PUBLIC HEALTH

Dorothy Porter

The health of populations helps to reveal transformations in social and economic conditions and highlights the changing relationships between the state and civil society. At one time the history of public health was written by public health professionals who wrote administrative histories of preventive health services and of the control of epidemic diseases. This historiographical tradition often traced a chronology of events from ancient to contemporary times, identifying the development of public health as a progressive achievement representing a triumph of rational knowledge over superstitious ignorance. In the late twentieth century, however, the history of public health was investigated by social historians, who explored the cultural significance of epidemics, the impact of disease upon demographic structure and economic change, and the role that protecting population health has played in state formation. Social histories of public health have also revealed the political and ideological conflicts created by collective actions aimed at improving the health of populations. This essay will examine the impact of such actions upon the changing social, political, and cultural relations of European societies from late medieval times, when Europe experienced one of its most devastating pandemics, the Black Death.

THE PLAGUE AND EPIDEMIC CONTROL

As the historian Paul Slack has pointed out, epidemics share many characteristics with other natural catastrophes like earthquakes and tidal waves. But the responses provoked by each vary widely. While all natural catastrophes disrupt social order, they attack the basis of social cohesion in different ways. Epidemic diseases not only cause widespread mortality that affects economic production and the defense capacities of societies, they also impose social stigma and alienation upon individual victims. The enduring metaphor of the social death of medieval leprosy sufferers, who were ordered to be segregated from the rest of society by the Third Lateran Council in 1179, continued to haunt the world of the infectious and chronically sick. Collective actions taken to limit the impact of epidemics therefore risk heightening social tension as much as they manage it.

The disease that eliminated up to a third of Europe's population in the fourteenth century, commonly referred to as the Black Death, is much disputed by contemporary historians. The traditional view that the Black Death was an epidemic of bubonic plague does not fit easily with the pattern and rapidity of the spread of the disease between 1348 and 1353 or some of the contemporary accounts of victims' symptoms. Some historians have therefore attributed the epidemic to other rapid killers such as anthrax. Whatever the organic origin of the disease, the Black Death affected European societies dramatically. Not only did it thin out social and political elites, it also devastated the agricultural laboring population, creating opportunities for social and economic mobility that severely weakened an already fracturing feudal system based upon rigid hierarchies and tied labor. Epidemic visitations of plague continued over the next three hundred years. New civil administrative structures to deal with plague were created in Renaissance and early modern Italian city-states that became models for public health administration throughout Europe.

The Black Death stimulated the first application of what became the favored method of epidemic control by early modern states, quarantine. Venice first closed its port to all suspected vessels for thirty days in March 1348. The period was extended to forty days, and quarantine was eventually adopted by all European port authorities to prevent the importation of numerous infectious diseases. Political authorities also adapted the system to isolate inland communities by enforcing military cordon sanitaires to prevent diseased travelers and goods from entering cities or fleeing from them. In premodern times, the most rational response to an infectious disease like plague was to flee an infected location, and this was resorted to by many who had the resources to do so. Political authorities anxious to maintain existing ruling structures tried to limit the hemorrhage of both the powerful and the productive classes. Reduction of ruling elites could create opportunities for social rebellion, especially as epidemics stimulated panic. Thus, from the time of the Black Death, Italian city-states set up special health boards to institute measures to control the spread of the disease by controlling the movements of both sick and healthy populations.

As outbreaks of plague continued after 1348, civil policing to suppress panic and disquiet grew incrementally throughout Europe during the Renaissance and the early modern period. Local civil authorities sometimes taxed those wishing to flee and posted guards to protect the property of the absent. Elaborate regulations were developed in order to control the behavior of the urban poor, whose swelling numbers were viewed as an increasing risk to social stability. The poor and the socially deviant were perceived as the prime victims and bearers of plague. Political authorities in Italian city-states recognized that economic deprivation, social deviance, and plague were a potentially volatile cocktail. Health regulations targeted the movements of the morally outcast, such as prostitutes, "ruffians," and beggars, as well as the plague-sick poor. Measures were also taken to separate the sick from the healthy through the establishment of isolation hospitals, often outside city walls. While health authorities justified their actions as necessary steps to prevent the spread of plague, their primary goal was maintaining social stability by controlling the mobility of the anarchic, unpredictable underclass. For similar reasons, the English central state in the sixteenth and seventeenth centuries reproduced many Italian plague controls. Here house arrest and isolation of victims' families were adopted in order to keep people in their place at moments of crisis in the same way as the Elizabethan Poor Law enforced local settlement when communities faced periods of economic failure and shortage. The English plague regulations, however, stimulated violent opposition and thereby contributed to increasing disorder.

