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

Abstract

Reviewed by Bill Luckin University of Manchester Simon Szreter. Health and Wealth: Studies in History and Policy. Rochester Studies in Medical History. Rochester, N.Y.: University of Rochester Press, 2005. xiv + 506 pp. $90.00, £65.00 (1-58046-198-0). This collection of previously published articles by one of the most talented writers in the fields of social, demographic, and medical-epidemiological history is divided into three parts. An opening section is concerned with "history as critique," and includes two articles that, if citation indexes are anything to go by, have already attained the status of minor classics. The first of these, which appeared in the inaugural issue of Social History of Medicine in 1988, challenges the credibility and internal cohesion of the McKeownite paradigm that for so long dominated interpretation of the decline of urban mortality in the nineteenth century. One of Szreter's major claims here is that McKeown's categories of quantitative evidence cannot be made to substantiate his conclusions. In addition, a myopic obsession with nutritional improvement, assumed to flow in some kind of semiautomatic way from increases in per capita income, leaves little room for the roles of human agency and coordinated social intervention. These latter themes would soon become central to Szreter's scholarly concerns. The second essay in the opening section confronts the intellectual lineage of the "demographic transition." Szreter identifies this grossly overused—indeed, clichéd—catch-all phrase as multiform: "theory, . . . historical model, predictive model, [and] mere descriptive term" (p. 47). He strongly urges historians working on fertility to escape from its clutches and commit themselves instead to the "reconstruction in specific contexts of the varying ways in which modifications have occurred in the perceived relative costs of child-bearing"; this, he claims, is the "central, complex variable" (p. 89). (Note here the echoes of the pioneering work of J. A. and Olive Banks in the 1950s and 1960s.) The second section reprints a cluster of pieces devoted to the "response to public health challenges of economic growth in nineteenth-century Britain." The best known focuses on the "four Ds": disruption, deprivation, disease, and death. Szreter argues that rapid economic growth is invariably achieved at the cost of major—at times catastrophic—political and social destabilization. Taking the British experience as template, he claims that "the sequence of the four Ds was redressed and economic growth translated into positive economic and social development only when the relations of social capital in . . . industrial communities were sufficiently strong that the politics of public health could direct collective resources toward the good of the community as a whole" (p. 237). One can quibble with the phrase "as a whole": between the 1870s and the outbreak of the First World War even progressive municipalities frequently excluded the "non-respectable" and abjectly poor slum-dwellers from visions of an imminently achievable urban utopia. At the same time, this essay creatively encourages historians of public health, long preoccupied with the micromechanics of water supply, sewage disposal, and rival theories of infection, to turn to explicitly political, communal, and institutional issues. As Szreter himself shows, such an approach encourages contact with a rich theoretical repertoire—particularly the now massive, indeed [End Page 878] bewilderingly massive, body of work concerned with social capital. (Robert Putnam and Richard Wilkinson loom large throughout the second and third sections of the book.) A final section, "History and Policy: From the Past to the Future," engages with the ways in which political institution-building and social capital link the experience of mass industrialization in the nineteenth century to analogous, yet subtly different, transformations in twentieth- and twenty-first-century Britain, Europe, and the developing world. In an essay on health, class, place, and politics, written with Michael Woolcock, Szreter urges New Labour to promote a "coherent moral program" as replacement for the Thatcherite obsession with a radical diminution of public provision. (That path, of course, had already been chosen during the years...