## Stephen J. Kunitz

Print publication date: 2006

Print ISBN-13: 9780195308075

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780195308075.001.0001

# The Standard of Living

Chapter:
(p. 45 ) 3 The Standard of Living
Source:
The Health of Populations
Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780195308075.003.03

# Abstract and Keywords

This chapter addresses explanations that have been offered for the decline of mortality in both the 19th and 20th centuries, and makes the argument that while it would be foolish to reject the importance of a rising standard of living, too often the role of purposeful intervention has been denigrated. The first explanation attributes the improvement to a rising standard of living due to economic expansion, generally understood to mean industrial development and improved agricultural productivity. The second explains the decline as the result of purposeful human agency: the application of a variety of public health interventions to the problems of water, food, and airborne infectious diseases. A third less-common explanation invokes the biological selection and adaptation of human hosts and/or microorganisms.

I wander thro’ each dirty street,

Near where the dirty Thames does flow,

And mark in every face I meet

Marks of weakness, marks of woe.

In every cry of every man,

In every infant’s cry of fear,

In every voice, in every ban,

The mind forg’d manacles I hear.

—W. Blake, London 1

This chapter addresses explanations that have been offered for the decline of mortality in both the nineteenth and twentieth centuries and makes the argument that while it would be foolish to reject the importance of a rising standard of living, too often the role of purposeful intervention has been denigrated. The two are not necessarily incompatible of course. The first attributes the improvement to a rising standard of living due to economic expansion, generally understood to mean industrial development and improved agricultural productivity. This translated into higher wages, improved nutrition, and better housing, and thus better health as measured by declining mortality. The second explains the decline as the result of purposeful human agency: the application of a variety of public health interventions to the problems of water, food, and airborne infectious diseases. A third less-common explanation invokes the biological selection and adaptation of human hosts and/or microorganisms. The first two explanations are manifestations of the optimistic and pessimistic sides of the standard-of-living debate.

# The Standard of Living and the Decline of Mortality in England in the Eighteenth and Nineteenth Centuries

Thomas McKeown had argued that it was improved nutrition, the result of rising living standards, that primarily explained the decline of mortality in the late eighteenth and nineteenth centuries. 2 Economic and demographic historians found his work important because it addressed the standard-of-living (p. 46 ) debate and gave support to the optimists. 3 McKeown argued that nutrition was the only possible explanation of most of the mortality decline after he had eliminated, to his satisfaction, other possibilities. This was in a sense a negative argument. Economic historians approached the problem more positively, by using adult height as a measure of nutritional status over the life course. Height was first used as a proxy for income, the usual measure of the standard of living, in populations such as slaves for whom there were no income data. Subsequently it has been used as a measure of the standard of living in populations for which estimates of real income were more or less uncertain.

Height has the advantage of being an output—a reflection of the standard of living—rather than simply an input as income is. This is indeed an advantage, but it is also a disadvantage. For height is responsive to both nutritional intake as well as to the so-called claims on nutrition. Thus, the growth of infants and children exposed to frequent bouts of gastroenteritis and respiratory diseases may falter and, depending upon subsequent nutrition and disease experience, the lost growth may or may not be made up subsequently. Height is therefore not simply a reflection of food availability but of the disease experience of infants and children and their ability to absorb nutrients, and this is often a reflection of the cleanliness and crowding of their environment.

Of course, the ability to withstand diarrhea and pneumonia in infancy and early childhood is also a result of, among other things, the child’s nutritional status. Thus, as has often been observed, malnutrition and disease in infancy are synergistic and their association often hard to disentangle. For this reason, height does not allow one to distinguish as clearly as might be wished between nutritional status as a reflection of the standard of living and the sanitary environment of the population.

Even recognizing these problems, height and subsequently weight have proven to be interesting and useful complements to other measures of well-being. 4 Summarizing much of the research through the early 1990s, Robert Fogel wrote that:

The available anthropometric data tend to confirm the basic results of the analysis based on energy cost accounting: chronic malnutrition was widespread in Europe during the eighteenth and nineteenth centuries. Furthermore, such malnutrition seems to have been responsible for much of the very high mortality rates during this period. Moreover, nearly all the decline in mortality rates in England and France between 1750 and 1875 appears to be explained by the marked improvement in anthropometric measures of malnutrition. 5

He went on to say:

[I]n the U.S. case reductions in exposure to disease were probably more important than improvements in the diet, accounting for perhaps half the nutritional effect on mortality. Applied to the European case, this proportion would imply that improvements in the diet (p. 47 ) per se may have accounted for 35 to 45 percent of the mortality decline before 1875 but only for about 25 to 30 percent of the mortality decline after 1875. 6

A large study of height and health in the United Kingdom by Roderick Floud, Kenneth Wachter, and Annabel Gregory 7 is particularly useful because

Figure 3-1. Life expectancy and male height, England, mid-eighteenth to early twentieth centuries. (Data from R. Floud, K. Wachter, and A. Gregory, Height, Health and History: Nutritional Status in the United Kingdom, 1750–1980. Cambridge: Cambridge University Press, 1990; E.A. Wrigley, R.S. Davies, J.E. Oeppen, and R.S. Schofield, English Population from Family Reconstitution. Cambridge: Cambridge University Press, 1997; and Human Mortality Database. University of California, Berkeley [USA], and Max Planck Institute for Demographic Research [Germany], available at www.mortality.org.)