Plague controls brought civil authorities into conflict with the interests of other ruling elites. Quarantine greatly interfered with trade and was vigorously resisted by merchants and their laborers, who were both adversely affected. Such tensions increased throughout the early modern period. By the seventeenth century the power and prestige of many Italian city health boards grew to the point where they were able to challenge the authority of the church. Festivals, religious assemblies, processions, and other public gatherings were often banned in epidemic times despite the strong opposition of the clergy. Health authorities justified their actions on the basis of experience. For the church, plague was the result of divine wrath that could be assuaged only by penance and observance. For health officials the divine origin was less significant than the miasmas that spread the disease along with the anarchy that it threatened to provoke.

SYPHILIS AND STIGMATIZATION

If plague prevention instituted new levels of political intervention into civil life, epidemic syphilis in the fifteenth and sixteenth centuries highlighted the consequences of stigmatization for disease sufferers. In the Renaissance and early modern world fears of social disorder were matched by the dread of the moral corruption that could result from disease. In the late fifteenth century the disease that came to be identified as morbus gallicus (French disease) was believed to be a new contagion. Numerous contemporary observers wrote accounts of a new epidemic pox appearing in Italy in 1495 following Charles VIII's campaign against the Spaniards for control of Naples. His army, which consisted largely of mercenaries from Belgium, Germany, southern France, Italy, and Spain, was believed to have spread the disease as it disbanded and soldiers returned to their homelands. Within a decade of the first outbreak noted at Fornovo, epidemic syphilis had spread throughout Europe. The stigma of syphilis is reflected in the way that national cultures frequently identified it as the disease of their enemy, but it was most commonly referred to as morbus gallicus.

The morbus gallicus was recognized to be spread venereally. Christian ideology accounted for it as divine retribution for licentiousness, but contemporaries such as Joseph Grunpeck also attributed it to astrological sources. From the sixteenth century the American origin of the disease was the source of much controversy and remains so even today. Isolation of sufferers was attempted by some authorities, the syphilitic being subjected to stigmatization similar to lepers in medieval times. Stricter controls were instituted against beggars and vagrants in France, where old leper houses were converted into accommodations for "incorrigible paupers." The hôtel-Dieu (city hospital) overflowed with émigré pox victims in the 1520s, who were provided with money to return home. In France inspection and stricter regulation of prostitutes was established from 1500. In Edinburgh in 1497 the city council required patients sick of the "gradgor" to be removed to the island of Inch until they were completely cured. Anyone resisting the regulations faced the penalty of complete exile and the branding iron.

Changing attitudes toward sexual practices were already evident in Renaissance societies. The late medieval tradition of the steam bath, which had been part of a cult of pleasure rather than an instrument of cleanliness or hygiene, began to decline in the sixteenth century. Many famous hotels offering the steam bath as a main attraction disappeared throughout Europe. The custom of visiting the steam bath to conduct a discrete liaison or simply to enjoy free and easy frolicking among naked men and women also began to decline. The pleasure dome of the steam bath became a target of the guardians of public morals, but their decline coincided with the rise of epidemic syphilis. The epidemic significantly affected changing attitudes toward libertine pleasure, adding caution to the justification for new codes of moral discipline. The aims of public authorities to control syphilitic contagion were assisted by broader changes in cultural beliefs and social behavior regarding the pursuit of pleasure. What may not have been successfully achieved through coercive public policy was perhaps accomplished through new moral ideologies.

