Health and Wealth: Studies in History and Policy (review)

Simon Szreter is perhaps best known to the history of medicine community as the author of the now-classic article "The Importance of SocialIntervention in Britain's Mortality Decline, c. 1850-1914: A Re-Interpretation of the Role of Public Health," published in the very first issue of Social History of Medicine in 1988. In that article, Szreter argues that Thomas McKeown's thesis—that improved standards of living, especially nutrition, were the trigger for the nineteenth-century decline in deaths from infectious disease—was misguided. Although he has since been heard to claim that this was a polemic, Szreter's underlying seriousness of purpose is demonstrated by the inclusion of that essay in this book. Health and Wealth is a collection of Szreter's published articles, including a modified chapter from his monograph Fertility, Class, and Gender (Cambridge and New York: Cambridge University Press, 1996). It is clear from these essays taken as a whole that Szreter has been working on a larger agenda since the early 1990s at least. In the first place, his interests actively extend beyond history into current social policy; second, he believes that history has an important part to play in interpreting the present and in informing plans that seek to shape the future. These essays generally, therefore, constitute a polemic, an illustration, and an argument for the uses of history and its relevance to policy-making and planning in the modern world. Far from being a random collection of reprints, Health and Wealth presents a unified and coherent intellectual argument, developed over time and here assembled, for a new interpretation of the causes of the decline in mortality in Britain and for the relevance of that interpretation to current national and international policy.

The book is divided into three sections. The first consists of five essays focused on the ideas that shaped the post-World War II policy consensus on the relationship between health and economic development: namely, the population health approach, the demographic transition theory, and McKeown's thesis. Szreter begins by arguing for the importance of population health as an epidemiological tool against the claims of risk assessment analysis: it is far more effective at detecting the adverse health consequences of accelerating economic growth. The essay that follows places the influential demographic transition theory in historical context, demonstrating that its adoption formed part of the American liberal response to the emerging power of Communism and of the Marxist model of historical change. These factors also favored McKeown's claim that health improvements followed directly from economic growth. Both examples clearly demonstrate the power of history to influence policy development. The final essays in this section critique McKeown's analysis, focusing particularly on the flaws in his methodology.

The second section subjects Britain's mortality decline to further analysis and demonstrates that rapid economic growth has a disruptive effect on disease regimes as well as on society as a whole. Herein lies the core of both book and argument. Nineteenth-century Britain was a democratizing society with a strong tradition of local government. Electoral policies, notably in the great provincial cities, Szreter argues, provided the key to resolving the problems caused by rapid economic growth. The emergence of a vigorous culture of local government in the last decades of the century drove policies of social intervention: by 1905, local government expenditure exceeded that of central government for the first and only time in modern history. It was in this local government context also that the medical profession acquired the experience—as local medical officers of health and medical inspectors of schools—that made their testimony so influential on the direction of central government policy toward intervention in the first decade of the new century.

The final section of the book moves the argument out of history and into policy. Major themes are the social inequalities that persist in modern societies, the concept of social capital, the problems of the developing world, and...