(p. 48 )

Figure 3-2. Life expectancy regressed on male height (in cm), England, 1741–1801, 1806–1846, 1851–1881.

it deals with the same place and most of the same period as McKeown did and clearly attempts to assess the impact of social change on nutrition. According to their data, which are displayed in Figure 3-1 , the height of men fluctuated but generally increased from the 1740s to the 1760s; decreased from the 1760s to the 1790s; increased from the 1790s to the early 1800s; stagnated from 1806 to 1821; declined to the mid-1840s; and fluctuated but generally increased until the early 1880s, when the series ends. Other studies show a continuing increase from the late nineteenth century through the twentieth century. 8

We may compare the height data with life expectancy at birth in the same years. 9 The results also appear in Figure 3-1 . Life expectancy fluctuated but generally increased from the 1740s to the 1820s, although the amplitude of the fluctuations diminished. Thereafter, life expectancy declined from the 1830s through the 1850s and then began a rapid increase, with only a small reversal in the late 1870s and 1880s. 10 It is striking that there appears to be no consistent relationship between height and life expectancy over the 160 years.

Figure 3-2 displays the association between life expectancy and height for three periods: 1741–1801, 1806–1846, and 1851–1881. These periods were chosen to examine specifically the association between height and mortality during the early nineteenth century in the period of earliest industrialization and urbanization. None of the associations is significant, which is itself significant. For it suggests that if early childhood nutrition is truly reflected in adult stature, then there was no association between childhood nutrition and life expectancy. A potential complication of the analyses above is that the height data are for (p. 49 ) birth cohorts whereas the life expectancies are for periods. This is considered in Appendix 1 : it appears that the use of period life expectancies is not a problem.

These findings do not eliminate the importance of short stature as a risk factor for premature death. The association has been demonstrated in the twentieth century both ecologically 11 and at the individual level in prospective cohort studies. 12 Not all causes of death are related to short stature, however. Respiratory and cardiovascular diseases are more common among short people, whereas a variety of cancers are more likely among tall people. George Davey Smith and colleagues have suggested that:

Height in Britain has continued to increase through the second half of the 20th century. The causes of death that are inversely associated with height are those that tend to be decreasing, such as stroke, stomach cancer and respiratory disease mortality. The causes of death that show a positive association with height are those showing less favorable trends, such as prostate cancer, lymphoma, and colorectal cancer. The factors that underlie the secular trend of increasing height in the population may also be influencing the cause specific mortality rates. 13

This is important because it means that some chronic diseases are positively, and other negatively, associated with height. Unfortunately, this and other cohort studies were all done when infectious diseases had waned in significance. It is therefore unclear whether there are associations between height and risk of death from infectious diseases, although tuberculosis is more common in tall than short people (see Appendix 2 ). This is a problem because historical anthropometric research assumes that what is true of the impact of height on life expectancy in the late twentieth century was also true of the impact of height on life expectancy under an entirely different epidemiological regime, that is, when the spectrum of prevalent diseases was different. Indeed, the same relative risks calculated for height as it affects mortality in Norwegians in the late twentieth century and among middle-aged American Civil War veterans in the early twentieth century have been applied to American and European data from a century or more earlier. 14

It appears that in severely malnourished infants the immune response may be permanently compromised, and this may lead to increased susceptibility to infectious diseases in later life. The degree and type of early malnutrition necessary for this to occur, however, is unknown but is evidently severe. 15 Severe malnutrition in adulthood is also a risk factor for premature death, but again the malnutrition must be extreme. Furthermore, as already noted, short stature is not associated with general susceptibility to all chronic diseases. Hence, the relative risks will vary over time as certain diseases wane and others wax. For all these reasons, it is problematic to apply relative risk figures from one population to others that lived under an entirely different epidemiological regime.

This simply serves to emphasize the striking fact that the same height is associated with different life expectancies historically in the United Kingdom as well as cross nationally. 16 For example, as Figure 3-1 illustrates, men born in (p. 50 ) the 1780s and 1840s achieved the same average height, 167 cm, but life expectancy was 35 in the first period and 39 in the second. And this means both that context matters, especially the prevailing epidemiological regime, 17 and that attempts to investigate the importance of McKeown’s nutrition hypothesis provide a spurious accuracy with respect to the proportion of the mortality decline attributable to improved nutrition. The same is true when body mass index (BMI) is considered rather than height (see Appendix 3 ).

# The Public Health Contribution to Mortality Decline in England

There have been many critiques of McKeown’s work and of the nutritional hypothesis more broadly. 18 Some are driven by a wish to recapture a central role for public health in particular and purposeful human and social intervention more generally in the decline of mortality in the United Kingdom and elsewhere. It is meant to reassert the importance of both national and local government: the visible hand of human agency as contrasted with the invisible hand of the market. Among the most polemical, most articulate, and most sustained of these is Simon Szreter’s. 19

McKeown had argued that respiratory diseases, including especially pulmonary tuberculosis, were particularly important in accounting for the mortality decline in England and Wales. And as respiratory diseases had begun to decline in the mid-nineteenth century, well before any preventive measures were available, only host resistance, not decreased exposure, could be given the credit. Szreter pointed out that only tuberculosis had declined, whereas other respiratory diseases had actually increased through the second half of the nineteenth century; tuberculosis had actually begun to decline later than McKeown had said; and it wasn’t significant in the mortality decline anyway. He argued further that it was the gastroenteric diseases that had declined from 1870 on, as a result of public health measures brought about by national and especially local governments responding to an expansion of the electorate in the late 1860s to include a large number of working class men. 20 Tuberculosis then declined because its victims were less and less likely to be weakened by other diseases.

Szreter provides suggestive evidence 21 of the many ways in which government medical officers used growing epidemiological knowledge to improve the quality of water and the safety of sewers. In addition, as Anne Hardy has demonstrated, much public health was not focused on large construction projects but was instead devoted to health education, isolation of contagious cases, inspection of homes and work places, and lobbying for various pieces of public health legislation. 22 Thus, expenditures on public works are not a sufficient index of the importance of public health interventions. 23 Taken together, both make a compelling case for the substantial role that health officers played in improving especially urban health in the late nineteenth century.