THE SOCIAL SCIENCE OF HEALTH IN THE EARLY MODERN PERIOD

As plague retreated from Europe from the late seventeenth century, geographical exploration, urban development, and imperial expansion created new disease patterns in the eighteenth and nineteenth centuries. Epidemic diseases of isolated communities became endemic in urban environments. By the eighteenth century shock invasions were replaced by rising levels of endemic infections and chronic sickness that occasionally became epidemic, such as malaria, smallpox, and gout. The absence of catastrophic disasters meant that emergency disease control was no longer a priority. Instead, the age of the Enlightenment became a period in which a new interest in the social scientific analysis of the health of populations developed. The eighteenth century also witnessed innovations in sanitation and immunization, and late Enlightenment thought made new connections between social improvement and environmental reform. By the nineteenth century the Enlightenment study of political arithmetic and human longevity evolved into the statistical enumeration of human misery and the social physics of human improvement. The Enlightenment pursuit of happiness through a felicific calculus translated into a social science of amelioration (investigations undertaken by voluntary researchers and social reformers into the social conditions of economic depravation and destitution that were aimed at informing social policies of improvement) in the nineteenth century that was inherently bound to the improvement of population health. ("Political arithmetic" is the term used by the seventeenth-century English man of letters William Petty to describe his quantitative analysis of what he called the political anatomy of Ireland; Petty believed that the quantitative analysis of the strength of the state—including the analysis of the health of the population, levels of production and "market research" into the sale of individual commodities—should become a general form of enquiry called political arithmetic. "Social physics" is the term given by the early nineteenth-century Belgian astronomer Lambert Adolphe Jacques Quételet to the quantitative analysis of social conditions, including the health of the population, using the statistical concept of the normal frequency distribution. "Felicific calculus" is the term given by the late eighteenth- and early nineteenth-century English political philosopher Jeremy Bentham to the analysis of the greatest happiness of the greatest number as the founding principle on which to base utilitarian philosophy of government.)

The relationship between the health and wealth of nations was extensively explored in political, economic, and social theory in the eighteenth century. The development of what the French ideologue Condorcet called "social mathematics" was highly significant in the development of the relationship between the emergent modern state and the health of its subjects. Various methods of counting the subjects of the state and measuring its size and strength in terms of their number and their health were introduced in the early modern period. These practices were supported by the political philosophy of mercantilism, which viewed the monarch's subjects as his paternalistic property and equated the entire well-being of society as coterminous with the well-being of the state as embodied by the sovereign. The political bookkeeping that enabled the state to measure its strength in terms of the size of its healthy population guided its administrative goals and objectives.

These were the early foundations of "vital statistics" and epidemiology that, by the nineteenth century, became a prerequisite for systematic disease prevention. Lambert Adolphe Jacques Quételet (1796–1874), a Belgian astronomer who devised the theory of the normal frequency distribution curve, took up the quantitative analysis of social physics in the early nineteenth century. A generation younger than Condorcet, Quételet believed that social physics could provide the basis of the scientific management of society.

In France in the early nineteenth century, the application of social physics did not lead to social reform. Instead, it created a new academic inquiry into the conditions that determine health and disease, an inquiry that founded the nineteenth-century European science of hygiene. An ex-army surgeon, Louis René Villermé, who was a friend of Quételet, translated social physics into elaborate studies of the differential mortality of the rich and poor and the health conditions of the proletariat and their average expectation of life. However, these studies did not stimulate political action. Villermé warned against the involvement of the state in health reform and suggested instead that the remoralization of the poor would eliminate epidemic disease and premature mortality.

In Britain the "geography of health" was examined as part of the discovery of the social conditions of the poor. Statistics was embraced as a tool for measuring social inequality by early Victorian reform movements. Statistical studies of health and the social determinants of disease were set up in response to the shocking effects of the cholera epidemics of the 1830s and 1840s, and subsequently Victorian epidemiology sought to eliminate the spread of disease by destroying the environment that bred it.

HEALTH AND THE MODERN STATE

The early modern state linked the investigation of population health to political strength through a mercantialist philosophy. This philosophy also inspired Enlightenment public health promotion through methods of "medical police" developed in Prussia and Sweden and explored theoretically, above all, by the Austrian court physician Johan Peter Frank. Public health featured prominently in the rhetoric of revolutionary democracy at the end of the eighteenth century, both in the newly established American republic and in the declarations of the revolutionary governments in France. The French revolutionaries declared health, like work, to be a right of man, making it an obligation of the social contract between the modern democratic state and its citizens. By the middle of the nineteenth century, the British state had translated this principle into a civil right, in which all possessed equal rights under the law to protection from epidemic disease. In 1848 French and German revolutionaries identified the key to improved population health to be the establishment of "state medicine." In France Jules Guérin, in the Gazette médicale de Paris, and in Prussia Rudolf Virchow, in his reports on typhus in Upper Silesia, both suggested that democratic freedom, universal education, and social amelioration would prevent epidemic diseases. In France and Prussia supporters of social medicine urged the medical profession to take on a political role and become attorneys to the poor and statesmen in disguise.

