[Paleopsych] Founders.net: The Determinants of Health from a Historical Perspective

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The Determinants of Health from a Historical Perspective

OUR CONCEPTIONS OF THE DETERMINANTS of health change periodically. At
certain times socioeconomic factors have figured predominantly in
policy-making; at other times the emphasis has been largely on
identifying the causes of disease and treating the sick. Theories
about the determinants of health--indeed, the definition of
health--necessarily affect how illness is defined, what public
policies are initiated, and how resources are allocated.
The National Health Services was introduced in the United Kingdom in
1948. At that time, it was believed that the gradient in health across
the social classes (the highest social class had the lowest mortality
rates, and the lowest social classes had the highest mortality rates)
would be decreased if the financial barriers to health care were
removed.^1 Similar arguments were used when Canada introduced its
national insurance program for health-care services nearly two decades
later. In the 1970s the Merrison Royal Commission on the National
Health Service in the United Kingdom^2 was surprised to find that the
gradient in mortality across social classes had actually widened even
though mortality rates had continued to fall. In 1977, the Labour
government established a research group, headed by Douglas Black, the
Chief Scientist in the Department of Health and Social Security, to
look more broadly at the factors influencing health. A major
conclusion of this compelling report, often referred to as the "Black
Report,"^3 was that, while health care contributed to improved health
and well-being, there were socioeconomic factors of equal or greater
importance in determining health and well-being. These factors were
primarily causing the gradient in health across social classes.
The publication of the "Black Report" unleashed a vigorous and, at
times, acrimonious debate and a deluge of studies. Black's working
group was itself split over how resources should be allocated to
reduce the inequalities in health. As Sir Douglas Black explained:
We were all agreed that education and preventive measures,
specifically directed towards the socially deprived, were necessary.
But the sociological members of the group (Townsend and Smith)
considered that the consequent expenditure should be obtained by
diversion from the acute services. On the other hand the medical
members-- and that means both of us (Black and Morris)--felt that the
acute services played a vital part in the prevention of chronic
disability and could not be further cut back without serious effects
on emergency care, on the training of doctors for both hospital Work
and for family practice and on the length of waiting lists. We spent a
long time, without real success, trying to resolve this matter.^4
The relative importance of investments in health care versus
investments in other determinants of health is still an unresolved
issue. The "Black Report," recent population-based epidemiological
studies, and new insights from medical science have begun to give us a
better understanding of how socioeconomic factors influence the health
and well-being of populations.^5 Some quite striking perspectives have
emerged from recent studies of the records in Western countries over
the last three hundred years. The early period of our history provides
some insights about our changing social environments and health.


Ester Boserup has provided an informative account of hunter- gatherer
societies and the Agricultural Revolution.^6 The hunter- gatherer
societies had limited supplies of food and were constantly moving.
Since only a small number of young children could be coped with under
such conditions, birth spacing, infanticide, and short life expectancy
constrained population growth. These groups, in addition to being
affected by changes in food sources, were also exposed to physical
hazards, predators, and, presumably, in certain environments, to
The basic social structure of the hunter-gatherer societies was the
troop or tribe (usually fewer than one hundred individuals). Because
the groups were so small, there was a great deal of social interaction
and support. Since social support appears to influence health and
well-being,^7 the individuals in these simple social units may not
have suffered from the negative effects on health of social
deprivation that are found in societies today.
A different social framework emerged in the agricultural evolutionary
stage, about ten thousand years ago, and began what some have called
our experiment with civilization. Populations became less nomadic. New
social environments with hierarchies were created through the
establishment of farming communities and towns. Mechanisms for the
control of land, food production, irrigation systems, and organization
of labor evolved to ensure that these more complex systems could work.
These new social orders did not have the collective, communal aspects
of the hunter-gatherer societies. As Boserup points out, many
hunter-gatherer societies stayed away from the new order to protect
their communal form of existence. It has been suggested that
hunter-gatherer societies knew of the technologies necessary for
agriculture long before the development of agriculture.