Moreover, Robert Woods has shown that tuberculosis did not contribute (p. 51 ) as much to the decline of mortality between 1861–1870 and 1891–1900 as McKeown had suggested (35% instead of 44%). The largest share of the decline of mortality in that period, about 57%, was in the combined categories of typhus/diarrhea (typhus and typhoid not having been distinguished in the 1860s). 24 Thus, Woods accepts Szreter’s and Hardy’s general argument that public health interventions were far more important than McKeown had allowed. He has also shown, however, that tuberculosis was more significant than Szreter seemed to allow and that its decline was more or less the same across the country, in contrast to the gastroenteric diseases, which declined primarily in the large cities. (For a more extensive discussion of the decline of tuberculosis, see Appendix 2 .)

George Davey Smith and John Lynch have argued that conditions for children improved after 1850 as fewer entered work at young ages, food consumption and housing conditions improved, and fertility declined. 25 They claim that these improvements occurred well before the public health movement was galvanized by previously disenfranchised working men who got the vote later in the century, as Szreter has shown. These claims have, of course, not gone uncontested. 26

There is no doubt that successive cohorts of English men and women died at lower rates than those who preceded them, as Figure A-1 in Appendix 1 indicates. With the important exception of the period 1831 to 1851 and some earlier times when life expectancy declined transiently, there was a general improvement from the mid-eighteenth century right through the nineteenth century. Improvement accelerated in the second half of that century, but improvement had been going on for 100 years by that time. The deterioration that occurred in the 1830s and 1840s is important because it is a reflection at the national level of the severe living and working conditions to which the urban working class was exposed.

Szreter and Mooney have estimated life expectancy in large English cities and have shown that in the first half of the nineteenth century urban life expectancy was 6 to 7 years less than the national figure. They summarize the pattern of urban change as follows: “ [A] sharp deterioration when the decade of the 1830s is compared with the 1820s and no significant recovery in the 1840s; a substantial recovery in the 1850s but not enough to make good the losses of the previous two decades; no further improvement in the 1860s; finally, a trajectory of sustained improvement from the 1870s through the 1890s (and beyond, of course).” 27

Thus, while sustained improvement in life expectancy nationally seems to have begun in the late 1840s and 1850s, in large industrial cities, improvement began at about the same time but was less dramatic, proceeded in fits and starts, and did not become sustained until the 1870s. These data suggest that the early improvement in life expectancy may well have been the result of the changes suggested by Davey Smith and Lynch, whereas sustained improvement in large cities had to await the major public health improvements of the 1870s.

The evidence shows that life expectancy fluctuated but generally improved (p. 52 ) from the mid-eighteenth century; that there was a downward deflection in the 1830s and 1840s, corresponding with the worst excesses of industrialization and urbanization; that the early improvements do not seem to have been associated with increased height, used as a measure of the standard of living; and that the dramatic acceleration of life expectancy after 1870 is associated with improvements in public health. That height and life expectancy are not impressively correlated does not necessarily mean that the standard of living was unimportant but, rather, that height imperfectly reflects the standard of living.

These data are all from England and Wales, not simply because the best records are to be found there, but because the standard-of-living debate was originally about England’s industrial revolution. Tracing England’s population history has thus been central to any resolution. But economic expansion and improvements in life expectancy were not only an English phenomenon, and the debate looks different when placed in a broader perspective.

# Mortality and the Standard of Living in Comparative Perspective

There are models of industrial and economic expansion and their impact on health other than England’s. For example, Jorge Vogele has shown that in the period 1870 to 1913, mortality in the 10 largest cities in England and in Germany followed somewhat different paths. He writes:

In Germany, the mortality rates of the 1870s were significantly higher than in England and Wales, with respect to both urban rates and nationwide, but due to the rapid decline in German urban mortality in the following decades the ten largest towns in both countries registered similar death rates after the turn of the century. By contrast, national figures still reveal better health conditions in England and Wales when compared with Prussia. 28

There were several reasons for the more rapid decline of urban mortality in German than in English cities. One was political. England had been a leader in public health legislation and in sanitary engineering. German cities were able to rapidly adopt these innovations without the time, trouble, and expense they had cost the English. Cities had “strong financial powers, a corps of trained bureaucrats, and far-reaching police rights that enabled them to intervene in private property rights and to regulate municipal building policies.” 29 Vogele goes on to suggest that municipal electoral power in Germany was in the hands of a small minority who “very probably gained the most substantial economic benefits” from sanitary improvements. 30 Improvements may have also been made for the same reasons Bismarck developed social insurance in the early 1880s: to pull the teeth of the Social Democrats.

In contrast, there was more resistance in England. In English cities, middle-class rate payers often blocked sanitary reform to keep their taxes low (p. 53 ) until the electoral reforms of the late 1860s that increased the number of working class men who could vote. 31 Moreover, as Anne Hardy has noted, the English idea that a man’s home is his castle, dating at least from the sixteenth century, was reinforced by “the growth of a middle-class culture in the later eighteenth and early nineteenth centuries” when “the notions of liberty became involved with refinement of social distinctions and the search for privacy.” 32 She suggests that these impediments to sanitary reform began to erode in the last decades of the nineteenth century.

In addition, gastroenteric diseases were more significant than respiratory diseases in German than in English cities. These were just the conditions that were responsive to improvements in the provision of pure water and the safe disposal of sewage. The result was that even with per capita incomes well below the English, 33 and with a narrower electoral base, German cities were able to reduce their mortality rates to the same level as those in English cities of comparable size.

