Book Review: A History of Public Health
A book review by Matteo Pinna Pintor of ‘A History of Public Health‘ by George Rosen.
Ebola and Zika outbreaks in the tropics make the reissue of this classic of medical history a timely event. Written in the late 1950s by a pioneer of American health education, the volume is a retrospective tour de force which tracks the evolution of public health from classical antiquity to the welfare state, focusing largely on the West. A generous editorial apparatus helps contextualize it.
Rosen’s history begins with scanty remarks on ancient civilizations, pointing to basic hygienic concerns revealed by archeological evidence. The naturalism of Hippocratic medicine is widely considered the first step toward empiricism, but Rosen’s appreciation is substantive: systematic observation of agroclimatic conditions enabled Greek physicians to discern between endemic and epidemic disease, identify seasonal incidence patterns, and establish meaningful correlations between swamps and malaria. Such knowledge informed strategies of selective settlement and made the agriculturalist Varro speculate about animate contagion. Rome adopted Greek knowledge but fostered institutional innovation: specialized boards dealt with aqueducts, sewerages and public baths in major urban centers; town appointments and supply restrictions turned physicians from itinerants to settled professionals.
After the fall of Rome, monasteries were initially the only organizations developing solutions to community health problems. From the XIII century municipalities began taking up public health functions, restricting the urban rearing of livestock, regulating food markets, paving and cleaning the streets. Plague induced another key institutional change: quarantine systems. Lazaret construction reinforced an underlying trend, and after the XV century ‘Europe was covered with a network of hospitals’ (p34). For Rosen this medieval townbased system ‘persisted […] until the nineteenth century’ (p67): the scientific revolution generated fundamental advances but public health ‘received very little, if any, direct benefit’ (p39); mercantilist states conceived population health as national wealth and began accounting for it by collecting life statistics; later, the enlightenment stimulated a new phase of hospital growth, characterized by the establishment of specialized institutions – maternities, dispensaries, asylums. Continuity had two major exceptions: the double shift in urban water supply, from public springs to private indoor distribution, and the adoption of inoculation — the precursor of vaccination.
The book culminates in the analysis of the sanitary movement which swept across Europe and the US in the mid-XIX century, laying the foundations of modern public health systems. The connection with capitalist development is clear: ‘equally dismal and brutal conditions were to be found […] wherever the new industrial system took root […]. In all these countries, the response was similar — a demand for sanitary reform’ (p114). This review cannot do justice to Rosen’s reconstruction of reformers’ massive achievements — in water supply, sanitation, housing, factory legislation — but it can sketch the mechanism through which these were accomplished in the (partly) archetypal British case. Rural-to-urban migration, boosted by industrialization, overwhelmed traditional public health systems, and urban health deteriorated markedly — as height data now confirm (Cinnirella 2008, Komlos 1998, Floud et al. 1990). Bourgeois families fled from city centers only to realize that typhus and cholera ran faster. Impulse for action often came from voluntary organizations and independent physicians, which then stimulated government involvement through official inquiries and eventually legislation. Reform was gradual partly because it was resisted: actively by employers, and passively by laissez faire. Anticipating McKeown’s (1976) influential thesis, Rosen acknowledges that ‘medicine played a secondary part’ (126) in the modern decline of mortality. Unlike him, he viewed sanitary reform as a crucial driver — a position currently gaining traction (e.g. Cutler and Miller 2005, Szreter 1988).
Two final chapters span from the late XIX century to Rosen’s days: the advent of microbiology, enabling the discovery of microbes and vectors, is deemed revolutionary, but as pasteurization exemplifies it enhanced public health instead of replacing it. Its expanding scope is thoroughly reviewed: child health, nutrition, health education, occupational health, insurance, and international cooperation are all discussed. Rosen concludes with sobering reflections on developing countries’ challenges in writing their chapter on the history of progressive sanitary reform.
To health-and-development economists, this book can offer background knowledge to develop their research agenda, hints into specific studies, and theoretical insights. Key among these insights is the emphasis upon institutions as mechanisms to implement medical science: the latter ‘provides a basis for preventive action and control’ but ‘effective application […] depends on a variety of nonscientific elements’ (p54), including institutional change, required ‘to incorporate new scientific knowledge into public health practice’ (p140). The current globalization of medicine invites optimism for developing countries (Deaton, 2013). Rosen was an optimist, but it is our ability to cooperate that made him so.
A History of Public Health
revised extended edition
George Rosen
Foreword by Pascal James Imperato,
Introduction by Elizabeth Fee
Biographical Essay and New Bibliography by Edward T. Morman
Paperback, 440 pages
ISBN:9781421416014
January 2015
$35.00
This review was first published in Economic Issues, 2016, 21 (2), pp.148-150.