In the towns and cities that emerged, the quality of the water supply
and sanitation systems became factors influencing health. The
increased population density created extreme vulnerability to any new
infectious agent that swept into the population. In addition, wars
were largely fought over controlling the sources of food and its
distribution. In this period, as today, war often contributed to
famine and epidemics. Although medicine emerged as a profession during
this period, the causes of disease were poorly under- stood and
therapies were limited in their effectiveness. Despite these factors,
there was steady population growth: from approximately 10 million in
8000 B.C. to approximately 750 million in A.D. 1750.
Towards the end of this period insight into socioeconomic policies and
the health of populations was gained. In the sixteenth century the
authorities in England recognized that famines were man-made rather
than natural disasters. Food was available, but the lower classes
could not gain access to it.^8 The state interfered and surplus food
was supplied to the poor. This intervention angered farmers,
producers, and merchants and contributed to the grievance against
Charles I and the Civil War. After the revolution the new government
abandoned the Tudor-Stuart program of food relief. This policy change
subjected England to nearly two centuries of periodic famines. For the
poorer members of the population, food riots became common. The issue
was not food production, but distribution. After the Industrial
Revolution, the government reinstated the old Tudor-Stuart program.
One of the criticisms that has been raised about the role of better
nutrition in the improved health of populations is the observation
that prior to the Industrial Revolution the peerage in England had the
same mortality rate as the general population even though they had
access to abundant supplies of food.^9 One explanation is that an
abundance of food did not ensure that the upper-class children had a
better diet than the general population.^10 After the Industrial
Revolution, and its associated cultural and' social changes, the life
expectancy and height (a measure of the adequacy of nutrition during
childhood) of the peers increased rapidly, while those of the general
population lagged behind. Interestingly, a health gradient between the
peers and the rest of the population emerged only after the Industrial


Although there were many technological innovations that affected
socioeconomic development following the Agricultural Revolution, a
major change occurred when it became possible to harness fossil fuels
as a source of energy. Prior to this, slaves or serfs were used for
most physical labor. Unfortunately, there is little data detailing the
differences in the health and well-being of serfs and slaves versus
those who were more privileged before the Industrial Revolution. As
Rosenberg and Birdzell have emphasized, the Industrial Revolution was
associated with vastly enhanced prosperity for Western societies,
which led to better health, the disappearance of slavery and serfdom,
and the development of democracy and universal surfrage.^11 During
this period we find a substantial improvement in health and a dramatic
rise in population. The world population has increased from
approximately 750 million in 1750 to nearly 6 billion today. The
decline in mortality rates over the past 150 years is one of the great
triumphs in human history. A UN report in 1953 attributed the trend to
four factors:
1) public health measures;
2) advances in medical knowledge and therapeutics;
3) improved personal hygiene; and
4) improved standards of living.^12
McKeown and Brown, attempting to better understand why health
improved, explored factors influencing the major decline in mortality
rates in the United Kingdom after 1840.^13 They found that the bulk of
the change in mortality rates could not be explained through medical
intervention because there were no effective treatments for the major
causes of death during most of this period. Furthermore, a large
decline in mortality from airborne diseases could not be easily
explained by the improved water and sanitation systems at the end of
the 1800s. McKeown's conclusion was that the decrease in mortality was
due to improved prosperity and nutrition.^14
Critics pointed out that while McKeown's argument about improved
nutrition was obviously part of the story, he gave too little credit
to public health measures and medicine. He also did not account for
discrepancies, such as why the mortality rate of infants and young
children in the United Kingdom did not begin to fall until 1900 when
the decline in death from tuberculosis started much earlier.^15 Reves
showed that the increase in child spacing that occurred in the United
Kingdom around the beginning of this century was sufficient to
increase the median age of exposure, and thus decrease susceptibility,
to infectious diseases.^16 In earlier societies, child spacing was, in
part, driven by culture, population density, access to resources, and
survival of the society. The dynamics of the practice of child spacing
cannot be determined by a simple formula. However, increased birth
spacing has been shown to have a positive effect on a nation's health.
Improved water systems and sanitation greatly decreased the number of
deaths due to waterborne diseases. The greatest decline occurred
during the latter part of the nineteenth century, when water and
sanitation systems in Britain were improved. Also in the nineteenth
century, the hygiene movement and its public health accomplishments^17
reversed the deterioration of the British environment that was
associated with the growth of urban centers during the Industrial
Revolution. The socially conscious citizens of an increasingly
prosperous society drove their economic and political institutions to
improve the urban environment, thereby improving health and well-being
for the society.