The political role of preventive medicine within the modern state became an urgent material as well as an ideological issue as exponential rises in epidemic and endemic infections among urbanized populations accompanied the process of industrialization in European societies. The diseases of industrial, urbanized civilization were those transmitted relentlessly among overcrowded populations living in appalling insanitary slums with totally inadequate refuse and sewage removal, drainage, and little or no access to uncontaminated water. Typhus, typhoid, amoebic diarrhea, tuberculosis, diphtheria, and, despite the introduction of smallpox vaccination throughout Europe, smallpox continued to haunt industrialized as well as agricultural populations. But perhaps the disease that conjures up the classic image of industrial society under siege from contagion is cholera. Asiatic cholera followed troop movements out of India through eastern, central, and western Europe between 1830 and 1832 and became the first of several pandemic invasions. Overall, cholera killed far fewer than endemic fevers, but the social psychological effect of the suddenness of its invasion and the speed and manner in which it killed was dramatic. Cholera highlighted the tenuous social stability of the class structures of European societies. Conspiracy theories were rife among the European proletariat and peasantry. Rioters in Russia attacked nobles and officials because they believed that the water was being poisoned as part of a Malthusian effort to reduce surplus population. The homes of noblemen and the offices of health authorities were ransacked throughout Prussia, and officials were murdered in Paris. In Britain Bristol's poor rioted in protest against the removal of the sick to isolation wards, believing that this was a means of providing the medical profession with bodies to anatomize.

Cholera coincided with crisis in nineteenth-century Europe, but often conditions were made ripe for its spread by social upheaval. Cholera was spread by social dislocation—the mobility of population created by the expansion of trade in the nineteenth century, which brought rural populations into the cities—and subsequently exacerbated it. This pattern of social dislocation and epidemic spread is equally demonstrated for another acute infection characteristic of the times, typhus. Typhus has a long history of being associated with war and famine, frequently flourishing in military encampments and jails, but it became almost endemic among some urban populations during the nineteenth century.

Sanitary reform developed at different rates in European states throughout the nineteenth century. By the end of the century most major European cities had sewage and drainage infrastructures and improved water supplies. Most northern European states established various types of local and, in some cases, central government health authorities who monitored health conditions and administered a wide range of public health regulations. Some city administrations, such as the Paris Health Council, became models for national governments. Other cities avoided the costs of public health imperatives as long as possible. When cholera attacked Hamburg in 1892, long after it had retreated elsewhere in Europe, the city-state paid a political price for neglecting to filter its water systems by being taken over by Prussian administration. Incremental environmental sanitary reform throughout Europe in the nineteenth century slowly reduced the effects of lethal infections. While historians and historical demographers continue to dispute the determinants of population growth, increased protection from the environmental hazards of industrial urbanization continue to figure prominently in assessments of mortality decline by the turn of the twentieth century. Historical epidemiologists still consider the reduction of infant amoebic diarrhea through cleaner, filtered water supplies to have played a significant role in that decline.

Providing for the health of communities, however, could lead the modern state to sacrifice the civil liberties of individuals. Movements developed in mid-nineteenth century Britain, France, and Germany opposing compulsory smallpox vaccination as tyranny rather than salvation. Acts passed by the British state establishing the compulsory inspection of prostitutes in garrison towns in the 1860s were opposed on similar political grounds. In the 1870s and 1880s the campaign to repeal the Contagious Diseases Acts in Britain interpreted the enforcement of health as a gross violation of civil liberties by a centralized power exercising a form of medical despotism and a double moral standard. By the end of the century, however, the Notification of Infectious Disease Acts in Britain interned those sick of a listed infection in an isolation hospital until they either recovered or not, but they provoked no libertarian opposition or alarm.

The civil disorder stimulated by state action during the cholera epidemics throughout Europe in the early nineteenth century was not repeated at the end of the century as modern democratic states made more and more interventions into the socioeconomic and biological lives of citizens. In industrialized and modernizing European states, a new political ethos of collectivism encouraged the development of compulsory social insurance schemes to protect workers from injury, sickness, unemployment, and old age. Population health policies began to incorporate medical services to vulnerable groups, including mothers, infants, school children, and the mentally retarded. In the twentieth century, obtaining population health was no longer limited to the prevention of disease but began to include public provision to cover the costs of medical services along with new strategies for encouraging individuals to adopt healthy lifestyles.

