— (1994) “Height, nutrition, and mortality risk reconsidered”, JIH 24, 465–92. Robb-Smith, A. H. T. (1969) “A history of the College’s nomenclature of diseases: its reception”, Journal of Royal College of Physicians, London 4, 5–26. Roberts, D. (1979). Paternalism in Early Victorian England, London: Croom Helm. Robertson, A. F. (1984) People and the State, Cambridge: Cambridge University Press. Romer, P. M. (1994) “The origins of endogenous growth” Journal of Economic Perspectives 8, 3–22.

Consolidated Bibliography

481

Rose, G. (1985) “Sick individuals and sick populations” International Journal of Epidemiology 14, 32–38. ——— (1992) The Strategy of Preventive Medicine, Oxford: Oxford University Press. Rose, M. E. (1970) “The anti poor law agitation”, ch.3 in Popular Movements, edited by T. J.Ward, Basingstoke: Macmillan 78–94. Rose, M. E. (1985), ed. The Poor and the City: the English Poor Law in its Urban Context 1834–1914, Leicester: Leicester University Press. Rose, M. E. (1986) The Relief of Poverty, 1834–1914, Basingstoke: Macmillan. Rose, N. (1985) The Psychological Complex. Psychology, Politics and Society in England, 1869–1939, London: Routledge. Rose, R. (2000) “How much does social capital add to individual health? A survey study of Russians” Soc Sci Med 51, 1421–35. Rose, S. O. (1992) Limited Livelihoods: Gender and Class in Nineteenth-Century Britain, London: Routledge. Rosenheck, R., J. Morrissey, J. Lam, et al. (2001) “Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness” Health Serv Res 36, 691–710. Rosenkrantz, B. G. (1972) Public Health and the State: Changing Views in Massachusetts, 1842–1936 Cambridge, MA: Harvard University Press. Ross, N. A., M. C.Wolfson, J. R. Dunn, et al. (2000) “Income inequality and mortality in Canada and the United States: A cross-sectional assessment using Census data and vital statistics” BMJ 320, 898–902. Rostow,W.W. (1948) British Economy of the Nineteenth Century, Oxford: Clarendon Press. ——— (1953) The Process of Economic Growth, Oxford: Clarendon Press. ——— (1960) The Stages of Economic Growth: A Non-Communist Manifesto, Cambridge: Cambridge University Press. Rothstein, B. (1998) Just Institutions Matter:The Moral and Political Logic of the Universal Welfare State, Cambridge: Cambridge University Press. Rowntree, B. S. (1901) Poverty: a Study of Town Life, London: Macmillan. ——— (1903) The Poverty Line: a Reply, London: Henry Good and Son. Rowntree, B. S., and G. R. Lavers (1951) Poverty and the Welfare State, London: Longmans, Green and Co. Rowthorn, B. (1992) “Government Spending and Taxation in the Thatcher Era” in The Economic Legacy 1979–92, edited by J.Michie, London: Academic Press, 261–93. Rubinstein, D. (1969) School Attendance in London 1870–1904: a Social History, Hull: University of Hull. Rumsey, H.W. (1856) Essays on State Medicine, London: John Churchill. Ryan, A. (1970) The Philosophy of the Social Sciences, London: Macmillan. Ryder, N. B. (1959) “Fertility” in The Study of Population:An Appraisal and Inventory, edited by P. M. Hauser, and O. D. Duncan, Chicago: Chicago University Press, 400–436. ——— (1984) “Frank Wallace Notestein (1902–83)” PS 38, 5–20.

482

Consolidated Bibliography

Samet, J. M., and T. A. Burke (2001) “The Bush administration, the environment and public health: warnings from the first 100 days” Int J Epidemiol 30, 658–60. Sampson, R., J. Morenhoff, and F. Earls (1999) “Beyond social capital: spatial dynamics of collective efficacy for children” Am Sociol Rev 64, 633–60. Sargant,W. L. (1865) “Inconsistencies of the English Census of 1861 with the RegistrarGeneral’s Reports; and deficiencies in the local registry of births” JSSL (1865), 73–124. Scammell, W. M. (1983) The International Economy Since 1945, 2nd edn., Basingstoke: Macmillan. Schneider, J., and P. Schneider (1976) Culture and Political Economy in Western Sicily, NewYork: Academic Press. ——— (1984) “Demographic transitions in a Sicilian rural town” Journal of Family History 9, 245–73. Schofield, R. (1973) “Dimensions of illiteracy, 1750–1850” Explorations in Economic History 10, 437–54. ——— (1994) “British population change, 1700–1871” in The Economic History of Britain since 1700, I: 1700–1860 2nd edn., edited by R. Floud, and D. McCloskey, Cambridge: Cambridge University Press, 60–95. Schuller T., S. Baron, and J. Field (2001) “Social capital: a review and critique” in Social Capital: Critical Perspectives, edited by S. Baron, J. Field, and T. Schuller, Oxford: Oxford University Press, 1–38. Schultz, T. W. (1945) “Introduction” in Food for the World, edited by T. W. Schultz, Chicago: Chicago University Press, v–xi. Schwarz, L. D. (1985) “The standard of living in the long run: London 1700–1860” EcHR 38, 24–41. ——— (1990) “Trends in real wages, 1750–1790: A reply to Botham and Hunt” EcHR 43, 90–98. ——— (1992) London in the Age of Industrialization: Entrepreneurs, Labour Force and Living Conditions 1700–1860, Cambridge: Cambridge University Press. Scott, J. (1998) Seeing Like a State: Why Certain Schemes to Improve the Human Condition Have Failed, New Haven:Yale University Press. Searle, G. R. (1971) The Quest for National Efficiency:A Study in British Politics and Thought 1899–1914, Oxford: Blackwell. ——— (1981) “Eugenics and class” in Biology, Medicine and Society 1840–1940, edited by C.Webster, Cambridge: Cambridge University Press, 217–42. ——— (1992) The Liberal Party: Triumph and Disintegration 1886–1929, Basingstoke: Macmillan. ——— (1973) “Introduction” to reprint of A. White, Efficiency and Empire (first published 1901), Brighton: Harvester Press. Seeman, T. E. (1996) “Social ties and health: the benefits of social integration” Ann Epidemiol 6, 442–51. Semmel, B. (1960) Imperialism and Social Reform. English Social-Imperial Thought 1895–1914, London: Allen and Unwin.

Consolidated Bibliography

483

Sen, A. K. (1999) Development as Freedom, Oxford: Oxford University Press. ——— (1981) Poverty and Famines. An Essay on Entitlement and Deprivation, Oxford: Clarendon Press. Sevigny, B., J. P. Belanger, and R. Sullivan (1999) “Social capital and improvement in health and wellbeing of populations” Canadian Jnl Public Health 90, 369–71. Shah, G. (1997) Public Health and Urban Development: The Plague in Surat, New Delhi, London: Sage. Sheard, S. “Profit is a dirty word: the development of public baths and washhouses in Britain 1847–1915” SHM 13, 63–85. Shkolnikov,V. M., F. Mesle,V. Hertrich, J. Rychtarikova, J. Shapiro,W.W. Kingkade, and S. Vasin (1997) “Mortality reversals and their causes in the former USSR and Eastern Europe” in IUSSP, International Population Conference, Beijing 1997, Vol. 2, Liège: IUSSP, 473–579. Shlomowitz, R. (1996) Mortality and Migration in the Modern World, Aldershot: Ashgate Press. Siegrist, J. (2002) “Social capital and health” Gesundheitswesen 64, 189–92. Simon, B. (1965) Education and the Labour Movement 1870–1918, London: Lawrence and Wishart. Simon, J. (1890) English Sanitary Institutions, Reviewed in Their Course of Development, and in Some of their Political and Social Relations, London: Cassell. Skocpol, T., and M. P. Fiorina, eds. (1999) Civic Engagement in American Democracy, Washington DC: Brookings Institution: Russell Sage Foundation. Slack, P. (1990) The English Poor Law 1531–1782, Basingstoke: Macmillan. Smelser, N. (1959) Social Change in the Industrial Revolution, London: Routledge and Paul Kegan. Smith, F. B. (1979) The People’s Health 1830–1910, Canberra: ANU Press. ——— (1988) The Retreat of Tuberculosis 1850–1950, London: Croom Helm. Smith, N., L. B. Littlejohns, and D.Thomson (2001) “Shaking out the cobwebs: insights into community capacity and its relation to health outcomes” Community Development Journal 36, 30–41. Snell, K.D.M. (1985) Annals of the Labouring Poor: Social Change and Agrarian England, 1660–1900, Cambridge: Cambridge University Press. Sokoll,T. (2001) Essex Pauper Letters 1731–1837, Oxford: Oxford University Press. Solar, P. M. (1995) “Poor relief and English economic development before the industrial revolution” EcHR 48, 1–22. ——— (1997) “Poor relief and English economic development: a renewed plea for comparative history” EcHR 50, 369–74. Solar, P. M., and R. M. Smith (2003) “An Old Poor Law for the New Europe?”, ch.16 in The Economic Future in Historical Perspective, edited by P. A. David, and M. Thomas, Oxford: Oxford University Press, 463–77. Soloway, R. A. (1982) Birth Control and the Population Question in England, 1877–1930, Chapel Hill, NC: University of North Carolina Press.