Following McKeown's pioneering work, Fogel^18 and others^19 have
provided new evidence about the relation between improved nutrition
and changes in mortality rates during the Industrial Revolution. They
shifted attention from famine (only a small factor in preindustrial
mortality rates} to chronically poor or inadequate nutrition as a
determinant of health. Before the middle of the nineteenth century,
national food production in countries like England and France was not
sufficient to provide adequate nourishment to the lower class. The
bottom 20 percent of the labor force took in enough calories to stay
alive but not enough to do much work.^20 In addition, undernourishment
led to weakened immune systems and increased vulnerability to
infectious diseases^21
Height and weight measurements have long been used as a means of
better understanding the relationship between nutritional status and
mortality. An individual's height in adulthood reflects the effects of
the nutritional experience during the growing years, including the
fetal period. Height at maturity is inversely associated with risk of
chronic diseases and dying in the later stages of adult life.^22
Weight represents the balance between nutrition in adult life and
energy demands. The association of height with adult mortality rates
reveals not the effect of adult nutrition but of nutritional levels
(and disease history) from conception to maturity. Individuals who are
poorly nourished or overnourished in adult life show higher mortality
rates than individuals who maintain an ideal weight for height.
However, short men who maintain an ideal weight are at a greater risk
of death than are taller men.^23 Height is determined by genetic
factors and nutrition, and the relative importance of each in
explaining individual variation in height is still being debated.
However, population mean height over time, which is used in these
population studies, is primarily determined by environmental
In Western countries, where records are available, the improvement in
nutritional status during infancy and childhood, as estimated by
changes in the mean height of the populations, is associated with a
decline in mortality rates. Examination of English and American data
has shown that Americans achieved mean heights and levels of life
expectancy by the middle of the eighteenth century which were not
achieved by the British upper classes until the beginning of the
twentieth century.^25 The evidence from these studies also shows that
the lower classes in England did not show a marked increase in height
until this century. Countries in which access to nutritious food
varies by social class, for whatever reasons, tend to show class
gradients in height and health status. In countries that have a high
degree of income equity and equitable access to good food, height
differentials by socioeconomic class have largely disappeared.^26
The historical records since the Industrial Revolution show
fluctuations in mean heights in populations in Western countries that
appear to be related to socioeconomic factors such as the state of the
economy, income distribution, and the effects of urbanization. These
studies of the relationship between poor nutrition during early life
and health and well-being in later life have shown that chronic health
problems are more common among short or stunted men than among tall
men.^27 Rejection rates for recruits into the Union army in the US
Civil War, based on medical conditions, were, coincidentally,
inversely correlated with the height of the potential recruits.
Fogel^28 notes that individuals in the last century who survived into
the later stage of adult life were not freer of chronic disease than
are persons of the same age today. He makes the point that reliance on
cause-of-death information has led to a significant misrepresentation
of the distribution of health conditions and an un- fortunate
separation of the epidemiology of chronic diseases from contagious
diseases. Poor development during early life, as a result of poor
nutrition, not only increases the risk of dying from contagious
diseases, it also increases the likelihood of chronic disorders in
adult life. The evidence also indicates that this phenomenon is not
disease-specific, but is related to the development of the immune
system and other organ systems.^29
A historical analysis of the influences of economic growth and
improved prosperity on health and well-being is constrained by the
limited information available. Thus, while the case for improved
nutrition, particularly during childhood, seems clear, the role of
other factors, such as better nurturing of children, the environments
in which individuals live and work, and other socioeconomic factors-,
cannot be readily determined. More recent studies have begun to show
the roles of these other factors.


The strong and pervasive relationship between an individual's place in
the social structure of society and his health status is striking.
Kitagawa and Hauser showed compelling evidence of different rates of
mortality according to socioeconomic class in the United States
between 1930 and 1960.^30 For several major causes of death, the rates
were highest for the lower social classes. Even though the mortality
rates in the United States have continued to decline, the social
gradient in health, as measured by levels of income and education, is
still present and the differences in mortality rates have widened.^31
This suggests that the widening in mortality rates is related to
changing socioeconomic circumstances, such as increasing inequalities
in income, education, and housing, a falling standard of living for a
large segment of the US population, and limited access to health care
for the poor and least educated.