HEALTH CARE SYSTEMS IN THE TWENTIETH CENTURY

The twentieth century witnessed the incremental growth of comprehensive, state-funded public health and medical services throughout Europe. In the interwar years a preliminary model welfare state with integrated health and medical services developed in Weimar Germany. Between 1919 and 1933 the Weimar Republic viewed the economy as an organism that could be managed by the state, which would redistribute wealth through welfare benefits. Weimar welfare facilitated the socialization of health and prioritized the goals of the social hygiene movement, focusing on the prevention of chronic disease, the health of mothers and children, and the treatment of psychiatric disorders.

The development of health services under Weimar was motivated by organisist, collectivist social ideology that included beliefs in regenerationist biology. Eugenic ideals about the need to plan population development were compatible with ideals of collective responsibility for welfare in numerous other European contexts during the same period. Demographic and eugenic concerns led to new directions in health and social policy in Scandinavia, Britain, and France. On the one hand, prioritizing the health of mothers, infants, and children and encouraging large families was legitimated as protecting the health of future generations and ensuring demographic balance. Pronatalism was promoted in Sweden and France following World War I. In Scandinavia, Belgium, France, and Germany various forms of family allowance were developed to ease the economic burdens of parenthood. On the other hand, preventing the reproduction of the eugenically "unfit" through restrictive marriage laws, the segregation of the mentally retarded and mentally ill, and the voluntary or compulsory sterilization of various social groups was aimed at reducing the potential for biological and racial decline.

Positive and negative eugenics in Europe before World War II was one expression of the increasingly influential ideology of social planning. The corporate management of capitalist economies based upon the ideas of John Maynard Keynes gained legitimacy in European states as the failures of unregulated markets threatened the survival of industrial capitalism. A comprehensive, integrated system of health and medical services for workers and their dependents was one of the linchpins of the vision of the welfare state outlined by the British liberal intellectual William Beveridge, whose 1942 report influenced the development of health and social security policies throughout Europe following the war.

According to the social policy theorist Gosta Esping-Andersen, three "worlds" of welfare emerged after World War II that relied on more or less bureaucratically administered state funding, voluntary and compulsory insurance, and market mechanisms. A significant division developed between the generous insurance-based social security systems that operated in parts of continental Europe and the lower level of insurance plus tax-funded, means-tested state benefits that operated in Britain. Further divisions occurred between universal statutory insurance-based systems constructed in Europe and the private insurance plus means-tested welfare provision that operated in the United States.

Within these broad frameworks different rates of welfare expansion continued for the first three decades following 1945, until international economic crises in the 1970s ended what has been eulogized as a "golden era" of political consensus, economic growth, rising living standards, and social justice. While the viability of the welfare state was increasingly challenged in the 1980s, comprehensive health coverage has been the most politically resilient of its features. In the 1980s New Right assaults on what it viewed as the culture of dependency produced by "nanny states" sought only to reform rather than remove state-funded health care systems. The continued popularity of state-funded health care perhaps emanated from the fact that, as the left wing British economist Julian Le Grand pointed out in 1982, the middle classes benefited from them most.

HEALTH CARE AND INDIVIDUAL BEHAVIOR

While the public provision of health care continued to be politically popular in the 1990s, fears concerning the demographic structures of twenty-first-century postindustrial societies support a culture of personal health responsibility that had been promoted by the state and commercialized by the marketplace throughout the twentieth century. As state medicine throughout Europe became involved in the provision of personal services, new emphasis was placed upon individual prevention through the development of healthy lifestyles. In the interwar years new perspectives on preventive medicine were developed in the Soviet Union, Germany, Belgium, and Britain that attempted to make clinical medicine a social practice through the interdisciplinary amalgamation of medicine and social science. Following World War II social medicine focused upon prevention through public education about health hazards to the individual. A precedent was set in the health education campaign aimed at reducing lung cancer through the prevention of cigarette smoking.