484

Consolidated Bibliography

Soloway, R. A. (1990) Demography and Degeneration. Eugenics and the Declining Birthrate in Twentieth-Century Britain, Chapel Hill, NC: University of North Carolina Press. Spencer, H. (1873) The Study of Sociology, London: Henry S. King and Co. ——— (1876) The Principles of Sociology, 3 vols, London:Williams and Norgate. Steckel, R. H. (1995) “Stature and the standard of living” Journal of Economic Literature 33, 1903–1940. Steckel, R. H., and J. C. Rose, eds. (2002) The Backbone of History. Health and Nutrition in the Western Hemisphere, Cambridge: Cambridge University Press. Stedman Jones, G. (1971) Outcast London. A Study in the Relationship between Classes in Victorian Society, Oxford: Clarendon Press. ——— (1983) “Working class culture and working class politics in London, 1870–1900: Notes on the remaking of a working class” in Stedman Jones,G., Languages of Class. Studies in English Working-Class History 1832–1982, Cambridge: Cambridge University Press, 179–238. Steedman, C. (1990) Childhood, Culture and Class. Margaret McMillan 1860–1931, New Brunswick, NJ: Rutgers University Press. Stepan, N. (1982) The Idea of Race in Science. Great Britain 1800–1960, London: Macmillan in association with St Anthony’s College, Oxford. Steptoe, A., and P. J. Feldman (2001) “Neighborhood problems as sources of chronic stress: development of a measure of neighborhood problems, and associations with socioeconomic status and health” Ann Behav Med 23, 177–85. Stevenson,T. H. C. (1925) “The laws governing population” JRSS 88, 63–90. Stiglitz, J. E. (2002) Globalization and Its Discontents, New York:W.W. Norton. Stix, R. K., and F.W. Notestein (1940) Controlled Fertility:An Evaluation of Clinic Service, Baltimore:The Williams & Wilkins Company. Stocking, G. W. Jr. (1968) Race, Culture and Evolution, Chicago: Chicago University Press. ——— (1987) Victorian Anthropology, New York: Free Press. Storch, R. D. (1993) “The policeman as domestic missionary: Urban discipline and popular culture in northern England, 1850–80” in The Victorian City:A Reader in British Urban History, 1820–1914, edited by R. J. Morris, and R. Rodger, London: Longman, 281–306. Stycos, J. M. (1955) Family and Fertility in Puerto Rico: A Study of the Lower Income Group, New York: Columbia University Press. ——— (1968) Human Fertility in Latin America: Sociological Perspectives, Ithaca: NY: Cornell University Press. Subramanian, S. V., A. Blakely, and I. Kawachi (2003) “Income inequality as a public health concern: where do we stand?” Health Serv Res 38, 153–67. Subramanian, S. V., I. Kawachi, and B. P. Kennedy (2001) “Does the state you live in make a difference? Multilevel analysis of self-rated health in the US” Soc Sci Med 53, 9–19. Subramanian, S.V., D. J. Kim, and I. Kawachi (2002) “Social trust and self-rated health in US communities: a multi-level analysis” Jnl Urban Health 79, S21–S34.

Consolidated Bibliography

485

Subramanian, S.V., K. A. Lochner, and I. Kawachi (2003) “Neighborhood differences in social capital: a compositional analysis” Health Place 9, 33–44. Subrtova,A. (1984) “Teorie demografické revoluce: prispèvek ke genezi” Demografie 26, no. 3, 193–200. Sutherland, G. (1973) Policy-making in Elementary Education 1870–95, London: Oxford University Press. Sutherland, G., (1984), in collaboration with Sharp, S., Ability, Merit and Measurement. Mental Testing and English Education 1880–1940, Oxford: Clarendon Press. Szreter, S. (1984b) “The genesis of the Registrar-General’s social classification of occupations”, British Journal of Sociology 35, 522–46. ——— (1986) “The First scientific social structure of modern Britain, 1875–83” in The World We Have Gained. Histories of Population and Social Structure, edited by L. Bonfield, R. Smith, and K.Wrightson, Oxford: Basil Blackwell, 337–54. ——— (1988) “The importance of social intervention in Britain’s mortality decline c. 1850–1914: a reinterpretation of the role of public health” SHM 1, 1–37. ——— (1991a) “Introduction:The GRO and the historians” SHM 4, 401–14. ——— (1991b), ed. The GRO of England and Wales and the public health movement 1837–1914, a comparative perspective, Special issue, SHM 4. ——— (1992) “Mortality and Public Health, 1815–1914” in New Directions in Economic and Social History Volume II, edited by A. Digby, C. Feinstein, and D. Jenkins, Basingstoke: Macmillan, 136–48. ——— (1993) “The official representation of social classes in Britain, United States, and France:The professional model and ‘les cadres’” CSSH 35, 285–317. ——— (1996) Fertility, class and gender in Britain 1860–1940, Cambridge: Cambridge University Press. ——— (1997) “British economic decline and human resources” in Understanding Decline, edited by P. Clarke, and C. Trebilcock, Cambridge: Cambridge University Press, 73–102. ——— (1999) “Rapid economic growth and ‘the four Ds’: public health lessons from nineteenth-century Britain for twenty-first century China?” Tropical Medicine and International Health 4, 146–52. ——— (2000) “Social capital, the economy and education in historical perspective” in Social Capital: Critical Perspectives, edited by S. Baron, J. Field,T. Schuller, Oxford: Oxford University Press, 56–77. ——— (2002) “The state of social capital: bringing back in power, politics, and history” Theory and Society 31, 573–621. ——— (2003) “Health and human security in an historical perspective” in Global health challenges for Human Security, edited by L. Chen, J. Leaning, and V. Narasimhan, Cambridge, MA: Harvard University Press, 31–52. ——— (2004) “Industrialisation and health” British Medical Bulletin 69 (2004), 75–86. Tarn, J. N. (1973) Five Per Cent Philanthropy: An Account of Housing in Urban Areas between 1840 and 1914, Cambridge: Cambridge University Press. Tatham, J. (1892) The Manchester Life Tables, Manchester: H. Blacklock.

486

Consolidated Bibliography

Tawney, R. H. (1922) Secondary Education for All: A Policy for Labour, London: Education Advisory Committee of the Labour Party: Allen and Unwin. Taylor,A. J., ed. (1975) The Standard of Living Debate in the Industrial Revolution, London: Methuen. Taylor, J. S. (1989) Poverty, Migration and Settlement in the Industrial Revolution: Sojourners’ Narratives, Palo Alto, Calif.: The Society for the Promotion of Science and Scholarship. Teitelbaum, M. S., and J. M. Winter (1985) The Fear of Population Decline, London: Academic Press. Temple, J. (1999) “The new growth evidence” Jnl Economic Literature 37, 112–56. Tendler, J. (1997) Good Government in the Tropics, Baltimore: The Johns Hopkins University Press. Tesh, S. (1988) Hidden Arguments: Political Ideology and Disease Prevention Policy, New Brunswick, NJ: Rutgers University Press. Thane, P. (1996) The Foundations of the Welfare State (rev. 2nd edn), Harlow: Pearson Education. Thompson, E. P. (1968) The Making of the English Working Class (first published 1963), Harmondsworth: Penguin. Thompson,W. S. (1929) “Population” American Journal of Sociology 34, 959–75. Timmins, N. (1996) The Five Giants.A Biography of the Welfare State, London: Fontana. Titmuss, R. M. (1950) Problems of Social Policy, London: Stationery Office. ——— (1968) Commitment to Welfare, London: Allen and Unwin. Tomes, N. (1998) The Gospel of Germs: Men, Women and the Microbe in American Life, Cambridge, MA: Harvard University Press. Townsend, P., and B. Abel-Smith (1965) The Poor and the Poorest, London: G. Bell. Townsend, P., and N. Davidson (1982) Inequalities in Health. The Black Report: Harmondsworth: Penguin. Trentman, F., ed. (2000) Paradoxes of Civil Society. New Perspectives on Modern German and British History, Oxford: Berghahn. Turner, J. “‘Experts’ and interests: David Lloyd George and the dilemmas of the expanding state, 1906–19” in Government and Expertise. Specialists, Administrators and Professionals 1860–1919, edited by R. MacLeod, Cambridge: Cambridge University Press, 203–23. Turner, S. P. (1990) “Forms of patronage” in Theories of Science in Society, edited by S. E. Cozzens, and T. F. Gieryn, Bloomington, Ind: Indiana University Press, 185–211. Turner, S. P., and J. H. Turner (1990) The Impossible Science: An Institutional Analysis of American Sociology, Newbury Park, California: Sage. Twarog, S. (1997) “Heights and living standards in Germany, 1850–1939: The case of Württemberg” in Health and Welfare During Industrialization, edited by R. H. Steckel, and R. Floud, Chicago: Chicago University Press, 285–330. van Leeuwen, M. H. D. (1994) “The logic of charity: the functioning of poor relief in pre-industrial Europe” JIH 24, 589–613.