There were, of course, differences among German cities and states, even after unification. Cities in the less-developed eastern part of the country had higher mortality than cities in the more developed West, for instance. And some states, especially in southern Germany, were active in improving water supplies in small towns and rural areas whereas Prussia was not. Thus, Prussia had not only higher death rates from gastroenteric disease than South German states, but the death rate was inversely correlated with community size in Prussia, unlike the pattern in the South. Similarly, some states were active in promoting smallpox vaccination whereas others were not. Differential mortality was the result. 34 And Hamburg’s political and economic structure was in many ways unique, with profound consequences for its experience of the 1892 cholera epidemic. 35

Regional differences in mortality were strikingly important up until 1890. In contrast, standard socioeconomic variables (e.g., income per capita) were not especially important. By 1910 to 1925, the pattern had reversed. Region was far less important and measures such as per capita income and urbanization had become far more important. 36 This suggests that regional differences in government policies, cultures, and breast-feeding practices had diminished in response to the growing integration of the German state.

A final example comes from a comparison of Swedish and English height and mortality data. 37 Figure 3-3 displays height and life expectancy at birth from 1820 to 1965 in Sweden. Sandberg and Steckel have described these data and their socioeconomic and political context in some detail. Here only a few observations are necessary.

First, Sweden’s industrialization began about 1870, well after England’s. Unlike England, however, there was no downturn in either height or life expectancy at that time. The earlier short and severe decline was due to an increase in child mortality resulting from a relatively brief period of serious malnutrition coupled with the spread of infectious diseases. The spread of infectious diseases followed upon (a) a large amount of internal migration, and (b) the passage and implementation of legislation requiring universal primary school attendance.

Figure 3-3. Life expectancy and height of men, Sweden, 1820–1965.

Sandberg and Steckel write that the usual explanation for the increase in life expectancy during the pre-1870 period is not an increase in income, which, in fact, had stagnated. It was due rather to the introduction of the potato, to peace, and to public health measures including, but going beyond, smallpox vaccination. Among the measures that were introduced “were marked improvements in sanitation, hygiene, and child care.”

Much of this was accomplished through government propaganda in favor of breast-feeding and general improvements in sanitation. The church and, even more so, the system of compulsory schools were effectively used to spread official views on these subjects. The fact that Sweden was a highly literate country with a long tradition of (p. 55 ) bureaucratic and church control over the individual’s private life meant that these campaigns were a good deal more successful than would have been the case in countries, such as England or the United States, where much more emphasis was put on individual freedom and autonomy. 38

The period of rapid industrialization from 1870 was remarkable for the sustained increases in height and life expectancy that accompanied it. As already observed, this is all the more remarkable when compared to the experience of England during its period of industrial expansion. Part of the explanation has to do with factors already noted as important in the earlier period: improvements in public health measures, adequate nutrition, and peace. Another important factor has to do with the fact that Swedish industrial development was not accompanied by nearly the same degree of urbanization as had occurred in England. Much industrial growth took place in towns, some of them small, as well as rural areas. There was, moreover, large-scale emigration from Sweden to the United States in these years, which contributed to a reduction in poverty among those who remained.

The importance of the Swedish and German examples is that they demonstrate that England’s experience of industrial growth and the responses to it was far from universal. First, countries that industrialized later benefited by being able to import English inventions and engineers to build their urban water supplies and sewer systems. 39 Second, political culture proved important as well. Local and/or national governments in Germany and Sweden had far more police power than national and local governments in England and were able to implement public health policies with less difficulty. Thus, they accomplished dramatic reductions in mortality at income levels that were less than half those of England (Table 3-1 ). 40

The construction of protected water supplies and adequate sewage disposal systems clearly reduced exposure to enteric pathogens, but it may have had another beneficial effect as well by causing a diminution in the virulence of enteric pathogens. Paul Ewald has argued that the virulence of pathogens is shaped to a large degree by their mode of transmission. 41 A highly virulent microorganism that reduces the mobility of its host to such a degree that the host cannot transmit the pathogen to another host will soon reach a dead end.