The antismoking campaign in Europe exemplified the new message of the clinical model of social medicine: the key to the social management of chronic illnesses—such as lung cancer—was individual prevention, fostered by raising health consciousness and promoting self-health care. While antismoking has achieved a degree of success in Europe, it has had much greater influence in North American societies. However, the model of prevention through individual education gathered momentum in the wake of the antismoking campaign. Subsequent postwar campaigns offered lifestyle methods for preventing heart disease, various forms of cancer, liver disease, digestive disorders, venereal disease, and obesity.

In 1981 T. Hirayama published the results of a study that demonstrated that nonsmoking wives of heavy smokers had a higher risk of contracting lung cancer than did the wives of nonsmokers. The campaign to prevent "passive smoking" subsequently took on the character of a nineteenth-century campaign to prevent infectious disease. Like all such public health campaigns, the collective benefit of state action penalized and stigmatized a specific social group, whose members were represented as social pariahs and failures and moral inferiors.

The mixed messages involved in the prevention of tobacco consumption have been fully represented in the campaigns against a new lethal infectious virus appearing in the early 1980s, human immunodeficiency virus (HIV), which leads to a fatal syndrome commonly referred to as AIDS. The emergence of a new killer infection in the early 1980s reawakened all the public health concerns associated with an earlier era. AIDS was initially compared to dramatic historical invasions of the past such as plague and cholera. The initial impact of AIDS upon popular, political, and expert perceptions raised familiar issues regarding the right of the state to police and regulate the spread of infection through surveillance, notification, screening, and quarantine. Those who favored authoritarian intervention called for the institution of compulsory testing, identity cards for people who were HIV-positive, and their isolation. Most of these goals were not taken up by national policymakers, but the question of identity cards came close to realization in some local contexts, such as Bavaria.

By the late 1980s its transmission through needle-sharing among impoverished intravenous drug users meant that AIDS was spread more and more by poverty and social despair rather than unprotected sexual intercourse. The length of time between contracting the HIV virus, the onset of the AIDS syndrome, and the death of the sufferer lengthened as more effective therapeutic treatment slowed the physiological progress of the disease. Thus by the 1990s AIDS began to be perceived as a chronic disease among minority high-risk groups rather than an epidemic infection. AIDS victims have suffered legal and social discrimination in the popular mind and by official agencies. The implication of bodily and spiritual corruption has persisted as a powerful contemporary trope.

A new social contract of health has been promoted in public health campaigns from antismoking to AIDS prevention. It is a contract based upon a model of prevention that utilized medical and social scientific analysis to maximize health chances by encouraging individuals to change their lifestyles. However, the state and its public health agencies have not had a monopoly on the promotion of health through lifestyle management. Health promotion through lifestyle education has also been successfully commercialized.

Since the eighteenth century "self-health" has been successfully commercialized through the publication of advice manuals and the promotion of dietary aids and exercise regimens by various entrepreneurs. In the nineteenth and early twentieth centuries health reformers promoted physical culture cults such as calisthenics, eurythmics, vegetarianism, and mastication techniques. Such traditions continued in the advertising campaigns for mass-produced foods such as cereals as health aids and in a commercialized exercise culture. In the early twentieth century the value of exercise for healthy living was commercialized by American entrepreneurs such as Eugene Sandow, Bernarr Macfadden, and Charles Atlas, who established their own brands of competitive bodybuilding and physical culture systems. In the United States and in Europe, the interwar years witnessed the symbolic association of the healthy body with racial health and national supremacy.

Following World War II bodybuilding expanded as a commercialized competitive sport and, along with the increased popularity of spectator sports as a leisure pastime, spawned a new fitness industry. The fitness and beauty industries in the late twentieth century became hugely successful international markets involving the sale of sportswear, health foods and dietary aids, commercial health and gymnasium clubs, health and beauty holiday resorts, fitness training, and plastic surgery. Slimming alone has become a large market industry. The message of the commercialized health industry mirrors that promoted by the state: health is an individual responsibility that has to be worked for through individual effort and paid for from individual pockets. By the early 1990s the healthy body became a symbol of social and economic success and the diseased became associated with social failure and dysfunction. As liberal democratic societies within and beyond Europe retreated from the public funding of health and social welfare, both the state and the marketplace sought to blame ill health on individual irresponsibility and ignorance.