Consolidated Bibliography

487

van de Walle, E. (1992) “Fertility transition, conscious choice, and numeracy” Demography 24, 487–502. Vann, R. T., and D. E. C. Eversley (1992) Friends in Life and Death: the British and Irish Quakers in the Demographic Transition, Cambridge: Cambridge University Press. Veenstra, G. (2001) “Social capital and health” Canadian Jnl Policy Res 2, 72–81. Veit-Wilson, J. H. (1986) “Paradigms of poverty: a rehabilitation of B. S. Rowntree” Journal of Social Policy 15, 69–99. Villaveces-Izquierdo, S. (2004) “Internal diaspora and state immigration: Colombia’s failure to envision a nation” in Categories and Contexts.Anthropological and Historical Studies in Critical Demography, edited by S. Szreter, H. Sholkamy, and A. Dharmalingam, Oxford: Oxford University Press, 173–84. Vogele, J. (1998) Urban Mortality Change in England and Germany, 1870–1914. Liverpool: Liverpool University Press. Waddington, I. (1984) The Medical Profession in the Industrial Revolution, Dublin: Gill and Macmillan. Wade, R. (1990) Governing the Market: Economic Theory and the Role of Government in East Asian Industrialization, Princeton, NJ: Princeton University Press. Wakefield, S. E. L., S. J. Elliott, D. Cole, and J. Eyles (2001) “Environmental risk and (re)action: air quality, health, and civic involvement in an urban industrial neighbourhood” Health Place 7, 163–77. Waller, P. J. (1983) Town, City and Nation. England 1800–1950, Oxford: Oxford University Press. ——— (1987) “Democracy and dialect, speech and class” in Politics and Social Change in Modern Britain, edited by P. J.Waller, Brighton: Harvester, 1–33. Walter, P. J. and R. Schofield (1989) “Famine, disease and crisis mortality in early modern society” in Famine, Disease and the Social Order in Early Modern Society, edited by J. Walter, and R. Schofield, Cambridge: Cambridge University Press, 1–73. Watts, S. (1997) Epidemics and History: Disease, Power and Imperialism, London: Yale University Press. Webb, S. (1890) Socialism in England, London: Swan Sonnenschein. ——— (1896) The Difficulties of Individualism, Fabian Tract 69. Webb, S., and B. Webb (1906–29) English Local Government from the Revolution to the Municipal Corporations Act, 9 vols, London: Longmans, Green. Webster, C. (1986) “The origins of Social Medicine in Britain” Society for Social History of Medicine Bulletin 38, 52–55. Weimin, Z., X. Li, J. Banister, and F. Peng (1997) “Mortality trends in China” in IUSSP, International Population Conference, Beijing 1997,Vol. 3, Liège: IUSSP, 1325–69. Weir, D. R. (1997) “Economic welfare and physical well-being in France 1750–1990” in Health and Welfare During Industrialization, edited by R. H. Steckel and R. Floud, Chicago: Chicago University Press, 161–200. Weitzman, E. R., and I. Kawachi (2000) “Giving means receiving: the protective effect of social capital on binge drinking on college campuses” AJPH 90, 1936–39.

488

Consolidated Bibliography

White, J. (1980) Rothschild Buildings. Life in an East End tenement block, 1887–1920, London: Routledge and Kegan Paul. Whitehead, M. (1987) The Health Divide, London: Health Education Council. Whitehead, M., and F. Diderichsen (2001) “Social capital and health: tip-toeing through the minefield of evidence” Lancet 358, 165–66. Whitwell, G., C. de Souza, and S. Nicholas (1997) “Height, health and economic growth in Australia 1860–1940” in Health and Welfare During Industrialization, edited by R. H. Steckel, and R. Floud, Chicago: Chicago University Press, 379–422. Wiebe, R. H. (1967) The Search for Order 1877–1920, London: Macmillan. Wilkinson, R. G. (1986), ed. Class and Health, London:Tavistock Publications. ——— (1996) Unhealthy Societies:The Afflictions of Inequality, London: Routledge. ——— (1997) “Health inequalities: Relative or absolute material standards?” BMJ 314, no. 7080 (online publication, 22 February). ——— (1999a) “Income inequality, social cohesion and health: clarifying the theory. A reply to Muntaner and Lynch” Int J Health Serv 29, 525–43. ——— (1999b) “Putting the picture together: prosperity, redistribution, health and welfare” in Social Determinants of Health, edited by M. Marmot, R. Wilkinson, Oxford: Oxford University Press, 256–74. ——— (2000a) “Deeper than ‘neoliberalism’: a reply to David Coburn” Soc Sci Med 51, 997–1000. ——— (2000b) “Inequality and the social environment: a reply to Lynch et al.” JECH 54, 411–13. ——— (2001) Mind the Gap: Hierarchies, Health, and Human Evolution, New Haven:Yale University Press. ——— (2002) “Commentary: liberty, fraternity, equality” Int J Epidemiol 31, 538–43. Williams, N., and G. Mooney (1994) “Infant mortality in an ‘age of great cities’ ” Continuity and Change 9, 185–212. Williamson, J. G. (1990) Coping with City Growth During the British Industrial Revolution, Cambridge: Cambridge University Press. ——— (1994) “Coping with city growth” in The Economic History of Britain since 1700, I: 1700–1860, 2nd edn., edited by R. Floud, and D. McCloskey, Cambridge: Cambridge University Press, 332–56. Wilmoth, J. R., and P. Ball (1992) “The population debate in American popular magazines, 1946–90” PDR 18, 631–68. Wilson, C., J. Oeppen, and M. Pardoe (1988) “What is natural fertility? The modeling of a concept” Population Index 54, 4–20. Wilson, C. H. (1965) England’s Apprenticeship, 1603–1763, London: Longmans. Wilson, E. (1977) Women and the Welfare State, London:Tavistock Publications. Wilson, W. J. (1996) When Work Disappears:The World of the New Urban Poor, New York: Knopf. Winch, P. (1958) The Idea of a Social Science and its Relation to Philosophy, London: Routledge and Kegan Paul.

Consolidated Bibliography

489

Winch, P. (1990) The Idea of a Social Science and its Relation to Philosophy, 2nd edn., London: Routledge. Winter, J. M. (1982) “The Decline of Mortality in Britain 1870–1950” in Population and Society in Britain 1850–1980, edited by T. Barker and M. Drake, London: Batsford Academic, 101–20. Winter, J. M. (1985) The Great War and the British People, London: Macmillan. Wohl,A. S. (1977) The Eternal Slum.Housing and Social Policy inVictorian London, London: Edward Arnold. ——— (1983) Endangered Lives. Public Health in Victorian Britain, London: Dent. Wolf, E. R. (1971) “Aspects of group relations in a complex society: Mexico” in Peasants and Peasant Society, edited by T. Shanin, Harmondsworth: Penguin, 50–68. Wolfson, M., G. A. Kaplan, J. W. Lynch, N. Ross, and E. Backlund (1999) “The relationship between income inequality and mortality is not a statistical artefact” BMJ 319, 953–57. Wood, L. B. (1982) The Restoration of the Tidal Thames, Bristol: Hilger. Woods, R. (1984) “Mortality patterns in the nineteenth century” in Urban Disease and Mortality in Nineteenth Century England, edited by R. Woods and J. Woodward, London: Batsford Academic, 37–64. ——— (1985) “The effects of population redistribution on the level of mortality in nineteenth-century England and Wales” JEcH. 45, 645–51. ——— (1993) “On the historical relationship between infant and adult mortality” PS 47, 195–219. ——— (2000) The Demography of Victorian England and Wales, Cambridge: Cambridge University Press. Woods, R., and P. R. A. Hinde “Mortality in Victorian England: models and patterns” JIH 18 (1987), 27–54. Woods, R. and N.Williams (1995) “Must the gap widen before it can be narrowed? Longterm trends in social class mortality differentials” Continuity and Change 10, 105–37. Woods, R. I., and J. Woodward, eds. (1984) Urban Disease and Mortality in Nineteenth Century England, London: Batsford Academic. Woods, R. I., P. A.Watterson, and J. H.Woodward (1988) “The causes of rapid infant mortality decline in England and Wales, 1861–1921, Part 1” PS 42, 343–66. ——— (1988) “The causes of rapid infant mortality decline in England and Wales, 1861–1921, Part 2” PS 43, 113–32. Woolcock, M. (1998) “Social capital and economic development: toward a theoretical synthesis and policy framework” Theory and Society 27, 151–208. ——— (2000) “Managing risk, shocks, and opportunity in developing economies: the role of social capital” in Dimensions of Development, edited by G. Ranis, New Haven:The Yale Center for International and Area Studies, 197–212. ——— (2001) “The place of social capital in understanding social and economic outcomes” Canadian Jnl Policy Res 2, 11–17. Woolcock, M., and D. Narayan (2000) “Social capital: implications for development theory, research, and policy” World Bank Research Observer 15, 225–49.

490

Consolidated Bibliography

World Bank (1991) World Development Report 1991, New York: Oxford University Press. ——— (2000) World Development Report 2000/01: Attacking Poverty, Oxford: Oxford University Press. World Development (1996), Special section “Development strategies across the publicprivate divide” World Development 24, 1033–1132. WHO/WTO Commission on Macroeconomics and Health (2001) Macroeeconomics and Health: Investing in Health for Economic Development, Report chaired by Jeffrey D. Sachs, Geneva. Wright, M. (1972) “Treasury control 1854–1914” in Studies in the Growth of NineteenthCentury Government, edited by G. Sutherland, London: Routledge and Kegan Paul, 195–226. Wright Mills, C. (1959) The Sociological Imagination, NewYork: Oxford University Press. Wrigley, E. A. (1967) “A simple model of London’s importance in the changing British society and economy, 1650–1750” Past and Present 37, 44–70. ——— (1987) People, Cities and Wealth, Oxford: Basil Blackwell. ——— (1988) Continuity, Chance and Change:The Character of the Industrial Revolution in England, Cambridge: Cambridge University Press. ——— (1993) “Mortality and the European marriage system” in Food, Diet and Economic Change Past and Present, edited by C. Geissler, and D. J. Oddy, Leicester: Leicester University Press, 35–49. ——— (2000) “The divergence of England: the growth of the English economy in the seventeenth and eighteenth centuries Transactions of the Royal Historical Society 10, 117–41. ——— (2004) “The quest for the industrial revolution”, ch.1 in Poverty, Progress and Population, E. A.Wrigley, Cambridge: Cambridge University Press, 17–43. Wrigley, E.A., and R. S. Schofield (1981) The Population History of England, 1541–1871: A Reconstruction, London: Edward Arnold. Wrigley, E. A., J. Oeppen, R. Davies, and R. Schofield (1997) English Population History from Family Reconstitution, 1580–1830, Cambridge: Cambridge University Press. Zamoyski, A. (1995) The Forgotten Few.The Polish Air Force in the Second World War, London: J. Murray.

