Health, wealth and medical science
University of York – by Sue Bowden
A global study of health in the 20th century is an ongoing research project based in the Centre for Historical Economics and Related Research at the University of York, involving colleagues based in York, elsewhere in the UK and overseas. The team includes economic historians, econometricians, health economists and development economists. The emphasis is on the interplay between the economy (what could be achieved given levels of growth and development) and medical science (what could be achieved in terms of prevention and cure given existing states of medical knowledge). By health we mean morbidity and mortality in the context of current medical knowledge and hence what was avoidable illness and death.
We have explored child illness and mortality in the UK during the depressed economic circumstances of the interwar years. Taking a cross-section approach that enabled researchers to explore child health in different parts of the country that experienced varying degrees of economic depression, this work found that improvements in living conditions and in medical provision reduced the risk of child mortality, but that variations in socioeconomic living conditions, medical provision, unemployment among males and female employment explained differences in the risks of mortality.
The team has conducted research on two global health issues in the postwar period: malaria and tuberculosis, which independently and together were the major causes of illness and death in many parts of the world between 1950 and 1980. As such, we have explored the relationship between the escape from poverty and prevailing levels of disease through a study of the economic significance of malaria eradication in the first half of the 20th century in Greece, Italy, Portugal and Spain. The findings emphasise the adverse effects of civil and international war on human capital accumulation in relation to disease eradication, and in particular the implications of unrest for the institutional and infrastructural frameworks necessary to eliminate disease. This work found evidence to support the thesis that the malaria eradication campaigns may have led to improved agricultural productivity, as a result of the associated land reclamation and agricultural expansion.
We have worked intensively on respiratory tuberculosis on a global basis between 1950 and 1980 – a discrete period of time when, in theory, medical science delivered in terms of prevention and cure and before drug-resistant tuberculosis emerged (largely a result of its interface with HIV/AIDS). To do this we have created new datasets that improve on those currently available, in terms of updated global information on morbidity, mortality and fatality. Using our new datasets we found that despite the advances of medical science, not only did respiratory tuberculosis remain a major cause of morbidity and mortality in many parts of the world but also there were significant differences across countries in the extent to which the potential promised by the advances of medical science were realised. To the extent that drugs existed that could cure the disease, deaths from respiratory tuberculosis between 1950 and 1980 were in theory avoidable. We believe that the history of tuberculosis provides important lessons about the fight against epidemic diseases in general, and offers valuable policy implications for the current tuberculosis epidemic in many low-income countries.
The research on respiratory tuberculosis morbidity and mortality in Europe in the postwar period demonstrated the fight against respiratory tuberculosis was won as a result of improvements in living standards related to economic growth, as well as owing to the provision of medical care and the development of public health systems. Using our new datasets, we found that by 1970 Europe could be divided into three groups of countries: those where the risks of dying once diagnosis was confirmed remained high (Spain, Italy, Austria, Hungary), those where the risk of fatality was low (England and Wales, Finland, Poland, the Netherlands, Iceland, Yugoslavia, Norway) and an intermediate group (East Germany, Northern Ireland, Romania, Sweden, Portugal, Denmark, Luxembourg). The research found that success in the fight against respiratory tuberculosis was a function of medical advance and of an institutional framework in which the pioneering advances of medical science in both prevention and treatment could be applied.
More recently, we have been examining morbidity, mortality and fatality from respiratory tuberculosis on a global basis between 1950 and 1980. Again, new datasets have been created to this end. We have found a tripartite divide in terms of all three dimensions of the health problem: significant gains in high-income countries, a growing problem in newly industrialising countries and a signal lack of improvement in many low- income countries, notably in Africa. We further explored the potential offered by medical science in these decades and considered how and why the interventions science and medicine made possible for identification, prevention and cure, while being highly effective and viable in developed- economy environments, were constrained in low-income countries given the costs of implementing these interventions, in terms of transport, storage and the existence of trained personnel. We further found that where resources were limited, and the health problem was infinite, the costs of identifying, preventing and curing tuberculosis were not possible for many developing economies in this period. We are currently pursuing two issues: the effects of urbanisation, migration and overcrowding on the risks of infection and the relationship between nutrition on the development of active symptoms of the disease, again on a global basis. Bringing our work up to the present, we are exploring the relationship between objective and subjective health measures and the social determinants of health. The purpose of this is to discover those variables that are important for objective health status and those that are important for subjective health status. The data we have collected are also providing us with an opportunity to measure the relationship between subjective and objective health evaluations for a given set of individuals across countries in the present day.
Sue Bowden is Director of the Centre for Historical Economics and Related Research at the University of York.