Book Review
Health, Civilisation and the State: a History of Public Health from Ancient to Modern Times
Reviewed by: Gert H. Brieger
The history of public health has been a flourishing field in the last three decades. Yet despite a spate of excellent monographs about various epidemic diseases and many good collections about health and disease in Africa, Asia, the Middle East, Latin America, as well as Europe and North America, the most recent textbook on the history of public health is four decades old. George Rosen's venerable, A History of Public Health, was first published in 1958. More recently, in 1993, it was reprinted with an excellent introduction by Elizabeth Fee and an updated bibliography and an essay on Rosen's work, both by Edward Morman.
Rosen was writing in the post-war period when public health seemed to be winning the battle over disease, mortality rates were declining, and life expectancy was increasing. Thus his was a narrative of hope and progress, and there was every reason to be optimistic - for had not so many of the infectious diseases that long plagued us succumbed to antibiotics? Hormones became available for replacement as well as treatment, and the medical research establishment was rolling in money from both public and private sources. The way historians choose to tell their stories usually tells the reader something about the times in which the story was written, and so it should not surprise us that Rosen's was generally an optimistic tone. Dorothy Porter understands the differences between the 1950s and the 1990s, and she brings a more questioning tone to her work. She is Wellcome Reader in the History of Medicine at Birkbeck College, University of London, and has been a highly visible part of the resurgence of the history of public health. In many essays and chapters, as well as edited volumes, she has established a secure place in the field, especially in the history of the British part of the story of public health. It should not surprise us then that she now weighs in with an ambitious new text, Health, Civilization and the State.
She calls hers a textbook of the history of public health in Europe and North America. She claims that she has redefined the content of public health as the "history of collective action in relation to the health of populations". In her words, this collective action involves the "structural operation of power". Public health is differentiated from therapeutic medicine, although the way that populations gain access to the results of biomedicine are a part of the story. What is important is the social context of the organization for health. She claims that her analytical themes were inspired by the work of Max Weber and Norbert Elias. In somewhat jargon-filled terms she says: "Health, Civilization and the State explores how collective actions which aimed to regulate or improve health of populations were involved in changing the historical relationship between the civilizing process and state formation in European and North American societies". (p. 7)
Public health, though often insufficiently appreciated by the other specialties of medicine, has since the nineteenth century helped to bridge the traditional gulf that exists between individual medicine and the greater society in which it functions. Thus it is public health, with its emphasis on populations rather than individual patients, that has provided medicine its ultimate rationale. And throughout the history of public health since the Renaissance, there has been a tension between the restriction of individual liberties and the greater interests of the community or the state. These tensions are reflected throughout Dr. Porter's book.
Dr. Porter has divided her book into three major parts and a fourth that looks to the contemporary scene. Part one, "Population, Health and the Pre-Modern State", is a straightforward description of health in the ancient world, in which she discusses briefly the major hygienic and epidemiological works in the Hippocratic and Galenic collections of medical texts. This initial chapter is followed by a discussion of the epidemics of the middle ages and their effects upon the public order. The various plague outbreaks receive some attention, but considering their importance in the growth of the modern state, readers will surely want to consult the many references Dr. Porter has supplied for us.
The plague has always fascinated historians, but leprosy during the centuries of its great prevalence, from about 1100 to 1500, also deserves more attention, if for no other reason than it was the model for disease as stigma well into our own time.
In the early modern world, after about 1500, the West grew in wealth and world dominance, but it did not grow healthier. Infections that took a terrible toll on previously isolated societies, so-called virgin populations, became domesticated as world travel increased and urbanization progressed. Diseases that had been epidemic became endemic in urban centres. The strength of the state was assessed by the size of its population; one way of assessing that strength was to count numbers of people. The rise of vital statistics, mercantilism and statecraft are all related. In fact, as Dr. Porter points out, the word "statistic" is derived from "statecraft". It is unfortunate that she barely mentions the specific preventive measures of the eighteenth century. The work of James Lind on lime juice as a preventive for scurvy, the beginning of inoculation to prevent smallpox, and the writings of John Pringle about the importance of sanitation in military camps and hospitals, all had an important secondary effect as well. They began to stimulate people to think preventively.
As she does rightly point out, the eighteenth century set the stage for public health. Significant overseas trade and travel spread the European influence, and urban centres began to feel the pressures of population when the infrastructures of the growing cities could no longer keep up with the growing demands for water, housing and refuse removal.
Porter is right to lay stress on the vexed subject of disease causation as it was framed in the early nineteenth century. Which theory one held determined what preventive measures could be fostered. She clearly delineates the different approaches to prevention of the two main theories of disease causation. The "predisposition-oriented theory" demanded a much more general social response than the "poison" or "miasmatic theory", which merely called for the removal of the miasma-spawning conditions. Such theoretical battles became especially important in England where miasmaticists such as Chadwick pushed the exciting causes of disease to the background, focusing only on the immediate environment such as sewage removal and the water supply.