Unpublished Sources Alesina, A., and E. La Ferrara (2001) “Preferences for Redistribution in the Land of Opportunities”, NBER Working Paper 8267, Cambridge, MA. Bellamy, C.A. (1982) “Central-Local Relations 1871–1919 (LGB)”, SSRC End of Grant Report HR7579. Bengtsson,T., and M. Dribe (2000) “New Evidence on the Standard of Living in Sweden during the 18th and 19th Centuries: Long-term Development of the Demographic Response to Short-term Economic Stress among Landless in Western Scania” Research Report 16, Danish Center of Demographic Research.

Consolidated Bibliography

491

Buchanan, I. H. (1983) “Infant Mortality in British Coal Mining Communities, 1880–1911” (unpublished Ph.D. thesis, University of London). Case, A., and A. Deaton (2004) “Health and Wealth Among the Poor: India and South Africa Compared” Research Program in Development Studies and Center for Health and Wellbeing, Princeton University, December 2004. Cooper, A. B. (1981) “Local Reports on Public Health by Government Medical Inspectors 1869–1908” (unpublished M.Lib. Studies thesis, Loughborough University). Cullen, M., and H.Whiteford (2001) “The Interrelations of Social Capital with Health and Mental Health”. Commonwealth of Australia: National Mental Health Strategy, Discussion Paper. Dowling,W. C. (1963) “The Ladies Sanitary Association and the Origins of the Health Visiting Service” (unpublished M.A. thesis, University of London). Goeschl, K. (1999) “A Comparative Study of Public Health in Wakefield, Halifax and Doncaster, 1865–1914” (unpublished Ph.D. thesis, University of Cambridge). Grootaert, C., D. Narayan, V. Nyhan Jones, and M. Woolcock (2004) Measuring Social Capital: An Integrated Questionnaire, Working Paper Number 18, World Bank, Washington, DC:World Bank. Howard, D. E. (2003) “How alienation and declines in social capital are affecting adolescent well-being” Working Paper, Department of Public and Community Health, University of Maryland. Jamison, D.T., M. E. Sanbu, and J.Wang (2004) “Why has Infant Mortality Decreased at such Different rates in Different Countries?” Disease Control Priorities Project Working Paper No. 21, N.I.H.: Bethesda, MD. Johansson, S. R. (1997) “Death and the Doctors: Elites, Mortality and Medicine in Britain from 1500 to 1800”, unpublished paper Cambridge Group for History of Population. Laxton, P. (1986) “Observations on Reconstructing the Population Dynamics of English Cities c.1750–1850: Liverpool as a Case Study”, unpublished paper delivered to I.U.S.S.P. seminar on urbanization and population dynamics, Keio University, Tokyo, Japan. Millward, R., and S. Sheard (1993) “Government Expenditure on Social Overhead Infrastructure in England and Wales, 1870–1914” University of Manchester Working Papers in Economic and Social History No. 23. Mooney, G. (1994) “The geography of mortality decline in Victorian London” (unpublished Ph.D. thesis, University of Liverpool). Nolan, G. M. (1982) “Infant Mortality as an Indicator of Environmental and Social Change, 1890–1939, with Special Reference to Derby” (unpublished Ph.D. thesis, University of Nottingham). Pollak, M. (1988) “Le Programme ‘Behavioral Sciences’ de la Fondation Ford”, unpublished paper given in Madrid on 26 May, to the first session of the conference of the International Sociological Association Research Committee for the History of Sociology.

492

Consolidated Bibliography

Ramirez, A., G. Ranis, and F. Stewart (1998) “Economic Growth and Human Development” Queen Elizabeth House Working Paper No. 18, Oxford. Stone, T. (1998) “The Integration of Women into a Military Service: The Women’s Auxiliary Air Force in the Second World War” (unpublished Ph.D. thesis, University of Cambridge). Szreter, S. (1984a) “The decline of marital fertility in England and Wales, c. 1870–1914” (unpublished Ph.D. thesis, University of Cambridge). Watkins, D. E. (now Porter, D.) (1984) “The English Revolution in Social Medicine” (unpublished Ph.D. dissertation, University of London). Wilkinson, A. (now Hardy, A.) (1980) “The Beginnings of Disease Control in London: the Work of the Medical Officers of Health in Three Parishes 1856–1900” (unpublished D.Phil. thesis, University of Oxford). Williams, P. (1970) (now Thane, P.) “The development of old age pensions in Great Britain 1878–1925” (unpublished Ph.D. thesis, University of London). Wilson, J. F., R. Millward, and S. Sheard (1993) “Trends in Local Authority Loan Expenditure in England and Wales 1870–1914” University of Manchester Working Papers in Economic and Social History No. 22. Winter, J. M. (1979) “The Impact of the First World War on Infant Mortality in Britain”, unpublished Final Report to SSRC on grant HR 5091. Wooldridge, A. (1985) “Child Study and Educational Psychology in England, 188–1950” (unpublished D.Phil. thesis, Oxford University). Young, R. K. F. J. (1964) “Sanitary Administration under the L.G.B. 1871–88” (unpublished B.Litt. thesis, University of Oxford).

INDEX Note: Page numbers with an f indicate figures; those with a t indicate tables; those with an n indicate endnotes Abercrombie, Patrick, 369 Acheson, Dean, 70 Acland, Henry, 250, 299 administrative cities, 175, 186–90, 191–92t Adulteration of Foods Acts, 123–24 air pollution, 42, 382 Airy, O., 311 Alameda County Study, 379 alcoholism, 379 Alison,W. P., 328 American City (journal), 34f American Medical Association (AMA), 227 Amsden, Alice, 404 Anderson, A. M., 312 Annales d’Hygiène publique et médecine légale, 25 anthropometric data, 166, 194, 300, 346 antibiotics, 38 Anti-Corn Law League, 217 apartheid, 392 Armstrong,W. A., 166, 181–82, 184 Army Medical Department, 303–5 Arnold, Matthew, 324 Asquith, H. H., 271 Assessed Rates Act, 224 Assisted Education Act, 299 Association of Municipal and Sanitary Engineers and Inspectors, 331n9 asylums, 300 Australia, 30, 205, 436 autonomy, “embedded,” 394, 404

Baker, O. E., 96n103 Balfour, Arthur James, 284 Balfour, Marshall C., 63 Bandung Seminar, 75 Barclay, George, 71 Barr, James, 296 Barrett, H. C., 304 Bartrip, Peter, 291 Bates, Robert, 404 Bateson,William, 317, 318 Behlmer, G. K., 332n28 Belfast, 334n56 Bell, R., 446n67 Berkman, Lisa, 40, 378 Beveridge,William, 363, 366, 368, 434 biometrics, 268–69, 282, 303, 310, 316–18 Birmingham, 10, 16–17, 32–33f, 124, 131, 140n50, 149, 169–72t, 176t, 185–86, 209, 221, 223–24, 248, 296, 300, 311, 334n56, 337n107, 349, 350t, 353, 355, 357, 400–402, 405 birth control. See contraception Bismarck, Otto von, 35 Black Report, 13, 14, 346, 360, 367 Boas, Franz, 91n12 Boer War, 268–69; aftermath of, 286, 294, 316; recruitment for, 282–84 Bolton: 190, 191t, 373n19; compulsory infectious disease notification, 11 Booth, Charles, 285, 304, 322, 335n65 Bourdieu, Pierre, 241n78, 386 Bowley, A. L., 340n149

493

494

Index

Bradford, 170–72t, 174, 176t, 197n18 Bradford, School Board, 11, 292–93, 300–301 Brazil, 32, 237, 405 breast-feeding, 127, 129 Brighton, 128, 191–92t, 292 Bristol, 149, 169, 170t, 172t, 175–76t, 181, 185–86, 190, 198n26, 214, 350t British Association’s Anthropometric Committee, 346 British Medical Association, 251 Broadbent, P., 130 Brookings Institution, 53 Brown, G.W., 362, 379 Brunton, Lauder, 304 Buchanan, George, 249 Buchanan, I. H., 128 Buck, Pearl, 96n103 building regulations and by-laws, 112, 127–28 Burnett, John, 155 Burns, John, 273 Bush, George W., 42 Butler Act, 368 Byles,W. P., 292 Bynum,William, 227, 279n83 Caldwell, John, 57, 109 Caldwell, Pat, 57 Cambridge Group for the History of Population and Social Structure, 6, 36, 137n12, 169, 174–75, 183 Cambridge University, 223, 259, 334n45, 334n56, 336n94, 339n135 Canada, 205, 381 capital/output ratios, 73 Carlisle tables, 25, 166, 177, 181–82 Carnegie Corporation, 69 Carter, O. H., 158, 160 Case, Everett, 70 caste, 392, 436