Although life expectancy has improved for all social classes in the
United Kingdom for the last sixty years, the gradient in social class
mortality has been widening.^32 In contrast, in Scandinavian countries
the gradient in health has not widened and life expectancy has
increased for all social classes.^33 It has recently been reported
that the mortality rate for the lowest social class in Sweden is less
than that for the top social class in the United Kingdom.^34
One of the best studies of the relation between socioeconomic factors
and the health of the middle class is the Whitehall civil service
study. This longitudinal study provides direct measures of the health
of individuals against their position in a well-defined job
hierarchy.^35 A striking finding from this study is the clear social
gradient in health. As in larger population studies,^36 among those
lower in the hierarchy there was found to be a higher risk of death
from coronary heart disease, strokes, cancer, gastrointestinal
disease, accidents, and suicides. The Whitehall study reported that
the risk of dying of a heart attack for those in the bottom tier was
more than 2.5 times that of the top tier. Marmot has shown that
adjusting for conventional risk factors, such as cholesterol, blood
pressure, and smoking, accounts for about 25 percent of the civil
service social gradient in coronary heart disease. The remainder of
the risk is related to factors in the social environments in which
those in the civil service live and work. What in the social
environment influences our vulnerability to a wide range of diseases
and has an effect equal to or greater than more conventional risk
factors? Since the civil service is largely a middle-class population,
the "something" that influences health is not affecting some
underprivileged minority, but is affecting a larger population.
There are many beneficial medical interventions available today for
sick or injured individuals. There are also a number of interventions
of questionable benefit. In the Whitehall study, it was concluded that
differences in medical care could not account for the three-fold
differences in mortality among civil servants.^37 The Whitehall study
also shows that life-style (e.g., smoking) is strongly influenced by
an individual's position in the social hierarchy. The study also
reinforced a key conclusion from the historical analysis: the mean
height of the civil servants, in each job classification, correlates
with position in the job hierarchy, sickness-absence rate, and risk of
An individual's sense of achievement, self-esteem, and control over
his or her work and life appears to affect health and well- being.
Studies in Sweden have shown that individuals in high demand jobs who
see themselves as having little control over their work have a much
higher incidence of coronary heart disease than do people in similar
jobs who believe they have control.^39 Similarly, the Whitehall study
found that a high proportion of people in the lower tiers of the civil
service feel they have less control of their work than do individuals
in the top tiers of the civil service.^40
How competence and coping skills relate to vulnerability to disease
may be explained by improved understanding of the links between the
brain and the endocrine pathways and the immune system.^41 We now
understand some of the biological pathways through which individuals,
coping with the demands of the environment in which they live and
work, can influence the host defense system and disease expression.
One set of animal experiments found that a friendly, supportive
environment influences the process of diet-induced atherosclerosis. In
these studies, two groups of rabbits were fed a cholesterol-rich diet.
Those that were treated kindly (i.e., had music played to them) had 60
percent fewer incidences of atherosclerosis than those given the usual
laboratory treatment.^42 Another research group working with monkeys
found that an unstable social environment can accelerate coronary
artery atherosclerosis, and that animals in the Same colony, fed the
same high cholesterol diets, show very different degrees of coronary
artery occlusion depending upon their position in the hierarchy of the
Emerging evidence from fields such as psychology and the neuro-
sciences points to how nurturing or stimulation influence brain
development, particularly when it is most plastic.^44 The
modifications and connections that are formed among the billions of
cells in the cerebral cortex occur very rapidly during the first few
months of life and continue throughout childhood. The development of
the brain is strongly influenced by the quality of the nourishment and
nurturance given to infants and children. The stimuli affect not only
the number of brain cells in the cortex and the number of connections
among them, but also the way the nerve cells are "wired." The stages
in the development of the brain appear to be linked so that events
early in life affect the development and function of the brain at
later stages. In addition, in adverse environments activated stress
hormones can have a negative effect on brain development and can
damage neurons, leading to permanent defects in memory and
learning.^45 Studies have suggested that children who were better
nurtured in early life are healthier and do better in adult life.^46
There is evidence from studies in animals ranging from rats to
nonhuman primates that show that this relationship exists.^47
This new understanding of the mind-body influence on disease
expression also has relevance to some of the earlier observations.
