IJE Advance Access originally published online on June 5, 2007
International Journal of Epidemiology 2007 36(3):491-492; doi:10.1093/ije/dym076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Commentary: Samuel Preston's ‘The changing relation between mortality and level of economic development’
University of Rochester Medical Center, Rochester, NY 14642, USA.
E-mail: stephen_kunitz{at}urmc.rochester.edu
Accepted 10 April 2006
Professor Preston's article1 is rightly regarded as an important contribution to the debate about the role of economic development and health services (broadly defined) in the decline of mortality. Like so much of his other work, it combines imaginative and innovative use of data with methodological rigour, in this case to argue the point that public and personal health interventions have had a measurable impact upon mortality over and above what would have been expected from economic expansion alone. In addition to this main point, however, the article touches on several related issues that are also of continuing importance: the association between income inequality and mortality, and the diffusion of innovations. I shall discuss the latter briefly, leaving for others a consideration of the former, but first I should like to consider the influence this article has, or hasn't, had.
Shortly after Professor Preston's article appeared, Thomas McKeown's two influential books that argued the other side were published.2,3 In them, he elaborated on the argument he had made in earlier articles, and against which Professor Preston had argued: that the modern rise of population had virtually nothing to do with personal or public health services and almost everything to do with economic growth and a rising standard of living. Despite what I think are persuasive arguments, Professor Preston's article and the book in which the same material appeared4 have been less widely known, and I believe less influential in respect of policy, than Professor McKeown's have been. For instance, a search of the Science Citation Index in early 2006 indicates that the article had been cited 131 times and book slightly more than 300. This does not indicate neglect by any means, but it is substantially less than the citations of Professor McKeown's two books: 489 (The Modern Rise of Population) and 466 (The Role of Medicine). And this doesn't include all of Professor McKeown's other articles on the same or similar topics. It was not the elegance of the analyses that account for the difference. If that had been the case, the numbers would certainly have been reversed. It was, rather, the audience and changing views of the importance of personal and public health services that account for it.
It is useful to distinguish between health policy in economically advanced nations such as the UK and the USA and international health policy with regard to poor countries. Professor McKeown's work struck a responsive chord in the UK and the USA in the 1970s and perhaps even more so in the 1980s for at least two reasons. First, among many influential policy-makers, it was understood to provide a historically informed rationale for reducing access to services at a time when health care costs were increasing rapidly and when both governments were backing away from commitments to the provision of services. For if health care had not had any impact in the distant or even recent past, why should large amounts be spent on it in the present? This was clearly an oversimplification of Professor McKeown's views, but that is another matter that I cannot deal with here.5 Second, on the political left Professor McKeown's argument also struck a responsive chord because it served to discredit a dominant profession. In contrast, Professor Preston's argument, which made a case for the measurably beneficial consequences of health services (public but also personal), did not lend itself to the same kind of policies, for if taken seriously, it would have justified increasing expenditures, or at least not reductions in services.
Health policy in poor countries in the late 1970s was moving in a very different direction, as the Declaration of Alma Ata demonstrates.6 The conferees at Alma Ata defined primary health care (including public health) as but one component of community development, and in that context Professor McKeown's work also struck a responsive chord because it gave pride of place to development. On the other hand, Professor Preston's work could have been understood to justify technical interventions that were separate from economic and community development.
In the event, the 1980s saw the redefinition of primary health care to selective primary health care,7 which ultimately came to mean that governments should provide only a limited range of services for poor children and people of working age, and user fees should be charged for what were considered discretionary services, as the World Bank's 1993 World Development Report advocated.8 In this new climate, Professor McKeown's advocacy of economic expansion as the underlying cause of better health was regarded as impossibly expensive for international lending agencies to support.9 The position that Professor Preston's article supported would also not have been especially attractive, for it could have been understood to justify very broad-based and potentially expensive interventions that would benefit entire populations. These observations are of course speculative, but they are consistent with the development of health policy as I understand it, and I believe they continue to be accurate.10
There are two additional points I should like to make. The first is that, like Professor McKeown's argument, Professor Preston's relies heavily on the position taken by Sherlock Holmes, who Professor McKeown cited in defence of his method: once several competing explanations have been shown to be impossible, then the improbable must be true. This is not an entirely satisfying sort of argument and would be considerably strengthened if evidence of a strong association between health care interventions and national levels of life expectancy could have been shown to be associated temporally.
The second is that Professor Preston invoked a set of universally shared values to account for the diffusion of health-promoting technologies among countries. This is at best short-hand for what I think Professor Preston would agree is a far more complex phenomenon. The diffusion of innovations has been studied in great detail at the individual level of analysis, and much is known about it.11 Less is understood about the diffusion process as it operates among institutions and countries. But surely he is correct that in the 19th century a variety of important innovations spread among European nations at very different levels of economic development. These included not only systems for the delivery of clean water and the disposal of sewage,12,13 but legal changes having to do with quarantine14 as well as with health insurance.15 But the spread of these institutional and technological innovations involved political processes in the 19th century, as they do today and as my discussion of health policy was meant to suggest. That they also involve universally shared values is not so obvious. If they did, in the United States there would be a universal entitlement to health care.
Despite this caveat, it should be clear that Professor Preston's article is a rich one. While it does not slight the importance of economic development for the improvement of the health of populations, it provides support for the importance of social interventions. Sadly, the policy implications have not been acted upon as thoroughly as one might have wished.
 |
References |
|---|
 Top References |
|---|
1 Preston S. The changing relation between mortality and economic development. Pop Stud (1975) 29:231–48. Reprinted Int J Epidemiol.2007;36:484–490.[CrossRef]
2 McKeown T. The Modern Rise of Population (1976) New York: Academic Press.
3 McKeown T. The Role of Medicine (1976) London: Nuffielde Provincial Hospitals Trust.
4 Preston S. Mortality Patterns in National Populations (1976) New York: Academic Press.
5 Kunitz SJ. The personal physician and the decline of mortality. In: The Decline of Mortality in Europe—Schofield R, Reher D, Bideau A, eds. (1991) Oxford: Oxford University Press.
6 World Health Organization (WHO)-United Nations Children's Fund (UNICEF). Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. (1978) Geneva: World Health Organization.
7 Walsh JA, Warren KS. Selective primary health care. New Engl J Med (1979) 301:967–74.[Abstract]
8 World Bank. World Development Report 1993: Investing in Health (1993) New York: Oxford University Press.
9 Halstead SB, Walsh JA, Warren KS, eds. Good Health at Low Cost (1985) New York: The Rockefeller Foundation.
10 Kunitz SJ. The Health of Populations: General Theories, & Particular Realities (2006) New York: Oxford University Press. Chapter 6.
11 Rogers EM. The Diffusion of Innovations (2003) 5th. New York: The Free Press.
12 Vogele J. Urban Mortality Change in England and Germany, 1870–1913 (1998) Liverpool: Liverpool University Press.
13 Brown JC. Coping with crisis? The diffusion of waterworks in late nineteenth-century German towns. J Econ Hist (1988) 48(2):307–18.[ISI]
14 Baldwin P. Contagion and the State in Europe, 1830–1930 (1999) Cambridge: Cambridge University Press.
15 Dawson WH. Social Insurance in Germany, 1883–1911: Its History, Operation, Results (1912) London: T. Fisher Unwin. reprinted in 1979.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  T. Blakely, M. Tobias, and J. Atkinson Inequalities in mortality during and after restructuring of the New Zealand economy: repeated cohort studies BMJ, February 16, 2008; 336(7640): 371 - 375. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||