Part 2 of Health, Civilization and the State covers the heart of the history of public health as we usually view it. In about 100 pages she covers the development of public health - the question remains whether Health, Civilization and the State will now take its place as the premiere text in the field. Will Rosen finally be displaced? The answer is not as simple as the first part of this review might lead one to assume. Unfortunately, Porter's book has sufficient problems that a good textbook simply cannot afford to have.
Problems begin with the title, which would lead us to conclude that this is a global history. Alas, as was true of Rosen's history too, the focus here is on Europe and North America. We have to believe Dr. Porter when she begs off on what would have been a far larger book, one she felt ill-equipped to write on her own. In 1994, she edited a wonderful collection of essays published as The History of Public Health and the Modern State, which does offer a global view of the developments on all five continents, as well as an excellent introduction with an extensive bibliography. It is to this book that I would prefer to send students who wish to see how the history of public health has developed in recent decades.
On the first page of her present book, Porter claims, correctly I believe, that both Rosen and René Sand, a Belgian physician who published The Advance to Social Medicine in 1952, wrote "grand narratives of progress". Then, unexpectedly and incorrectly, she claims that this heroic vision of public health and medicine was reinforced by Thomas McKeown's 1976 book, The Modern Rise of Population. While McKeown was oft-criticized in the years to follow for a quite selective use of historical data, one thing he surely accomplished was to set the stage for a far more questioning historiography of medicine. In fact, writing about this issue in the introduction to her 1994 collection, The History of Public Health and the Modern State, she said it clearly: McKeown "irrevocably cast a shadow of doubt over the heroic history of public health". This no small matter in a book aimed at students and public health workers, and foreshadows more trouble ahead.
As there is emerging a new history of public health so there has emerged a new historiography of disease as reflected in The Cambridge World History of Disease (1993). This book, edited by Kenneth Kiple, who had the help of 160 contributors, has proven itself as a very useful source book. Dr. Porter has relied on it extensively, and, I believe, appropriately. In her reference to it in chapter one she claims it is a five-volume work. This will confuse readers who look for the four that do not exist.
Porter's new history of public health clearly is more sophisticated in its interpretations than was George Rosen's in 1958. She cites most of the pertinent secondary literature of the last few decades. Yet there are some gaps and far too many blemishes that will mar its rise to the lofty status of primary textbook in the field. In the first place there is a total disregard of George Rosen's mentor, Henry Sigerist. Surely one needs to cite some of his work, so pertinent to the history of public health. For example, the five essays that make up Landmarks in the History of Hygiene (Oxford University Press, 1956) are still worth reading. Those on Galen and Johann Peter Frank in particular would have enriched Porter's discussion. A closer familiarity with such literature as well as Rosen's and Sigerist's other articles and chapters on Frank and mercantilism might have prevented her from spelling his name as Franck. This is an annoying and mistaken Germanism, like adding a "c" to Fishbein in another part of the book.
Many small errors have crept into the text. Thus, John H. Griscom becomes Henry, Carlo Cipolla becomes Charles, and middle names are misspelled, as are some place names. On p. 286, for instance, Staten Island is Statten, The Centers for Disease Control are Centre, and a former Governor of California becomes Cage instead of Gage. All small and inconsequential errors one might say. All this leaves me very uneasy, because if this is how she handles the things about which I happen to know something, I am at her mercy when it comes to the many things about which she doubtless knows more than I do.
There are also some important topics she has decided to leave out, the most troubling being public health nurses. The long tradition of popular hygiene texts, such as those by John Wesley, William Buchan and S. A. Tissot, is also neglected here, but included by Rosen in his book.
Both Rosen and Porter have synthesized the history of public health in the context of the history of medicine in Rosen's case, and in the context of a broader social history in Porter's case. Porter has had the advantage of four decades of much new work in the history of health and disease that was barely beginning when Rosen was writing in the 1950s. In fact, it was he and his mentor, Henry Sigerist, who were urging their fellow historians to widen their angle of vision, something we now take for granted.
Some of Rosen's emphases and interpretations have clearly needed to be revised. The work of Christopher Hamlin on Chadwick and the British public health movement in the middle decades of the nineteenth century clearly demands a fresh look. And as compared with Porter's, Rosen's is a much less sophisticated historiography. He wrote a straightforward story of what happened, with less attention to the broader context and the subtleties required when we ask why, or why then, did laws get passed or new practices begin. It is here that Porter has provided a far richer fare for us, but her book is also not as easy to read. For those who want entertainment and inspiration with their history, Rosen still commands pride of place. But for those who are willing to view history in much more of its complexity, Porter clearly deserves primacy. If indeed Health, Civilization and the State comes to be the textbook for the history of public health, I hope she and the publisher will correct the many small but very irritating mistakes that ought not to mar a leading text in its field.
July 1999