Could the post-1900 improvement in infant mortality in Britain^48 have
been due, in part, to the link between breast-feeding and immune
system responses, including the mother's early response to antigens in
the infant's saliva? A mother, who is in circumstances that she has
difficulty coping with and whose mind-body dynamics are suppressing
her immune capability, may not be adequately building the defenses of
the child she is feeding.
McKeown observed the steady decline throughout the nineteenth and
twentieth centuries in mortality from tuberculosis, a disease which
affects primarily children and young adults.^49 We know that
tuberculosis is influenced not only by family age, structure, and
crowding but also by host response capability, which may well be
affected by the social environment as well as adequacy of nutrition.
Thus, it may be that the increased prosperity and control people had
over their lives after the Industrial Revolution, accompanied by
improved nutrition, increased the population's host defense
capabilities and this inhibited expression of the disease. The
relationship among the nervous system, the endocrine system, and the
immune system is emerging as a pathway that can help our understanding
of the changes in health which are associated with changing social and
economic conditions.
People's positions in the hierarchy of a society, the degree of
control they enjoy, and the adequacy of their diet appear to be
important factors in determining vulnerability to a wide range of
diseases. The relationship between the quality of nurturing and
adequacy of nutrition in early childhood and health risks in adult
life has implications not only for health policies but for policies
concerning the competence and coping skills of the population (human
capital). This is a key factor in determining economic growth. We need
to better understand how economic forces influence the quality of
social environments and human development. Countries with major
improvements in health status and less in- equality in health tend to
be countries that are prosperous and have a high degree of social and
income equity, and a small proportion of children living in poor
social environments. Are societies that are more coherent or
communitarian in character likely to provide better environments for
health than are extremely individualistic, fragmented societies? How
does economic growth and prosperity determine the quality of social


In a recent essay on economic growth, The Economist said: "true
enough, economists are interested in economic growth. The trouble is
that, even by their standards, they have been terribly ignorant about
it. The depth of that ignorance has long been their best kept
secret."^50 A key issue has been the inability of the theoretical
frame- work of neoclassical economics to cope with the role of
technological innovation as an endogenous force in economic growth.
The new framework of understanding of the determinants of economic
growth, that embraces the role of technological innovation,^51 makes
it important to understand better the relationships between
technological innovation, economic growth, and the effects of these
changes on society.
In his analysis of the improvements in the health of populations since
the Industrial Revolution, Fogel points out that technological
innovation can be a mixed blessing for populations that have to live
through the associated socioeconomic changes^52 For example, there
have been periods of technological change and vigorous economic growth
which produced limited, if any, improvements in the health status of
the populations.^53 As Sen has pointed out, how societies create and
distribute their wealth determines the health and well-being of the
population.^54 In periods of profound technological change, with
associated changes in wealth creation and distribution, individuals,
particularly the young, will be at risk.
Changes since World War II in Eastern Europe and Japan illustrate this
relationship. The decline in the economies of Eastern Europe has been
associated with a decline in the health status of the populations
while the improved prosperity of Japan has been associated with a
marked improvement in health status. In a recent analysis for the
World Bank on the decline in health status in Eastern Europe, Hertzman
concluded that, in addition to the deterioration in the physical
environment, a strong factor seems to be the deterioration in the
quality of the social environment in which families live and work.^55
In contrast, the extraordinary improvement in the health of the
Japanese^56 is associated with enhanced prosperity and what appears to
have been a remarkable ability to sustain the quality of social
environments and reasonable income equity throughout the society.