Although the contract of health between the social democratic state and its citizens is thus being reconfigured, at the beginning of the twenty-first century there are, nevertheless, signs that the structural causes of ill health are not being entirely overlooked. As the gap between the affluent and the impoverished widens in postindustrial societies throughout Europe, the relationship between poverty and ill health has again become a focus of state concern. Mortality differentials and rising levels of the traditional diseases of poverty, such as tuberculosis, have re-created an awareness of the impact of inequality on levels of health. Poor people die earlier because their health is compromised by low incomes, unemployment, poor housing, and social exclusion. Population health is compromised in areas with poor social facilities and where people are intimidated by high levels of crime and disorder. The poor and industrial workers are also often exposed to greater risks from environmental pollution and occupational hazards.

The impact of inequality upon health is beginning to be taken into account by social democratic policymakers in Europe. In Britain, for example, New Labour health ministers acknowledge that in tackling the root causes of avoidable illness, "in recent times the emphasis has been on trying to get people to live healthy lives" (Dobson and Jowell, Our Healthier Nation, p. 2). The New Labour government suggests, however, that they want to try an approach with "far more attention and Government action concentrated on the things which damage people's health which are beyond the control of the individual" (Our Healthier Nation, p. 2). The consequences of the absence or shrinkage of welfare states in industrial societies throughout the world also impacts upon European thought regarding the restructuring of networks of social security that help to ensure population health. Population health within and beyond Europe, however, continues to be an ongoing negotiation between civil society and the state. The outcome of that negotiation depends, as it has always done, upon the political will of both.

See alsoHealth and Disease (volume 2);Urbanization (volume 2);The Welfare State (volume 2);Doctors and Medicine (volume 4); and other articles in this section.

BIBLIOGRAPHY

Carmichael, Anne G. Plague and the Poor in Renaisance Florence. Cambridge, U.K., 1986.

Cipolla, Carlo M. Fighting the Plague in Seventeenth-Century Italy. Madison, Wis., 1981.

Coleman, William. Death Is a Social Disease. Madison, Wis., 1982.

Crosby, Alfred, W. Ecological Imperialism: The Biological Expansion of Europe. 900–1900. London, 1986.

Dobson, Frank, and Tessa Jowell. Our Healthier Nation: A Contract for Health. London, 1998.

Esping-Andersen, Gosta. The Three Worlds of Welfare Capitalism. Princeton, N.J., 1990.

Esping-Andersen, Gosta, ed. Welfare States in Transition: National Adaptations inGlobal Economies. London, 1996.

Evans, Richard J. Death In Hamburg. Society and Politics in the Cholera Years, 1830–1910. Oxford, 1987.

Fee, Elizabeth, and Daniel M. Fox, eds. AIDS: The Making of a Chronic Disease. Berkeley, Calif., 1992.

Flora, Peter, ed. Growth to Limits: The Western European Welfare States Since WorldWar II. Berlin, 1986.

Fox, Christopher, Roy Porter, and Alan Wokler, eds. Inventing Human Science:Eighteenth-Century Domains. Berkeley, Calif., 1995.

Gilman, Sander I. Sexuality: An Illustrated History. New York, 1989.

Hacking, Ian. The Taming of Chance. Cambridge, U.K., 1990.

Hardy, Anne. The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900. Oxford, 1993.

Hardy, Anne. "Urban Famine or Urban Crisis? Typhus in the Victorian City." Medical History 32 (1988): 401–425.

Johannisson, Karin. "The People's Health: Public Health Policies in Sweden." In The History of Public Health and the Modern State. Edited by Dorothy Porter. Amsterdam and Atlanta, 1994. Pages 165–182.

Porter, Dorothy. Health, Civilization, and the State: A History of Public Health fromAncient to Modern Times. London, 1999.

Quetel, Claude. History of Syphilis. Translated by Judith Braddock and Brian Pike. London, 1990.

Slack, Paul. The Impact of Plague in Tudor and Stuart England. London, 1985.

Twigg, Graham. The Black Death: A Biological Reappraisal. London, 1984.

Vigarello, Georges. Concepts of Cleanliness: Changing Attitudes in France since theMiddle Ages. Translated by Jean Birrell. Cambridge, 1988.

Weindling, Paul. "Eugenics and the Welfare State during the Weimar Republic." In The State and Social Change in Germany, 1880–1980. Edited by W. R. Lee and Eve Rosenhaft. Munich, 1990. Pages 131–160.