The population health approach in historical perspective

Abstract

The origin of the population health approach is an historic debate over the relationship between economic growth and human health. In Britain and France, the Industrial Revolution disrupted population health and stimulated pioneering epidemiological studies, informing the early preventive public health movement. A century-long process of political adjustment between the forces of liberal democracy and propertied interests ensued. The 20th-century welfare states resulted as complex political mechanisms for converting economic growth into enhanced population health. However, the rise of a "neoliberal" agenda, denigrating the role of government, has once again brought to the fore the importance of prevention and a population health approach to map and publicize the health impacts of this new phase of "global" economic growth.

Figure 2

Cartoon from the September 1919 issue of the journal American City depicting the defeat of typhoid fever by the large-scale municipal measures of water filtration and chlorination. (American City. 1919;21:247.)

Figure 3

A Punch cartoon from June 1848 of Lord Morpeth, the central government’s representative, promoting the bill for Chadwick’s Public Health Act. The legislation is depicted as “sanatory” pearls being thrown in vain by the enlightened national statesman to the unappreciative “swine”: the lazy, ignorant, and venal councilors of the nation’s cities, content to wallow in their own filth.

Figure 4

Illustrations from The Lancet of water impurity in London’s commercial supplies. By 1851, the microscope enabled water analysts to make precise drawings such as these depicting the organic contents of the drinking water supplied by London’s increasingly notorious private companies. Some of these companies’ defective systems were clearly implicated by pioneering epidemiological research into the major cholera epidemics of the period.

Figure 5

Joseph Chamberlain, wearing his trademark monocle and occupying the moral “high ground,” fighting the 1878 Birmingham municipal election. Three decades after the failed Public Health Act, Chamberlain led the Liberal caucus, a highly organized party machine, to a series of municipal electoral victories on an ambitious platform of civic spending and improvement. These programs were to be financed from long-term loans, revenue-raising municipal services such as gas and water, and rising tax rates on property.

FIGURE 1—

Life expectancies at birth in major British provincial cities, 1801 to 1901, compared with the national aggregate trend. Source. Derived from Szreter and Mooney.³⁹ Note. Britain’s industrial cities were significantly less healthy than the national average at the beginning of the 19th century. Thereafter, they were plunged into an abyss of high mortality during the 1830s and 1840s, which prompted much social comment and a Royal Commission on the Health of Towns during the 1840s. There was some recovery in the 1850s, but no real improvements above the level of the 1820s until the 1870s and the era of “the civic gospel” and municipal “gas and water socialism.”