Wilkinson has found in his analysis of a number of Western countries
that life expectancy is correlated with the degree of in- come equity
in the society.^57 A recent study of Northern England showed a
widening inequality in health that was linked to increasing income
inequality.^58 How societies create and distribute the resources
necessary to sustain their populations is a fundamental question. Adam
Smith concluded that there were sectors of the economy that produced
the wealth that made other activities in society possible. Smith
described these sectors in his chapter entitled "Of the Accumulation
of Capital, or of Productive and Un-Productive Labour:"
The labour of some of the most respectable orders in the society is,
like that of menial servants, unproductive of any value, and does not
fix or realise itself in any permanent subject, or vendible commodity,
which endures after that labour is past, and for which an equal
quantity of labour could afterwards be procured. The sovereign, for
example, with all the officers both of justice and war who serve under
him, the whole army and navy, are unproductive labourers. They are the
servants of the public, and are maintained by a part of the annual
produce of the industry of other people. Their service, how
honourable, how useful, or how necessary soever, produces nothing for
which an equal quantity of service can afterwards be procured. The
protection, security and defence of the commonwealth, the effect of
their labour this year will not purchase its protection, security, and
defence for the year to come. In the same class must be ranked, some
both of the gravest and most important, and some of the most frivolous
professions: churchmen, lawyers, physicians, men of letters of all
kinds, players, buffoons, musicians, opera-singers, opera-dancers
The new understanding of the factors determining economic growth has
implications for Smith's splitting of the economy into productive and
nonproductive labor. Since both sectors are important to a society,
the productive labor section can be considered the primary
wealth-creating sector (the engine of economic growth) and the other
sector, the secondary wealth-creating component (the quality of the
environment in which we live and work). When the primary
wealth-creating sector falters, the income that flows to the secondary
sector decreases, with associated changes in our social environment
that can reduce our quality of life. The old economic theory tended to
treat all outputs in the economy as being equal in wealth creation.
The new concept clearly brings out the importance of a better
understanding of a healthy primary wealth-creating sector and the
synergy between this sector and the secondary wealth- creating sector.
Many activities in the secondary sector, like some aspects of
education, health care, and the support of children, are key parts of
the infrastructure for all innovative economies.
Britain is regarded by many as a nation that has failed to make
investments during this century in new technologies on the scale
necessary to maintain its wealth-creating capacity, and its economy
has fallen behind those of other developed countries.^60 An
interesting question is how many of the inequalities in health in the
United Kingdom, particularly in the regions of major economic
decline,^61 are products of the failure to invest in the key
technological innovations that determine economic growth?
Krugman makes the point that the United States has two major problems:
slow growth in productivity and rising poverty.^62 To increase the
nation's wealth through enhanced productivity, ideas, and innovation
is key. To help control expenditures, he points out, it is necessary
to make the nation's health-care system more cost- effective. In a
sense, we are back to the debate in the "Black Report" concerning the
need to allocate resources wisely in the secondary wealth-creating
sector of our economies. In Canada this debate has become part of the
policy considerations concerned with health in the provincial
governments.^63 In Manitoba, the new Centre for Health Policy and
Evaluation has shown from its analysis of the records of their
health-care system^64 (a proxy for the health status of the
population) that there is a clear gradient in health against measures
of social deprivation. It is not lack of access to health care that is
setting this gradient but the underlying social economic factors
(unemployment, income, and education) as in Marmot's study of the
Whitehall civil service. As might be expected, the most deprived part
of the population places the greatest demands on the health-care
system. Manitoba is trying to confront the need for reallocation of
resources, from the least appropriate health-care expenditures to the
social needs of the population in greatest difficulty, particularly
children in poverty. As Sen has pointed out, it is not the level of
wealth a country has that improves the health of the population, but
its commitment to allocate resources to key sectors, such as mothers
and children, education, and adequate nutrition.^65
Canada, for the past twenty years, has not been creating sufficient
wealth to sustain its consumption in the public and private sectors.
Consequently, it has borrowed to maintain its standard of living,
leading to the largest external debt per capita (private and public
sector) in the developed world.^66 Canada faces the challenge of
trying to sustain its social systems, including health care, social
support, and education with diminished resources while simultaneously
trying to rebuild the economy.
To sustain quality social environments with diminished resources is a
difficult task. It is possible that societies with high-quality social
capital will be better able to adjust than will fragmented
individualistic societies. Societies that have a strong, coherent
sense of what is important, and a collective will, will probably be
most successful. Putnam's description of what constitutes "civic
societies" appears to be important in this regard.^67
It is time to integrate our understanding of the determinants of
health and the determinants of economic growth. Governments and their
societies are mistaken to concentrate on the economics of business
cycles rather than the long-term forces affecting economic growth,
prosperity, and health and well-being. Fogel has concluded that 50
percent of the economic growth in Britain since the Indus- trial
Revolution has been due to better nutrition of the population.^68 A
society that handicaps large segments of its population during periods
of major technological change may be handicapping its future economic
growth. We now have a better understanding of the relationships among
economic growth, prosperity, and health and well-being, and the need
for a long-term, integrated perspective on the determinants of health
and economic growth. Can we make intelligent and wise use of this


1 William Beveridge, Social Insurance and Allied Services (New York:
Macmillan, 1942).