Chadwick, Edwin, 26, 120, 131, 250; backlash against, 122, 355; Public Health Act and, 347; “Sanitary Idea” of, 7, 222, 328, 331n9 Chamberlain, Joseph, 32, 124, 248, 400–405; “civic gospel” of, 17, 401; “gas and water socialism” of, 10, 31f, 33f, 224, 288, 401; Local Government Board and, 298; co-founder of National Education League, 337n107 Charity Organization Society (COS), 285, 300, 322–28, 331n10 Chartist movement, 193, 217, 357 Chesnais, Claude, 82 Chester-Beatty life expectancy values, 174–75, 188–89t Chiang Kai-shek, 67–68, 71 child abuse, 285 child labor, 25, 192–93, 202n64 childrearing, 358; costs of, 97n120; single parents and, 424; social capital and, 379 China, 204, 230–32, 237; family planning in, 3–4, 65, 83; globalization and, 443n2; Great Leap Forward, 205; revolutionary, 67–76;Taiwan and, 71, 237 chlorination, 34f cholera, 110; epidemics of, 119–20, 125, 222, 277n41; eradication of, 125; McKeown on, 116–17; mortality from, 104t; water analysis and, 28f civic gospel, 31f, 32, 224; Chamberlain and, 17, 401; Dawson and, 16–17; origins of, 223, 433 civilization, diseases of, 24, 206 class, 345–72, 383–84; caste and, 392, 436; education and, 307–9, 368; environmentalism and, 301–13; life expectancy and, 24, 25; mortality differentials of, 345–47, 361–62; occupation and, 346; public health

Index alliances across, 32; regional politics and, 352–57; residential segregation and, 348–52, 369–70; social capital and, 367–72, 386, 398; welfare state and, 359–69;World War II, 358–59 Cleland, James, 177, 178, 194, 198n27 Clode,William, 251 Coale, Ansley J., 60, 73, 79, 90n4 Cold War, 37, 205, 437; economic growth and, 236, 416–18; liberal policies during, 4, 76–77; McCarthyism and, 68; nuclear weapons and, 68, 437 Coleman, James, 386–87 Combination Acts, 431 Committee on Physical Deterioriation. See Interdepartmental Committee on Physical Deterioriation computers, development of, 79 contagionism, 26, 258–59, 276n41, 279n83 contextualism. See realism contraception, 50, 58–64, 74–76, 83–84. See also family planning Cooper, Anthony Ashley, 194 “cooperative conflicts,” 232 Corn Laws, 429 COS. See Charity Organization Society Costa Rica, 204 County Councils, 287, 289, 433 covering-laws methodology, 49 Cromwell,Thomas, 439–40 Cronjé, Gillian, 112, 126, 154–56 cultural capital, 241n78 Cunningham, D. J., 306, 319 Curtin, Philip, 220 Cuvier, G, 339n137 Dairies, Cowshed and Milkshop Order, 129 Darwinism. See evolutionary theory Davey Smith, George, 381

495

Davis, Kingsley, 49, 71, 72, 88; on family planning, 59; at Harvard, 65; at Princeton, 60 Dawson, George, 16–17, 337n107 De Soto, Hernando, 438, 439 deductivist method, 85–86 Demeny, Paul, 47, 57, 81–82 demographic transition theory, 2–5, 36–38, 420–22; alternatives to, 116–17, 147; critiques of, 5–7, 108–16; economic growth and, 204, 438–39; fertility change and, 46–90, 97n118; Notestein and, 52–53, 57–67; persistence of, 76–81; reception of, 52–57; Ryder on, 78; tenets of, 49–51;Warren Thompson and, 52–53; tuberculosis and, 101–2; after World War II, 48–52. See also McKeown,Thomas Dendy, Mary, 300 dependency ratios, 73 depression, 362, 377, 379. See also mental health diarrhea, 104t, 110, 115, 116, 127, 129, 144n105, 149, 159–60, 199n39, 213, 226 Dicey, A.V., 289, 290 Dickens, Charles, 216 diphtheria, 104t, 107 Disraeli, Benjamin, 194, 223 Dixon, George, 311, 337n107 Dobson, Mary, 5, 151 Dodds, Harold, 69 Domar, Evsey, 54 Donaldson, Peter J., 75–76, 81 Dorfman, Robert, 235 Drèze, J., 232 Drosophila, 317 Dublin, 223, 251, 334n45, 339n135 Dublin, Louis, 84 Dulles, John Foster, 74 Dumbarton Oaks meeting, 67 Dunbar,W. C., 268, 270

496

Index

Durand, John, 60, 75 Durkheim, Emile, 376 Dwork, D., 129, 143n92 Dyos, H. J., 173, 215 East Lambeth Teachers’ School Dinner Association, 311 East London Waterworks Company, 119, 123 Easterlin, R. A., 441 Edinburgh, 177t, 292; university, 26, 275, 306, 319, 328 Edmonds,T. R., 199n33 education, 193; cultural capital and, 241n78; cutbacks in, 366; environmentalism and, 285–86; family planning, 58, 62–63; health, 40, 129, 220, 256; meal programs and, 299–300, 307–11, 313, 331n15; medical inspections and, 11–12, 292–93, 300; physical training and, 301–2; “Feeble minded,” 299–300; universal, 33 Education Acts, 193 Eicholz, Alfred, 296, 306–11, 329, 336n94 Eliot, George, 430 “embeddedness,” 236, 394–95, 402–6 enfranchisement. See voting enfranchisement Engels, Friedrich, 194, 206, 207 “enteric fever.” See typhoid fever environmentalism, 321–29; class and, 301–13; hereditarianism versus, 282, 284, 297–301, 304, 314–21; local government and, 295 epidemiology, 40–41, 266; class and, 346–47; comparative, 379; endemicization and, 150–51; individualist approach to, 377; occupational classification and, 254; paradigms of, 2, 24 Escherichia coli, 129 eugenics, 12, 52, 84, 268–71; hereditarian, 282, 284, 297–301,

304, 314–21; Osborn and, 69; as religious movement, 327. See also race Eugenics Education Society, 296, 313 European Fertility Project, 79, 90n4 Evans, Peter, 386, 394, 404 evolutionary theory, 51, 267–69, 321–29; anthropology and, 91n12; Boer War and, 282, 286, 316; Hobhouse and, 329n1, 341n157; Mendel and, 317–18, 329; urbanization and, 315 Eyler, J. M., 258–60, 325 Fabianism, 282, 284, 285, 296, 301, 303 Factories Acts, 193 Factories and Workshops Acts, 112 Factory Inspectorate, 291 Factory movement, 217 Family Allowance, 358 family planning, 47, 62–63, 76; attitudes toward, 50, 58, 62, 74–76, 83–84; availability of, 59–60, 63–64; in China, 3–4, 65–66; Coale-Hoover model of, 73–74; education for, 58, 62–63; history of, 92n33; in India, 3–4 FAO. See Food and Agriculture Organization Farr,William, 9–10, 25, 26, 251, 273, 436; accuracy of, 168, 175, 197n24, 238n18, 259–61; on cholera epidemics, 119; on disease prevention, 11f, 255–56; Eyler and, 258–60; Graham and, 257, 263, 264, 277n56; Healthy Districts concept of, 247–48; “Letter to the Register-General” of, 251–52, 264, 278n77; life-tables of, 118–19, 211–12, 243–44; nosology of, 252–53, 276n41; Ogle and, 266–67; successors to, 178, 242–43, 247, 253; on tuberculosis, 115–16 Farrow, S. C., 137n3 Feinstein, Charles, 124

Index fertility rates, 103, 204; demographic transition and, 46–90, 97n118, 204; mortality rate and, 3, 5, 37; social policy and, 81–90 Fitzroy, Almaric, 330n7 Flinn, M.W., 178–79t Floud, R., 147, 167 flu. See influenza Fogel, Robert, 38, 418–19, 421 Food and Agriculture Organization (FAO), 51, 52, 55, 56 food inspectors, 33, 40, 123–24, 285 food poisoning, 123, 129–30 Ford Foundation, 75 Ford Motor Company, 53 Fosdick, Raymond B., 70, 91n21 Foucault, Michel, 38–39 “four Ds,” 8–9, 8f, 19, 30, 35, 204–37, 420 Franco-Prussian War, 35, 226 Frankland, Edward, 266 Friendly Societies, 398, 429 fruitflies, 317 Fukuyama, Francis, 386, 402 Galbraith, John Kenneth, 54 Galton, Francis, 267–69, 300, 310, 313–16, 325–29 “gas and water socialism,” 10, 31f, 33f, 224, 288, 401 Gaskell, Mary, 216 General Register Office (GRO), 9–10, 11f, 103, 125, 242–74; annual reports of, 193n14, 245, 248, 262; changing roles of, 263–72; decennial supplements of, 169, 186, 188, 260, 268; establishment of, 138n15; Local Government Board and, 249–50; Medical Officers of Health and, 243, 246, 257, 260–62, 272–73; responsibilities of, 229; “statist” and “popularization” strategies of, 260; tuberculosis and, 110, 153 George, Dorothy, 153

497

“germ” plasm, 314 germ theory, 227, 265–66, 279n83; miasmatism versus, 258–59; microscopy and, 26, 28f, 37, 266; social implications of, 293–94 Giddings, Franklin H., 84 Gladstone,William, 120, 219, 223, 287 Glasgow, 117, 175–85t, 198n27, 199n29, 209, 212–14, 248, 331n15, 397, 421 Glass, D.V., 197n24, 238n18 global warming, 42, 382 globalization, 19, 416–21; disruptiveness of, 426–30; health impacts of, 3; institutional deficits of, 434–38 Godber, George, 136n1, 139n45 Gorst, John, 301, 311 Gouldner, A., 95n94 gout, 24, 206 Graham, George, 244, 246, 257, 263, 264, 277n56 Gray, Kirkman, 332n28 Great Fog of 1886, 126 Great Reform Act, 217, 399, 427 Greenhow, E. H., 275n29 GRO. See General Register Office “growth accounting,” 236 Guha, Sumit, 5, 6, 146–60 Guy,William, 260 Haddon, A. C., 318–19 Hagen, Everett E., 65 Hajnal, J., 90n5 Hamilton, Alexander, 206 Hamlin, Christopher, 227 Hanham, H. J., 288 Hansen, Alvin, 54 Hanson, James, 292 Hardie, Keir and ILP, 338n117 Hardy, Anne, 154, 156, 289, 291, 294 Harley, C. K., 238n9 Harris, F. D., 300 Harris,T., 362, 379 Hassall, A. H., 28f