Table 3-1 GNP per Capita (in 1985 U.S. $) Year United Kingdom Germany Sweden 1850 1943 835 871 1900 3792 1743 1895 Source: R.H. Steckel and R. Floud, eds., Health and Welfare During Industrialization. Chicago: University of Chicago Press, 1997, p. 424. (p. 56 ) Vector-borne pathogens such as malaria and yellow fever do not become less virulent because, even though the host may be immobilized, mosquito vectors are still available to transmit the pathogens. Enteric pathogens that cause diarrheal diseases may not lose virulence as long as they can be efficiently transmitted by water, by flies, by human hands, and by other means. However, when water purification systems are developed, there is no selective advantage to virulence. Indeed, the selective advantage would be towards reduced virulence so that the sick host would be less immobile and would thus be a more efficient transmitter of the pathogenic organisms. And indeed, as Ewald points out, this is precisely what happened as water systems were purified in India in the 1950s. This may be part of the explanation of the reduction of mortality due to diarrheal diseases in the 1- to 4-years age group in the second half of the nineteenth century in England. Thus, human intervention may create selective pressures toward reduced virulence, just as it has produced selective pressures towards increased virulence of some microorganisms with the profligate use of antibiotics more recently. # The Personal Physician and the Decline of Mortality McKeown’s work attracted such interest among policy makers and analysts in the 1970s and subsequently, not because they were persuaded by the argument favoring nutrition and its acceptance by neoclassical economic historians. They were attracted because it discredited claims by the medical profession to have had a significant impact on health in the past and by implication in the present as well. And this in turn was understood to legitimate contemporary efforts at cost containment, as well as a more generalized attack on the welfare state, 42 at a time when costs were escalating at a high and increasing rate. There is no doubt that many members of the medical profession had believed that declining mortality in the nineteenth and early twentieth centuries could be attributed in large measure to the care provided by personal physicians to their individual patients. 43 Before the 1880s, such a claim would have been dubious, except perhaps under special circumstances such as long sea voyages. 44 On the other hand, the passage of sickness insurance in various European countries, beginning with Germany in the early 1880s (Table 3-2 ), at the same time as the discovery of the infectious origins of many of the most important causes of mortality and morbidity, may well have had a beneficial effect. Sickness insurance broadened exposure of the working classes to physicians at a time when knowledge of the causes of infectious diseases was expanding rapidly. 45 The political origins of state support for health care in the modern era are widely recognized. The first program of social insurance began in Germany in the 1880s and was understood by Bismarck to be a means of assuring the loyalty of the working class to the state. 46 Details of the organization, administration and financing of accident, sickness, and old age insurance programs in (p. 57 ) Table 3-2 Dates of the Introduction of Compulsory Health Insurance in Europe Year Country 1883 Germany 1888 Austria & Hungary 1901 Luxemburg 1909 Norway 1910 Serbia 1911 Great Britain Russia Switzerland (several cantons) Irish Free State France (Alsace-Lorraine) 1912 Roumania Esthonia 1918 Bulgaria 1919 Czechoslovakia Portugal 1920 Poland 1921 Austria 1922 Kingdom of the Serbs, Croats, and Slovenes Greece Soviet Union Latvia 1925 Lithuania Italy (new provinces) Source: International Labour Office, Compulsory Sickness Insurance. Studies and Reports, Series M (Social Insurance) No. 6. Geneva, 1927, p. 11. Europe varied widely. 47 Some programs were compulsory, others voluntary. Financing was from the state, from workers, and/or from employers. The extent of coverage varied greatly although it increased over time, generally starting with adult male workers. Despite these differences, there is suggestive evidence that increased availability of health care from the late 1870s to 1913 was associated with an acceleration in the decline of mortality. 48 The greater the coverage in the five continental countries analyzed by C.R. Winegarden and John Murray, the more rapid the decline, even taking into account real per capita GDP and several other covariates. Although surgical techniques and safety were improving in the late nineteenth and early twentieth centuries, there was not much that physicians had to offer individual patients in terms of curative interventions for most diseases that would have had a major impact on mortality rates. Nonetheless, in the context of increasing knowledge regarding the causes of infectious diseases, (p. 58 ) broadening health care coverage and sickness benefits may have (1) increased the likelihood that sufferers with tuberculosis would be able to rest in hospitals and sanatoria, (2) reduced the risk of pauperization of the family when the breadwinner was sick, and (3) made advice about appropriate child care increasingly accessible. All this may have been beneficial, especially for tuberculosis. 49 For example, in his 1912 study of social insurance in Germany, Lord Dawson, a leading English expert on Germany at the time, 50 described the changes in tuberculosis death rates that he thought were attributable to social insurance. It is not without significance that from 1876 to 1885, prior to the insurance era, the rate of mortality … for German towns, stood still; from 1885 forward from that time there was a steady fall from 3.1 to 2.2 per 1,000 in 1897; from that time the normal influence of the three Insurance Laws [Sickness, Invalidity and Old Age, and Accident], all now in full operation, was reinforced by the anticonsumption crusade of the Pension Boards, and there was simultaneously a further fall in the mortality rate to a figure which in 1908 was little less than that of the United Kingdom. 51 More generally, he thought that the work of the insurance system in Germany was unique in its preventive activities, including inspection of dwellings and lectures and literature on questions of personal health and sanitation. In fact, he continued, programs “do their utmost to discourage amongst the working classes personal habits prejudicial to health.” 52 Quoting a German physician, he wrote: “As is the case with insurance in general,” writes Dr. Zahn, “the German social insurance legislation educates the working classes in providence, self-control, and prudence, and it is well known that the social causes of poverty are specially operative where these qualities are lacking, for wholesale poverty is due not merely to faulty organisation of production, but to the absence of education and foresight on the part of the workman. … The moral influence of industrial insurance must not be overlooked. To a large extent the self-help of the workers is promoted by the insurance institutions; the sense of frugality, prudence, and self-control is extended, and voluntary benevolence is vitalised and stimulated to a degree which would have been inconceivable without the Insurance Laws.” 53 As another contemporary German medical professor had written: It must be regarded as a happy dispensation for the crusade against tuberculosis that at the very time Koch pointed the way to the prevention of this disease the German Insurance Legislation came into (p. 59 ) operation, giving to the less favoured sections of the population, which are the special victims of this disease, a legal claim to treatment in the event of sickness. 54 Thus, while the personal physician system cannot explain most of the decline in European mortality in the late nineteenth and early twentieth centuries, the evidence suggests that its contribution was more significant than McKeown had claimed, 55 and that it varied depending upon the extent to which populations were protected by social insurance. More generally, the European pattern of mortality decline indicates that the causes were not everywhere the same and that the mix of government intervention and economic expansion varied from place to place. The discussion of mortality and life expectancy in the nineteenth century should have made clear that (1) historically, measurement of the standard of living is no mean feat; and (2) when countries are compared, mortality rates and life expectancy vary in ways that cannot readily be explained by differences in the standard of living, even when reasonably adequate comparative income estimates have been constructed by economic historians. In the second part of this chapter, the same case is pursued using comparative data from the late twentieth century. The argument is that mortality patterns reflect many more variables than can be captured in a single measure such as income per capita. # The Discovery of Income in Public Health As observed previously, economic position had been used in the nineteenth century to account for differences in the health of populations. In the United States, however, the use of this measure occurred later. In 1920 Edgar Sydenstricker described the method used in the pellagra studies for classifying families according to income. He wrote: In studies of disease prevalence and incidence, emphasis is being laid nowadays upon the possible influence of environmental conditions that formerly were given no more than cursory consideration. This tendency undoubtedly is in line with the realization that the occurrence of most diseases, especially those which are of the non-infectious type, is more or less intimately dependent, not upon a single condition or set of conditions, but upon the mass of interrelated conditions under which a population lives. 56 The problem, he continued, was that so many conditions were implicated in the cause of disease that it was impossible to deal with all of them effectively. Therefore a general expression—“an index of living conditions“—was required, and “for purposes of accuracy and convenience [it] should be expressed in numerical form.” The desired index must then be both specific and commensurable, and the only single index yet discovered which meets these requirements and which also conveniently and accurately approximates the whole complex of conditions under which a family lives is family income. The reason for this is obvious. Whether or not nutritious diet, sanitary housing, adequate clothing, proper facilities for the care of children, opportunity for wholesome recreation, and sanitary neighborhood conditions can be enjoyed is determined mainly by the family’s financial status. 57 Thirteen years later he wrote, “Environment is not merely the physical world upon which we live. … Nor does it include also only the physical changes that man has accomplished in adapting his physical habitat to himself. … Our ‘social heritage,’ as Graham Wallas put it, is also a very important part of human environment.” The environment was to a large degree the social environment: occupations, social class, economic status, “tradition, superstition, and mores; modes of living, fads, and fashions; standardization of ideas and attitudes by the press, movies, radio, and schools; cultural factors, such as the esthetic idea of posture or a religious regimen of diet or of personal cleanliness.” 58 Income was meant to capture the whole range of conditions that affected the health of individuals. Increasingly in the 1920s and 1930s it was used to powerful effect to explain regional mortality differences, 59 to chart the impact of the Depression on the health of the population, 60 and to discredit climatologic explanations of the distribution of disease. 61 It is not too much to say that the use of income in these ways represents the domestication of nature and a repudiation, perhaps premature, of the importance in western epidemiology of the Hippocratic concern with Airs, Waters, and Places. Indeed, its use has become second nature. In England, the use of occupation as a measure of social class occurred slightly earlier than income was used in the United States, but for much the same reason. In each case, these measures of stratification had become the most salient as well as the most convenient for measuring social distinctions. But to expect one numerical measure to adequately represent all the elements of the social environment that are relevant to health is unrealistic, for many of the relevant dimensions may on occasion act independently of income. # Mortality Decline in the Twentieth Century The nineteenth-century European evidence suggests that reductions in mortality were achieved by populations at very different economic levels. Something similar happened in the twentieth century when many poor countries began to achieve life expectancies equal to those of countries with much higher incomes. For example, Samuel Preston 62 compared the association (p. 61 ) Figure 3-4. National life expectancies and GDP per capita, 1960–2000. between life expectancy and per capita income using data from a large number of countries over a period of several decades and demonstrated that at the same income per capita, life expectancy was higher in more recent than in more distant years. He interpreted this to mean that something other than GNP per capita explained the increase in life expectancy, and he argued that this factor was imported public health technologies in developing countries. Figure 3-4 displays data comparable to those Preston analyzed, but for the years between 1960 and 2000. They demonstrate, first, that life expectancy and per capita income are positively associated, thus supporting the strong relationship between the two. Second, however, the data indicate that at the highest income levels the association weakens, though it does not entirely disappear. And third, though the patterns were essentially the same in 1960 and 1980, by (p. 62 ) 2000 the same per capita income (in 1995 U.S.$) was associated with higher life expectancy than in the more distant periods of observation.

