Patrick Vaughan

London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England



Health, civilization and the state: a history of public health from ancient to modern times


by Dorothy Porter. Published by Routledge, London and New York,
ISBN 0-415-20036-9, 1999, 376 pages, price £50 hardback, £16.99 paperback


This academic and well-referenced book is a masterly overview of the historical context and development of public health. It focuses mainly on the provision and organization of health services from ancient times to the 21st century, placing public health within its political, social and economic context. Few books have been written with such breadth. The author is a well-known academic in the history of medicine, who received Wellcome Foundation support to complete this work. There is an excellent index.

The book, which focuses mainly on Europe and North America, is divided into four parts. The first summarizes the period from ancient times to the 18th century, showing how protecting the health of powerful elites has always been closely linked to the existing state and power structures. For instance, On airs, waters and places, by Hippocrates, was largely for itinerant Greek physicians, to help them advise the wealthy on how to choose a healthy place to live in and where to found new city states.

The more substantial second and third parts are the most interesting. Part Two examines the first instances of better health being upheld as a human right following the French Revolution, and describes how the emerging social sciences were applied to explaining and controlling patterns of disease. The newly formed and more centralized national European states in the 19th century became the enforcers of public health laws and regulations, and the rise of a national public health service in Victorian Britain extended this state control to local government. Interestingly, the USA favoured a less bureaucratic model, in which social reforms were guided by Puritan moral codes linking social cleanliness to godliness. Part Three describes how the collection of population statistics was centralized as recognition grew of the state’s responsibility for the health of its citizens. This was followed by the rise of the classical European welfare state from the early part of the 20th century. Modern European public health developed from its association with governments, while preventive medicine began in the USA, reflecting different perceptions of the respective roles of the individual and the state in maintaining health, and different political models of welfare.

Part Four, a weaker section, shows how more recently individuals have been given greater responsibility for protecting their own health and how this is linked to modern concepts of health promotion. The epilogue is disappointing, as the future policy implications arising from this strong historical analysis are not made explicit. Another disappointment is the absence of diagrams or figures, which would have enlivened a dense text. However, I strongly recommend this book to anyone who wants to understand the provision of public health within the perspective of history and political economy.

World Health Organization Genebra - Genebra - Switzerland