498

Index

Hassan, J. A., 221–22 Health of Towns movement, 7 Healthy Districts concept, 247–48 Hempel, Carl G., 85 Henle, F. G. J., 276n41 Henniker, Brydges P., 253, 264 Hennock, E. P., 10, 240n51, 277n52, 322 hereditarianism, 282, 284, 297–301, 304, 314–21 Heysham, John, 25, 177, 181–82 Higgs, E., 254 Hill, Joseph, 84 Hill, Octavia, 327 Hilton, Boyd, 240 hip replacements, 409 Hirschman, Charles, 82 Hobbes,Thomas, 29 Hobhouse, L.T., 323, 329n1, 341n157 Hobsbawm, E., 165–66 Hodgson, Dennis, 47, 57, 59, 60, 77; on New Deal, 53; policy and social science, 81–82, 84–86 Holland, 205, 422, 423, 443n2 Holmes, Oliver Wendell, 277n41 Hoover, Edgar M., 73 Hope, E.W., 296 Horrell, S., 192–93 Hoselitz, Bert F., 65 House, James, 378 housing, public, 33, 40, 382, 398 Housing Acts, 112, 127–28 Huck, P., 166, 182–84 Huddersfield, Special Scheme Against Infantile Mortality, 130 Humphreys, Noel, 260–61 Humphries, J., 192–93, 201n64 Huxley,T. H., 323, 329n1, 341n157 hydrocephalus, 116 hysteria, 24 immunization. See vaccination income inequalities, 36–37, 379–84, 392, 411. See also living, standard of

India, 30, 56, 71, 72, 204, 237, 421; castes of, 392, 436; democracy in, 405; family planning in, 3–4, 83; public health projects in, 32 infant mortality, 126–31, 158–60; adult immunity and, 150–51; child mortality versus, 183; class differential and, 346; disease prevention and, 254, 268–70; industrialization and, 30; malnutrition and, 129–30, 309; feeding practices and, 129–30; Scottish, 248; sewage systems and, 147, 158–60; World War I and, 126–27, 130–31, 155. See also mortality rates influenza, 104t, 106, 107; Farr on, 116; Guha on, 152–53; McKeown on, 111, 152–53. See also respiratory diseases Institute for Pacific Relations, 70 Institution of Public Health Engineers, 331n9 insurance companies. See Friendly Societies Interdepartmental Committee on Physical Deterioriation, 301–13, 316–17, 321, 329; Boer War and, 281–85; school medical inspections and, 293;Tatham and, 292 International Bank for Reconstruction and Development, 55 International Monetary Fund (IMF), 42, 55, 428, 442 Ireland, 30, 421, 426, 430 Japan, 71; income inequality in, 381; industrialization of, 30, 234–35; mortality rates in, 205; population health in, 35; before World War II, 56–57, 83, 433 Jenkins, Edward, 122 Jenner, Edward, 180, 181, 213 Jessup, Philip, 70 Jim Crow laws, 392 Johanssen,W. L., 317

Index Johansson, Sheila Ryan, 38, 158, 220 Johnson, Chalmers, 404 Johnson, Lyndon Baines, 410 Jones, Greta, 334n56 Joseph, Keith, 364 juvenile rheumatism, 23 Keefer, Philip, 386 Kennedy, John F., 410 Kerala (India), 204, 237 Kerr, James, 292–93, 300, 301 Keynesian economics, 54, 77, 363 King, Steve, 444n30 Kirk, Dudley, 55–56, 60, 75 Klinenberg, E., 410 Knack, Stephen, 386 Korean War, 70, 74 Krause, J.T., 200n49 Kunitz, S., 380 Kyoto Protocols, 42 Lady Health Visitors, 130, 285 Lalonde Report, 23 Lam, D., 198n24, 238n18 Lambert, Royston, 120, 249, 259 Landers, John, 5, 150, 151 Laslett, P., 90n5 Lavers, G. R., 361 Laxton, Paul, 198n27 Le Roy Ladurie, Emmanuel, 420 League of Nations, 69 Lee, R., 198n24, 238n18 Leeds, 170t, 172t, 176t, 185–86, 240n45, 307, 350t Legge, J. C., 306 Leibenstein, Harvey, 73 Leibig, Jutus von, 276n41 Leicester, 190, 191t, 295, 334n56; “System” of isolation of infectious disease, 144n104 Letheby, Henry, 260–61, 316 Levy, Marion, 65 Lewes, Fred, 249

499

Lewis, Jane, 270 LGB. See Local Government Board Libby,W. H., 301, 311 life expectancy: calculation of, 174–75; by city, 170–73t, 176t, 187f, 188t, 191–92t, 350–51t; income inequality and, 381; national averages for, 169, 181, 187f, 188–89t; by registration district, 350–51t; Scottish, 176–78, 177t, 179t, 185, 212; urbanization and, 165–94, 211–12, 213t. See also mortality rates life-tables, 181–82, 199n33; Carlisle, 21, 166, 177, 181–82; Farr’s, 118–19, 211–12, 243–44; publishing of, 274n9 Lindert, Peter, 18 Lingenism, 287, 291 Liverpool, 11f, 32, 117–19, 128, 149, 169–79t, 184–86, 190, 198n27, 201n54, 209, 211–13, 243–45, 248, 350–51t, 353, 397 living, standard of, 190–94; dual careers and, 388; income inequalities and, 36–37, 379–84, 392, 411; “invisible hand” and, 133, 235; McKeown’s definition of, 140n53; nutrition and, 18, 100, 108–9, 148; urbanization and, 165–94 Lloyd George, David, 271, 433 local government, 291–97; expenditures, 11, 124–25, 222, 240n54, 283, 288, 347t, 370, 433, 446n67; loans, 33f, 124, 142n74, 221, 225, 403, 446n67; Poor Law and, 290; silent revolution in, 284–91 Local Government Act(s), 249; of 1858, 243, 287; of 1871, 122–23; of 1888, 287, 293; of 1894, 287 Local Government Board (LGB), 249–50, 265, 273, 287, 290 Locke, John, 297 London, 25, 28f, 117–19, 126–28,

500

Index

London (continued) 139n45, 140n50, 141n60, 142n78, 148–53, 170t, 174, 176t, 188–89t, 197n21, 198n27, 209–11, 213–14, 222, 225, 246, 266–67, 293–94, 299, 304, 307–8, 330n9, 333n40, 353, 369–70, 375n56, 396, 403 London County Council (LCC), 289–90, 292, 333n34, 356, 433 London School Dinners Association, 299 Lorimer, Frank, 84 Luddites, 234 Lynch, John, 381, 383, 385–86, 395, 409 MacKenzie, D. A., 284 MacKenzie,W. Leslie, 301, 306–7, 309, 311 Macleod, R. M., 265, 287 Macmillan, Harold, 362–63 Macnamara,Thomas, 301, 311 Malaya, 71 malnutrition, 129–30, 307–11. See also nutrition Malthusianism, 17, 56, 61, 428; China and, 83; demographic transition and, 85; Poor Laws and, 206–7 Manchester, 32, 128, 137n2, 149, 169–79t, 184–86, 190, 201n53–54, 209, 211–12, 221, 275n29, 280n95, 292, 296, 300, 307, 323, 331n12, 331n15, 334n56, 350t, 357, 397–98 Manchester and Salford Sanitary Association, 333n43 Mann, Michael, 228 Mao Tse-tung, 67–68 Marmot, Michael, 40, 362, 381, 407–8 Marshall Plan, 92n28 Marx, Karl, 206, 207, 233, 363 maternity services, 12, 33, 128–30, 269–70 Matossian, Mary, 153–54 Maurice, Frederick, 284, 286, 294–95, 304

Maxwell, J. C., 80 McCarthyism, 68 McCleary, G. F., 296 McKeown,Thomas, 2–5, 37–40, 99–108, 206, 418, 421; Caldwell on, 109; career of, 131–33, 144n102; on cholera, 116–17; critiques of, 5–7, 108–16, 133–36, 146–47, 226; disease categories of, 104t, 105, 127; Guha on, 146–60; on milk supply, 129; on respiratory diseases, 110–12; on scarlet fever, 111; on standard of living, 140n53, 148; on tuberculosis, 101–2, 109–15. See also demographic transition theory McMillan, Margaret, 301 McMillan, Rachel, 301 measles, 107, 116, 199n39 Medical Officers of Health (MOH), 32, 123, 223; birth statistics and, 128–29; environmentalism and, 285, 326; GRO and, 243, 246, 257, 260–62, 272–73; infant mortality and, 130; professionalization of, 263, 273, 291–93; smallpox and, 125; Society of, 295, 331n9 Mendelism, 317–18, 329 mental health, 24; depression and, 362, 377, 379; education of the “feeble minded” and, 300; Foucault on, 38–39; social capital and, 377, 379 Metropolis Local Management Act, 289 Mexico, 237 miasmatists, 26, 258–59, 276n41, 279n83 microscopy: germ theory and, 26, 28f, 37, 266;Weisman and, 314, 316 Midwives Act, 128 Milbank, A. G., 69 Milbank Memorial Fund, 58, 62, 69, 71, 85 milk supply, 123–24, 129, 130 Mill, John Stuart, 86, 206, 277n52