The problem is that the explanation offered by Preston of the importance of imported public health interventions suffers from the same deficiency as Mc-Keown’s: it is not based upon the observation of a positive association between public and personal health care interventions on the one hand and reduced mortality on the other. A cause is inferred in the absence of more persuasive explanations. Thus, while suggestive, to deal with that problem a more refined analysis of the impact of different health care systems on mortality is required.

## Causes of Death Amenable to Health Care Interventions.

There are several types of evidence pointing to an important role for health services in the reduction of mortality in the contemporary era. None by itself is definitive, but taken together they support the proposition that there has been a discernible and important effect. In the 1970s, perhaps responding to the same influences that had made Thomas McKeown’s work so influential at the same time, a Working Group on Preventable and Manageable Diseases first proposed a way of measuring the quality of medical care available to populations. “Medical care,” the Working Party wrote,

[I] s used in its broadest sense. Included are the application of all relevant medical knowledge, the basic and applied research to increase that knowledge and make it more precise, the services of all medical and allied health personnel, institutions and laboratories, the resources of governmental, voluntary, and social agencies, and the co-operative responsibilities of the individual himself. Quality is the effect of care on the health of the individual and of the population. Improvement in the quality of care should be reflected in better health. But quality must be differentiated from the efficiency of medical care. Both are important, but they must not be confused. Whereas quality is the output of the medical-care machine in the form of better health, efficiency has to do with how well the parts of the machine work, how well they work together, and at what cost. In a word, quality is concerned with outcome, and efficiency is related to the process of care. 63

The Working Party proposed a method for “establishing quantitative negative indexes of health. Cases of unnecessary disease, and unnecessary disability, and unnecessary untimely deaths can be counted. Their occurrence is a warning signal, a sentinel health event, that the quality of care may need to be improved.” 64 Sentinel events, they continued, are like airline crashes: they need to be investigated to determine where the health care system failed in its ability to prevent and manage the occurrence.

