Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times (review)

Dorothy Porter. Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times. New York: Routledge, 1999. vi + 376 pp. $U.S. 85.00 (cloth), $U.S. 25.99 (paperbound); $Can. 128.00 (cloth), $Can. 38.99 (paperbound).

This comprehensive study of the relationship between the health of the people and the state through time is the culmination of two decades of research and reflection by the author Dorothy Porter (née Watkins). Building on her Ph.D. thesis completed in 1984 (Watkins, "The English Revolution in Social Medicine"), Porter refers in the text to sixteen articles on aspects of public health history that she has written since then. This is not to say that the book is simply a summary or résumé of her own work; rather, she draws on an impressive array of up-to-date secondary sources to construct and support her argument.

The book is a synthesis of secondary sources, intended as a textbook for students of the history of public health--whether they have been trained in history, public health, or medicine. While the book spans ancient times to the 1990s, its strength lies in the post-Enlightenment Western states; specifically, Porter focuses on the modern nation-states of Britain, Sweden, Germany, France, and the United States. Within these she details political, social, demographic, and ideological changes as they related to public health. She provides the context for specific social policy changes within the different locations, yet draws out general trends throughout the Western world.

Porter argues that health citizenship became a "right of man" within democratic states from the late eighteenth century, and she proceeds to discuss different interpretations of the rights and obligations of citizens within the "social contract" of health between the state and civil society since then. Nineteenth-century sanitary reform and state medicine were based on a belief in the environmental determinants of disease, the remedy for which was seen as political intervention and bureaucratic structures regulating the health of communities. The freedom of the individual was overridden in favor of the power of the state to reduce diseases perceived to be preventable. The most important consequence of the bacteriological revolution, she argues, was to expand the parameters of the concept of the environment to include social behavior: individuals and their social behavior were now understood to be the bearers of disease.

The further individualization of health-care responsibility occurred in the late twentieth century, specifically from the early 1970s, which saw an economic downturn in the Western world, accompanied by changing ideas on social welfare and on the obligations of the state more generally. Individual lifestyles were now seen as the source of social health. As Porter writes, "Since before the Second World War, older ideas about the cultivation of individual health have been reinvigorated in new ideologies which have reinvented the individual body as a map of social and economic relations" (p. 279). She also discusses, in a section that makes fascinating reading, the ways in which individual health has been commercialized in the late twentieth century. As she puts it, "The macrobiotic muscle-bound revolution took off among the healthy wealthy chattering classes. From the mid-1980s bran sales went up, cigarettes were sold cheaply to the Third World, business in the gymnasium started to boom and anyone who wanted to be a citizen preparing for the twenty-first century began jogging in Central Park" (p. 297). A vast industry began servicing Western society with a new moral code: "shape up or ship out of the affluent society" (p. 297). She further argues that this "designer form of the healthy body" served "as a moral instruction to the powerless masses and economically disadvantaged" (p. 313)--with the message that achieving health, beauty, and desirability was their own responsibility and social duty...