Regional Cultures and Mortality in America by Stephen J. Kunitz (review)

The mortality of individuals and groups of people has long fascinated historians and public health officials. By the mid-nineteenth century, sickness and death, healthy and unhealthy landscapes formed the prism through which Americans understood their bodies within the construct of nature. Bad airs, winds, oozes, and miasmatic theory were clearly reflected in the letters and descriptions of nineteenth-century western migrants, while New York City, Boston, and Philadelphia were considered to be unhealthy urban landscapes where not only disease but also the health perils of crime and vice were rampant. Scholars of the twentieth century have written about the poor or lagging public health infrastructure of Milwaukee, poor housing of Baltimore, and the so-called regional distinctiveness of the U.S. South. Places are different, and therefore the ways in which we understand morbidity and mortality might reflect the specificity of place and landscape.

Regional Cultures and Mortality in America is a mostly synthetic account of how we might rethink this important question of region. The fundamental question that Kunitz begins with in this book is one that has dogged scholars for many years: “What is an American?” In other words, while people identify as American they also identify as Californians, North Carolinians, or Texans, southerners or northerners. Regional variation has given way to more recent conversations among scholars regarding cuisine, and particularly whether the United States has a national cuisine. The Mexican-inspired cuisine of San Antonio differs markedly from the West African–inspired cuisine of the South Carolina Lowcountry, for instance. As a result, regional variation can be an important interpretive lens for thinking about questions of health.

Kunitz brings the concept of region to bear in two parts that include six chapters and a conclusion, highlighting the “National Perspective” and “Local Studies” of mortality, as well as “Appendices.” Strengths of his regional analysis lie in how racism and inequality affect health outcomes and social capital. Drawing on the long-standing works of D. C. Ewbank and Edwards Beardsley, he makes the point that “in the first decades of the twentieth century, for instance, 79 percent of White women in rural Mississippi had their deliveries assisted by a physician, compared to only 8 percent of African American women, and one-third of White women but only 12 percent of African American women had some prenatal care. Similar patterns were found elsewhere in the rural South” (p. 83). Lack of access to health resources among poor and middle-class African Americans and poor whites during the twentieth century is the reason parts of the South suffered high mortality rates in the past. “Even by the last decade of the twentieth century, income inequality was greatest and spending on libraries, schools, hospitals, Medicaid programs, and other services least in the South among regions of the United States. These patterns of inequality have consistently been shown to be associated with higher mortality in the southern states than elsewhere” (p. 83).

However, Kunitz builds his arguments on secondary works, and sometimes relies on outdated scholarship such as that by Stanley Elkins. The result is that his sweeping and broad story glosses over quite a bit of the more recent scholarship and trends that might have made his account more nuanced. For instance, while pointing out that racial segregation (and the resulting dislocation of resources that results in vast public health inequalities) also occurs outside of the South, he makes a mostly macroeconomic-based argument about region and inequality. The narrative of suburbs as being a place of resources and middle-class wealth and the inner city as a place of perpetual decline has recently been displaced. As Kunitz writes, “As the central city tax base shrinks, financial support for public schools declines even as the population served requires additional academic support, accelerating the departure of middle class families (both White and non-White) with school-age children. Indeed, the migration of middle class African Americans to...