The lists of events classified by the Working Party need not detain us here (see, however, Table 3-3 for a more recent example that is the basis for subsequent analyses). Inclusion was based upon consensus. Their occurrence was to be used to determine whether any particular health care system was dealing appropriately (p. 63 )

Table 3-3 Selected Avoidable Causes of Mortality

Cause

ICDA 9th Revision Code

Age Group

Responsible Health Care Sector

Other Potential Factors Contributing to Excess Mortality

Maternal mortality

630–676

All ages

Primary care Hospital

Perinatal

All causes

< 1 wk and stillbirths, >28 wks gestation

Primary care Hospital

Prevalence of premature births

Chronic reheumatic heart disease

393–398

5–44 yr

Primary care Hospital

All respiratory diseases

460–519

1–14 yr

Primary care Hospital

Hodgkin’s disease

201

15–64 yr

Primary care Hospital

Cervical cancer

180

15–64 yr

Public health Primary care Hospital

Sexual habits, coding error

Breast cancer

174

25–64 yr

Screening programs Public health Primary care Hospital

Risk factors affecting incidence: obesity, family history

Tuberculosis

010–018, 137

5–64 yr

Public health Primary care Hospital

Ethnic group (immigration) Noncompliance with treatment

Asthma

493

5–44 yr

Primary care

Prevalence of disease

Appendicitis, cholelithiasis, cholecystitis, abdominal hernia

540–543 574–575.1 576.1, 550–553

5–64 yr

Primary care Hospital

Coding error

Ischemic heart disease

410–414, 429.2

35–64 yr

Public health Primary care Hospital

Coding error Health behavior affecting incidence: smoking, weight, nutrition

Hypertension and cerebrovascular disease

401–405, 430–438

35–64 yr

Public health Primary care Hospital

Coding error Health behavior affecting incidence: smoking, weight, nutrition

Peptic ulcers

531–534

25–64 yr

Primary care Hospital

Drug use, alcohol, smoking

Diabetes

250

All ages

Public health Primary care Hospital

Diet, obesity

HIV/AIDS

042–044

All ages

Public health Primary care Hospital

Drug use, sexual behavior

Boldface emphasizes the most important sector.

Sources: Adapted from D.G. Manuel and Y. Mao, “Avoidable mortality in the United States and Canada, 1980-1996.” American Journal of Public Health 92: 1481–1484, 2002 and from EC Working Group on Health Services and “Avoidable Deaths,” European Community Atlas of “Avoidable Death” 1985–89. Oxford: Oxford University Press, 1997. HIV/AIDs and diabetes do not appear in either publication.

(p. 64 ) with the problems confronting it, including primary, secondary, and tertiary prevention. Primary prevention refers to prevention of the condition entirely. Secondary refers to early detection and treatment. Tertiary refers to treatment of the full-blown condition and prevention of disability and/or death. Hence the occurrence of vaccine-preventable diseases such as polio and measles represents a failure of primary prevention. Death from cervical cancer represents a failure of adequate screening (secondary prevention). Deaths from myocardial infarction represent a failure of tertiary prevention. The method is particularly valuable for comparative purposes. For if the beneficiaries of one health care system have higher death rates from a condition than the beneficiaries of another system, that should be cause for investigation of possible deficiencies in the former system. 65

The lists of avoidable events have been modified and expanded over time, and they have been used not simply for comparative purposes but to chart the decline of mortality. In general, such studies show that causes of death defined as amenable to interventions by health care systems have declined more rapidly than causes of death not considered amenable to such intervention. 66 The inference has been that health care has been the ingredient most responsible for the difference. However, rarely have studies shown a significant correlation between indicators of health care availability, such as physicians per 1000 population or percent of GDP spent on health services, with differences in rates of occurrence or decline of these different categories of causes. 67 On the other hand, studies that include temporal trends before and after the introduction of specific types of interventions have often shown a downward deflection in mortality, as when the rapidity of the rate of decline of tuberculosis accelerated after the introduction of antibiotic treatment.

(p. 65 ) The study of avoidable deaths has been expanded to include the study of avoidable hospitalizations, that is, hospitalizations that could be avoided were adequate primary care available. 68 The results indicate that poor people have higher rates of preventable hospitalizations than those who are more affluent, and again the inference is that inadequate access to primary services is the major cause. And although not generally treated as part of the same literature on avoidable deaths, a substantial number of publications in the 1980s showed that increased mortality from a variety of causes was associated with the loss of health care benefits. 69

On the other hand, there have been a number of studies showing little or no effect of health services on mortality. For example, although the rate of hospitalization of Medicare beneficiaries was much higher in Boston than New Haven, mortality rates were virtually identical in the two cities. 70 And the RAND Health Insurance study found inconsequential differences in the health of people randomly assigned to fee-for-service and prepaid health care, though the latter had much lower rates of hospitalization than the former. 71

The discrepant findings may result from the fact that poor people are especially vulnerable to the loss of health care benefits, and they tend to be swamped in studies that are concerned with total populations. For example, the RAND Health Insurance Experiment found that the poor benefited more than the nonpoor from the availability of free care with respect to the treatment of hypertension. 72 Thus it is ironic that investigators on the political left 73 who have taken up McKeown’s work with enthusiasm as a way of debunking the claims of the medical profession may have contributed in some small way in the 1980s to loss by the poor of what benefits they had.