2 Great Britain Royal Commission on the National Health Service,
"Report of the Royal Commission on the National Health Service (The
Merrison Report)" (London: HMSO, 1979).
3. Douglas J. Black, Cyril Smith, and Peter Townsend, Inequalities in
Health: The Black Report (New York: Penguin Books, 1982). Since the
contribution of socio- economic factors was not a thesis the Thatcher
government wished to have widely publicized, the government only
allowed 260 copies of the report to be published. It was subsequently
published by Penguin Books under the title Inequalities in Health.
4. Ibid.
5. Margaret Whitehead, The Health Divide (London: Health Education
Council, 1987).
6. Ester Boserup, Population and Technological Change (Chicago, Ill.:
The University of Chicago Press, 1981).
7. Lisa Berkman and S. Leonard Syme, "Social Networks, Host
Resistance, and Mortality: A Nine-Year Follow-up Study of Alameda
County Residents," American Journal of Epidemiology 109 (2) ( 1979):
186 -204.
8. Robert W. Fogel, "The Conquest of High Mortality and Hunger in
Europe and America: Timing and Mechanisms," in David Landes, Patrice
Higgonet, and Henry Rosovsky, eds., Favorites of Fortune: Technology,
Growth and Economic Development Since the Industrial Revolution
(Cambridge, Mass.: Harvard University Press, 1991 ).
9. Robert W. Fogel, "Nutrition and the Decline in Mortality since
1700: Some Preliminary Findings in Long-Term Factors in American
Economic Growth," in Stanley L. Engerman and Robert E. Gallman, eds.,
Conference on Research in Income and Wealth, vol. 41 (Chicago, II1.:
University of Chicago Press, 1986).
10. The quality of early childhood nutrition can set health risks in
adult life. See David J.P. Barker, Fetal and Infant Origins of Adult
Diseases (London: BMJ, 1992).
11. Nathan Rosenberg and L. E. Birdzell, How the West Grew Rich (New
York: Basic Books, Inc., 1986).
12. The United Nations, The Determinants and Consequences of
Population Trends, Population Studies no. 17 (New York: United Nations
Publication, 1953).
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38. Ibid.
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47. Ibid. Stephen J. Soumi, "Adolescent Depression and Depressive
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48. McKeown, The Modern Rise of Population.
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52. Fogel, "The Conquest of High Mortality and Hunger in Europe and
America: Timing and Mechanisms."
53. Ibid.
54. Amartya Sen, "The Economics of Life and Death," Scientific
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55. Clyde Hertzman and Wendy Ayers, "Environment and Health in Central
and Eastern Europe," Report for the World Bank, No. 12270-ECA, 1993.
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Living Longer?" BMJ 299 (1989): 1547-51.
57. Richard G. Wilkinson, "Divided We Fall," BMJ 308 (1994): 1113;
Richard G. Wilkinson, "National Mortality Rates: The lmpact of
Inequality?," American Journal of Public Health 82 (1992): 1082.
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Alfred A. Knopf, lnc., 1910).
60. Bernard Elbaum and William Laxonick, eds., The Decline o[tbe
British Economy (Oxford: Oxford University Press, 1986). Ralf
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61. Michael Eames, Yoav Ben-Shlomo, and Michael G. Marmot, "Social
Deprivation and Premature Mortality: Regional Comparison Across
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62. Paul Krugman, Peddling Prosperity, Economic Sense and Nonsense in
the Age of Diminished Expectations (New York: W. W. Norton & Company,
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63. Nurturing Health: A Framework on the Determinants of Health"
(Toronto: Premier's Council on Health Strategy, Government of Ontario,
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65. Sen, "The Economics of Life and Death."
66. Peter J. Nicholson, "Competitiveness and the Canadian Economy"
(Toronto: The Canadian Institute for Advanced Research, 1992).
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68. Fogel, "The Conquest of High Mortality and Hunger in Europe and
America: Timing and Mechanisms."
John W. Frank is Director of Research at the Institute for Work and
Health, Toronto, and a Fellow of The Canadian Institute for Advanced
Research's Population Health Program at the University of Toronto.
]. Fraser Mustard is President of The Canadian Institute for Advanced
Research, Toronto, Canada.

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