Index Millard, C. K., 295 Mills, C.Wright, 95n94 Millward, R., 225, 446n67 Milne, Joshua, 25, 177, 181, 182 Mines Acts, 193 modernization theory, 65, 78–81, 95n94 Moore, S. G. H., 130 Moore,Wilbert E., 60 morbidity trends, 157–58 Morgan,T. H., 317 Morpeth, Lord, 27f Morris, Jerry, 23, 40 mortality rates, 165–94; antibiotics and, 38; by disease, 103–5, 104t; in Eastern Europe, 380–81; fertility rates and, 3, 5, 37; Guha on, 146–60; Healthy District, 247–48; income and, 36–37, 380–81; industrialization and, 31f, 135, 204; seventeenthcentury, 25; social intervention and, 98–136; tuberculosis and, 101–2, 104t, 107–16, 154–56; for typhoid fever, 34f. See also infant mortality; life expectancy Municipal Franchise Act, 224, 348 Municipal Reform Act, 217, 221 “municipal trading,” 288 Muntaner, Carl, 381 Nathanson, Constance, 226, 228–29, 234 National Association for Promoting the Welfare of the Feeble-Minded, 300 National Association for the Promotion of Social Science (NAPSS), 250, 251 National Education League foundation 1869, 337n107 National Efficiency movement, 281–84, 303, 433 National Health Act, 434 National Health Service (NHS), 132, 358, 368

501

National Society for the Prevention of Cruelty to Children (NSPCC), 285, 299, 300 National Union of Sanitary Inspectors, 331n9 Nazism, 53 neoliberalism, 36–42, 135–36 “neo-materialists,” 409 Netherlands, 205, 422, 423, 443n2 New Deal, 35, 53 “new growth theory,” 236 New Poor Law, 214, 217, 219, 324, 398, 428–29, 432. See also Poor Laws Newcastle, 128, 169, 170t, 172t, 176t, 186, 197n19, 350t Newman, George, 291, 296, 301 Newsholme, Arthur, 269–73, 291–93, 296, 324–26 Newton, Isaac, 8 NHS. See National Health Service Nigeria, 237 Nightingale, Florence, 107 Nisbet, Robert, 78, 89 Niven, James, 292, 296 Nolan, G. M., 130 nongovernmental organizations (NGOs), 16, 19, 229, 392, 439 North, D. C., 438 nosology: Farr’s, 252–53, 276n41; Ogle’s, 253, 258; Royal College of Physicians’, 253; statistical, 252; Tatham’s, 253–54 Notestein, Frank W., 49, 80–81, 88, 237n1; demographic transition theory and, 57–67, 75–78; at FAO conference, 51, 55; at Milbank Memorial Fund conference, 58, 62; Warren Thompson and, 52–53 notification of births, 12, 129–30 Notification of Births Act, 129, 130 notification of infectious diseases, 11, 125, 144n104, 275n29, 291–92, 294, 333n43

502

Index

Notification of Infectious Deseases Act, 125 Nottingham, 190, 191–92t, 291 NSPCC. See National Society for the Prevention of Cruelty to Children nuclear weapons, 68, 437 nutrition, 154–55, 382; food poisoning and, 123, 129–30; inadequate, 129–30, 307–11; mortality rates and, 36–40, 99–102, 146–47, 206, 423–26; poverty and, 307–11; respiratory illnesses and, 152–55; rising wages, 18, 100, 108–9, 148; school programs for, 299–300, 313; sex-differentials with, 155; vaccination and, 111. See also food inspectors “nutritional determinism”, 112–14 Nutt,Thomas, 424 obesity, 206 occupational categories, 346, 354t occupational hazards, 254, 267 Odd Fellows Friendly Society, 157 Oddy, Derek, 155 Oeppen, Jim, 188n Office of Population Research (Princeton), 49; Chinese Revolution and, 67–76; personnel at, 60 Ogle,William, 253, 258, 262, 264, 266–68 Oklahoma City bombing, 388 Omran, A. R., 418 Organization for European Cooperation and Development (OECD), 92n28, 390 orphans, 191 Osborn, Frederick, 69, 75 Oxford, 337, 370 Pakistan, 71, 72 Palestine, 71 Parsons,Talcott, 65, 78 Parton, C., 130 Pearson, Karl, 269, 270, 282–83, 313–21, 328–29

Pember Reeves, Maud, 155 pensions, 335n65, 434 peptic ulcer disease, 23 Percival,Thomas, 25 Peru, 439 Petrie,W. M. F., 339n135 Philip, Robert, 138n17, 292 Physical Deterioration Committee. See Interdepartmental Committee on Physical Deterioriation Pinsent, Ellen, 300 plague, 105; in medieval Europe, 31, 397; in modern India, 32 pneumonia, 104t, 107; Guha on, 152–53; McKeown on, 111, 152–53. See also respiratory diseases Pollack, Michael, 95n88 pollution, air, 42, 382 Poor Laws, 207, 230, 272, 396, 397; boards of guardians of, 287; eligibility and, 311; establishment of, 423–25; local government and, 290; Royal Commission 1905–9, 338n120. See also New Poor Law; social security; welfare Population Council, 75 population health approach, 2–3, 40–42; economic growth and, 29–36, 419–21, 430–34; origins of, 3, 23–29;Washington consensus and, 36–40 “population industry,” 82–83 Porter, D., 298, 328 Porter, R., 298, 328 Portes, A., 380, 387 Porto Alegre (Brazil), 32, 405 postmodernism, 38–39 pregnancy, teen, 377 Preston, Samuel, 39, 101, 419 preventable diseases, 251–58, 268 prisoner’s dilemma, 232–33 Pritchett, Lant, 443n9 probability distributions, 188–89t

Index prostitutes, 25 Public Health Act, 12, 123; of 1848, 7, 26, 27f, 33f, 98, 120, 221–22, 244, 247, 347, 400; of 1872, 123, 125, 262; of 1874, 8, 36; of 1875, 123, 387 Public Health (journal), 295, 330n9 public health medicine, 26, 220–29; cholera and, 120–21; diploma in, 223, 259, 262, 293, 334n45; GRO and, 242–74; importance of, 98–136; local government and, 291–97; McKeown on, 6, 38; nineteenthcentury crisis in, 396–406; privacy issues with, 131; social capital and, 376–412; social medicine versus, 23–24; urban congestion and, 116–31 puerperal fever, 276n41 Putnam, Robert, 15–16, 377–79, 383, 385, 402; Coleman versus, 387–88; on trust relationship, 391 “pythogenesis,” 276n41 Quakerism, 323 quarantine, 111, 125 race, 392, 436; genetics and, 318–19; social capital and, 386. See also eugenics Rankin, Robert, 181, 198n26 Ransome, Arthur, 259, 275n29, 333n43 Ravenholt, R.T., 75–76 Reader,W. J., 250 realism, 87 recapitulationism, 51 Record, R. G., 106, 113 Reeder, D. A., 173, 215 Reform Act (1867), 224, 402 Registrar-General’s Office. See General Register Office registration: civil, 9, 17, 19, 25, 138n15, 139n38, 177, 251, 259, 427, 435–36, 438, 440; parish, 423, 426, 439 Registration Act, 259 registration districts (R.D.s), 171–75,

503

172–73t, 184; administrative cities and, 188–90, 191–92t; life expectancies by, 350–51t Representation of the People Act, 263 respiratory diseases, 24; Farr on, 115–16; Guha on, 152–53; McKeown on, 110–15, 152–53; mortality from, 104t, 106; public health measures and, 126. See also specific types, e.g., pneumonia rheumatic heart disease, 23 rheumatism, juvenile, 23 Ricardo, David, 206 rickets, 155, 306 Rickman, John, 244 Riley, J. C., 148, 157–58 rinderpest epidemic, 294 risk factors, 2 Robertson, John, 296 Rockefeller, John D., Jr., 94n64 Rockefeller, John D., 3rd, 69–70, 75, 85 Rockefeller Foundation, 63–64, 69–70, 85 Rossiter,William, 84 Rostow,W.W., 4–5, 7, 206, 235 Rowntree, B. Seebohm, 285, 304, 307, 309, 312–13, 321–24, 331n11, 361 Royal College of Physicians, 253, 304, 307–9 Royal Commission on Physical Training, 301–2, 306, 309 Royal Institute of Public Health, 295 Royal Sanitary Commission 1869–71, 122 Royal Sanitary Institute of Britain, 331n9 Ruml, Beardsley, 91 Rumsey, H.W., 123, 251, 259, 275n29 Russia, 237, 443n2 Ryder, Norman B., 69, 78 Sachs, Jeffrey, 441 Sale of Food & Drugs Act, 124 Salford, 137n2, 143n92, 190–91t, 275n29, 292, 307–8, 331n12

504

Index

Salvation Army, 285 Samuelson, Paul A., 54 Sandlebridge, Cheshire, 300 Sanger, Margaret, 92n33 Sanitary Act (1866), 122, 127 “Sanitary Idea,” 7, 222, 328, 331n9 Sanitary Inspectors’ Association, 331n9 “sanitary revival,” 250 Sargant,William Lucas, 279n94 scarlet fever, 104t, 106–7, 110, 111 Schofield, R. S., 117–18, 147, 150–51, 181, 210 school boards, franchise for local, 287 school medical inspections, 11–12, 292–93, 300 Schultz,Theodore, 51 Schwarz, Leonard, 150, 211 Scotland: infant mortality in, 248; life expectancy in, 176–78, 177t, 179t, 185, 212; physical training in, 301–2, 306; public health in, 207; smallpox in, 213–14 Searle, G. R., 296 Seeman,Teresa, 378 Sen, Amartya, 39, 232, 424 September 11th attacks, 42 settlement houses, 285 sewage systems, 6, 26, 33, 40, 119–20, 397; economics of, 220–29, 399–400; Farr on, 256; infant mortality and, 147, 158–60; railroads and, 219–20. See also water supply and treatment plants sex workers, 25 sex-differentials, 112, 154–56, 261 sexually transmitted diseases (STDs), 105, 206, 330n7 Shaftesbury, 7th Earl of. See Cooper, Anthony Ashley Sheffield, 170t, 172t, 176t, 185–86, 350t Shipley, M., 362 Shlomowitz, R., 220 Shuttleworth, G. E., 300 Shuttleworth, James Kay, 26

