Health, Civilisation and the State: a History of Public Health from Ancient to Modern Timesby Dorothy Porter
Gert H. Brieger
I would like to thank Professor Brieger for his thoughtful review. I am especially grateful to him for pointing out proof reading errors that will be corrected as soon as there is an opportunity to do so. The attention that Professor Brieger gave to my text is extremely rewarding and I am very pleased with his summary of its analytical scope.
I wish to address one point he raised in particular, and that concerns the interpretation of the work of Thomas McKeown. Since finishing Health, Civilisation and the State I have become more fascinated than ever with the influence of the late Professor McKeown upon post-war debates regarding medical care, public health and social inequality. Professor Brieger correctly points out that in a publication in 1994 I suggested that McKeown helped to undermine an heroic history of public health. An overstatement perhaps, but I was referring to McKeown's unintentional influence upon social historians of medicine writing in the last decade or so. His message was received differently by his contemporaries working in public health and social medicine or writing about its history at the time that he published The Modern Rise of Population and The Role of Medicine. In the 1970s, McKeown contributed to a critique of the role of medical care in eliminating health inequalities that had first been addressed by Julian Tudor Hart in a highly significant article on 'The Inverse Care Law', published in the Lancet in 1971. The spirit of this critique continued to inform work on health inequalities in Britain up to the publication of the Black Report in 1980. Neither McKeown nor Tudor Hart was concerned to eulogise sanitary or environmental models of public health but their critique of the role of medical care reinforced the importance of 'collective actions in relation to the health of populations' amongst their sympathetic contemporaries, that is, amongst those of their contemporaries who travelled along sympathetic ideological pathways. I am exploring the full implications of these events in my current work on the post-war world of medicine, social science and public health in Britain. My point in Health, Civilisation and the State was simply that if we start to broaden our object of enquiry by investigating 'collective actions in relation to population health', then it will perhaps afford us rich interpretations such as the example I have given here. Such an insight might have been overlooked perhaps by earlier historiographical approaches that used rather narrower definitions of their subject that were inspired by the achievements of pioneer practitioners of public health itself.