Simon, John, 120, 124, 247, 249, 250, 293 smallpox, 116; eradication of, 125, 153, 182; mortality from, 104t, 180; and Poor Law, 333n37; vaccination for, 107, 111, 180, 181, 213 Smith, Adam, 206 Smith, F. B., 156 Smith, Grafton Eliot, 339n135 Smith,T. E., 71 Smith,W. R., 300 Smoke Nuisance Abatement Act, 126 smoking, 24; cessation of, 377–79; tobacco company settlements and, 26 Snell, K. D. M., 192–93 Snow, E. C., 222, 277n41 social capital, 15–16, 376–412; assessment of, 406–8; bonding, bridging and linking types of, 374n29, 375n50, 388–90, 392–93, 402–7; criticisms of, 382–85; cultural capital versus, 241n78; definitions of, 379, 387, 390–91; early trade unions and, 429; education system and, 368–69; Friendly Societies and, 398; functions of, 380; importance of, 229–37; lack of, 367–72; measurement of, 390–91; policy implications of, 409–12; religious congregations and, 398–99; social theory and, 385–96; the state and, 393–95 Social Science Research Council, 53 social security, 14, 17–19, 40, 212, 217, 241n69, 335n66, 396–98, 421–26, 430, 431–34, 400, 442. See also Poor Law; welfare socialism: eugenic, 284; Fabian, 282, 284, 285, 296, 301, 303; “gas and water,” 10, 31f, 33f, 224, 288, 401 Society for Organising Charitable Relief and Repressing Mendicity. See Charity Organization Society (COS) Society of Medical Officers of Health, 295, 331n9 Society of Public Analysts, 331n9

Index Solar, Peter, 423–24 Soto, Hernando de, 438, 439 South Africa. See Boer War Southwood Smith,Thomas, 26, 250 Spencer, Herbert, 267, 329n1 Spengler, Joseph J., 65 Sri Lanka, 204 “stamping out” of communicable diseases, 294 standard of living. See living, standard of Standard Oil, 53 Statistical Society of London, 260, 279n94 Stedman-Jones, Gareth, 267 Stevenson,T. H. C., 254, 271, 324, 346 Stiglitz, Joe, 40 Stopes, Marie, 92n33 Strang, John, 177 streptococcal infections, 139n30 Subramanian, S.V., 380 suffrage. See voting enfranchisement sulfonamides, 38 Summers, Larry, 418, 441 Sun Yatsen, 67 Surat (India), 32 Surrey, life expectancy 1841, 118–19 Sweden, 395, 443n2; income inequality in, 381, 411; infant mortality in, 183; population health in, 35–36, 421 “Swing” riots, 211 Sydenstricker, Edgar, 96n103 Taeuber, Irene B., 60, 63, 70, 71 Taiwan, 71, 237 Tatham, John, 98–99, 101, 137n2, 155, 178, 268, 333n43; early career of, 292; eugenics of, 270; Healthy Districts and, 247–48; nosology of, 253–54 Taylor,William, 303–5 TB. See tuberculosis teen pregnancy, 377 television, 388 Temperance League, 285

505

Ten Hours movement, 217 Tendler, Judith, 404 terrorism, 42, 388 Test and Corporation Acts, 217, 427 Thatcher, Margaret, 365–67, 372 Thompson,Warren S., 49, 52–53, 84 Titmuss, Richard, 23, 40 tobacco company settlements, 26. See also smoking Tobin, James, 54 Torres Straits expedition, 339n135 town planning, 128, 369–70 transition theory. See demographic transition theory trust networks, 374n29, 375n50, 382–84, 391, 429 tuberculosis (TB), 24, 101–2, 104t, 107–16, 306; and bronchitis, 139n43, 152–53; Cronjé on, 112, 126, 154–56; etiology of, 112–13; Farr on, 115–16; Guha on, 151–56; as inherited disease, 138n17; and migration, 155–56; and nutrition, 154–55; reporting of, 291–92; risks for, 112, 116, 154–56; as secondary breakdown disease, 139–40n45; as sequlae of whooping cough, 113; and sexdifferential incidence, 156 Turner, S. P., 97n117 typhoid fever, 110, 138n16; eradication of, 125, 182; mortality from, 34f, 104t, 115; risks for, 116 typhus, 105, 138n16; mortality from, 104t, 115; risks for, 116 unemployment, 366; affluence and, 361, 364–65; disease incidence and, 23; structural, 370 UNESCO, 55, 437 UNICEF, 55 Union of Soviet Socialist Republics (USSR), 205, 418, 437. See also Cold War; Russia

506

Index

United Nations (UN), 3; demographic transition theory and, 49; Development Program of, 39; Food and Agriculture Organization of, 51–52, 55; origins of, 67;World Population Conference of, 75 “urban advantage,” 422 “urban penalty,” mortality rate and, 6–7 USAID family planning, 75–76 U.S., 4, 32, 35, 37, 42, 54–55, 67, 70–71, 73–74, 79, 82–83, 92n28, 156, 272, 379, 388, 410–11, 437, 442, 447n90 vaccination, 107, 111; Jenner and, 180, 181, 213; Poor Law and, 125 value-added tax (VAT), 233, 365 van de Walle, Etienne, 49, 97n118 Voices of the Poor (World Bank), 39–40 voting enfranchisement, 348, 357, 358t, 405–6 Vries, Hugo de, 317 Wade, Robert, 404 Wallas, Graham, 323 Waller, P. J., 128 Warner, Francis, 300 Washington consensus, 36–41, 418, 425, 438, 440–41 water companies, private, 26–27, 27f, 28f; cholera epidemics and, 119–20; government purchase of, 123 water supply and treatment plants, municipal, 6, 40, 107, 117, 146, 256, 397; politics and economics of, 220–29, 399–400; railroads and, 219–20; typhoid fever and, 34. See also sewage systems Webb, Beatrice, 290 Webb, Sidney, 282–84, 288–90, 355–56 Weber, Max, 233 Weights and Measures Acts, 124 Weismann, August, 314, 316, 318, 324, 325

Weldon,W. F. R., 316, 318 welfare: policy, 14, 36, 39, 214, 219, 287, 313, 357, 397, 430–1; “society,” 425; state, 32, 35, 231, 356, 360–68, 411, 434, 442. See also Poor Law; social security. Whelpton, P. K., 75 White, Arnold, 283, 322 Whitelegge, B. A., 291 WHO. See World Health Organization whooping cough, 107, 113 Wilkinson, Richard, 373n2, 379–85, 408–10 Willcox,Walter F., 84 Williamson, J. G., 168 Wilson, H. J., 307, 312 Wilson,Woodrow, 94n65 Winter, J. M., 137n9, 309 Wohl, Anthony, 121, 124 Woods, R., 141n55, 142n75; probability distributions of, 184–87, 187f, 188–89t; urbanization model of, 166–68 Woolcock, Michael, 15, 16, 376n, 386, 394, 404 World Bank, 3, 19, 229, 390, 440; demographic transition theory and, 49, 438–39; precursor of, 55; World Development Report of, 39–40, 418–19 World Fertility Survey, 75 World Health Organization (WHO), 55, 437; definition of health by, 23; developing countries and, 229 World Trade Organization, 441–42 World Values Survey, 390 Wright, Maurice, 332n20 Wrigley, E. A., 117–18, 147, 150–51, 181–84, 210, 444n23 York, 304, 309, 322, 324, 361, 373n19 “zymotic” diseases, 253

HealthandWealthPpbkmech

8/29/05

5:44 PM

Page 1

“These essays are an intellectual delight. They also have profound implications for policy. Szreter arrays persuasive evidence that the preconditions for economic growth include economic and social security that is initiated and sustained by effective governments in collaboration with autonomous civic institutions.” —Daniel M. Fox, Milbank Memorial Fund

“To understand Brazil in the 21st century, study the English city of Birmingham in the 19th. The powerful insight at the heart of this nuanced and highly readable account of health and social change is that the lessons of history are fundamental to understanding the relation of economic growth to health. Szreter compellingly argues that growth, without the development of appropriate civil institutions, ultimately may be harmful.” —Professor Sir Michael Marmot, Director International Institute for Society and Health “Simon Szreter has been prepared to grapple with some of the big issues in history, health and economic growth, and their implications for the present. This book is a vivid and outspoken contribution to the necessary relationship between history and policy.” —Virginia Berridge, Professor of History, London School of Hygiene and Tropical Medicine

Health and Wealth Studies in History and Policy

Health and Wealth

“Health and Wealth is applied history at its most perceptive and most timely. Simon Szreter deploys his profound knowledge of the history of mortality to critique Britain’s welfare policies, and to argue that in poorer countries government provision for pubic health should be developed before, not after, economic modernisation. This book is essential critical reading for policymakers.” —John Tosh, Professor of History, Roehampton University, UK

Szreter

University of Rochester Press 668 Mt. Hope Avenue, Rochester, NY 14620-2731 P.O. Box 9, Woodbridge, Suffolk IP12 3DF, UK

www.urpress.com

Simon Szreter