There have been studies of a variety of specific conditions that have attempted to determine the share of the decline in mortality that may be accounted for by specific interventions. 74 To take but one example, in a study of the decline of stroke mortality in a defined population over approximately 20 years, 75 it was observed that the incidence of stroke remained the same over the period but the severity declined significantly, and, as a result, case-fatality rates and overall stroke mortality also declined. It is possible that more effective treatment of hypertension may have reduced the severity of strokes even though the incidence had remained unchanged. 76

All of these various studies point to the utility of considering the impact of health services on mortality, primarily for purposes of comparing health care systems, but also to consider how health services may have influenced changes in mortality over recent decades. The United States and Canada are an apt pair for comparison because they are neighbors with access to the same health care technologies. Both are English-speaking, liberal democracies, although there are important political and cultural differences. Most significant for present purposes, until the early 1970s, Canada had a health care system similar to the one in the United States. Since then, all Canadians have been covered by national health insurance, whereas a substantial proportion of the United States population has not had health insurance. In addition, over the (p. 66 )

Figure 3-5. Life expectancy at birth, total U.S. and Canadian populations, 1930–2000. (Source: M.R. Haines and R.H. Steckel, Eds. A Population History of North America. Cambridge: Cambridge University Press, 2000, pp. 697–698.)

same period, Canadian per capita income has been 70% to 73% of per capita income in the United States. 77

## Comparisons Among and Within Two National Populations.

It has been widely recognized that white and African American citizens have long had very different mortality experiences. 78 Perhaps somewhat less well-known is the fact that the populations of the United States and Canada have also had different rates of mortality. Figure 3-5 indicates that for most of the twentieth century Canada has had a small but significant advantage with regard to life expectancy.

Figure 3-6. Life expectancy of all Canadians, African Americans, and white Americans, 1850–2000. (Source: M.R. Haines and R.H. Steckel, Eds. A Population History of North America. Cambridge: Cambridge University Press, 2000, pp. 697–698.)

(p. 67 ) Figure 3-6 provides more detail and shows that white American life expectancy was the same as, or better than, that of all Canadians for most of the period from 1850 to 1950. 79 Only in the 1970s did the Canadian figures rise above those of white Americans. Life expectancy of African Americans was substantially below that of white Americans and of Canadians for the entire twentieth century. That is primarily what accounts for the Canadian advantage until 1970. After that (p. 68 ) date, both whites and African Americans have had lower life expectancy than Canadians.

## Disparities Due to Avoidable Conditions.

Amenable causes of death among whites and African Americans have been examined in several studies to consider the differential effects of access to health services. 80 The EC consensus conference observed that “An excessive number of such unnecessary events serves as a warning signal of possible shortcomings in the health care system, and should be investigated further.” 81 “Warning signal” is emphasized because it is not claimed that all the disparities are attributable only to unequal access to, and utilization of, health services even broadly understood. But disparities in causes of death widely regarded as amenable to intervention by the health care system should not simply be dismissed. At the very least, differences in rates of death from avoidable causes between populations should be cause for concern that a health care system is not functioning adequately.

Conditions considered amenable to intervention by the health care system are listed in Table 3-3 . Among them are several that account for much of the difference between white and African American life expectancy, most notably cardiovascular diseases and hypertension. 82 Figure 3-7 displays curves of the rates of death due to several of these causes from 1980 to 1984 through 1995 to 1998 in the broad age groups displayed in Table 3-3 , and then age adjusted within each age group to the 2000 standard U.S. population. 83 Among the causes accounting for the greatest disparity in life expectancy of African Americans and whites are ischemic heart disease, and hypertension and cerebrovascular disease. Although there has been a decline in both causes of death among African Americans, a decline that began as early as the 1950s but was generally more rapid for whites, 84 there is still a substantial difference in the rates in the two populations. Some of the difference is due to lower rates of vascular surgery among African Americans than among whites. 85

One sees similar substantial differences between the two populations in the other causes of death amenable to interventions by the health care system. In a few, there have been dramatic declines (Hodgkin’s disease, cervical cancer, peptic ulcer, and tuberculosis). Indeed, the decline of tuberculosis began for each group early in the century, before effective therapy was available. 86 In a few there has been little or no change (breast cancer, appendectomy, cholecystectomy and hernia, and maternal mortality). Of these, breast cancer has been of particular concern. There is reasonably persuasive evidence that mammography has had a beneficial impact upon death rates due to this condition. 87 However, African American women have benefited less than white women because they tend to be screened less frequently, to have lower rates of repeat mammography, and to have lower rates of follow-up of abnormal examinations. Factors such as breast density and obesity, which are more common among African American than white women, may also reduce the efficacy of mammography when it is used. Thus, the story is complicated, but the evidence (p. 69 )

Figure 3-7. Avoidable mortality in the United States by race, 1980–1998/9. (Age-adjusted mortality rates using U.S. 2000 standard population.) Continued on p. 70.

suggests that programs specially targeted to African American women do increase the use of mammography and may well be beneficial. 88

Unlike the preceding conditions, there has been a substantial increase in asthma among both African Americans and whites, although greater in the former than the latter. Hospital admissions for acute asthmatic attacks are much more common among African American than white youngsters and are much more common from inner city than other urban or suburban neighborhoods. (p. 70 )

Figure 3-7. Continued.

It has been suggested that both adverse environmental conditions and lower quality primary care are responsible for the differences. 89

Two of the causes of death that account for much of the difference between white and African American life expectancy are not mentioned by the European Community consensus conference: HIV/AIDS and diabetes. 90 Nonetheless, there is reason to believe that the health care system has a great deal to offer in each case, both with regard to advice about prevention and (p. 71 ) with regard to treatment. In both cases, there has been an increase since 1980, more dramatic for African Americans than whites. In the case of HIV/AIDS, however, there has been a sharp decline since the 1990s, the result of both preventive and therapeutic interventions. 91 This sharp decline parallels the dramatic acceleration in the decline of the death rate from tuberculosis in the same period, suggesting that the two are associated. In the case of diabetes, there has been no such decline. Indeed, there has been a much greater increase of the diabetes death rate among African Americans than whites, and the evidence suggests that the former are admitted to hospital with advanced disease requiring amputation more frequently than the latter. 92

It is difficult to say with certainty how much of the disparity in death rates from conditions amenable to health care interventions is the result of unequal access to, and use of, the full range of public and personal preventive, therapeutic, and rehabilitation services, and how much is due to circumstances beyond the reasonable reach of health care systems. Nonetheless, such consistent differences lead to the conclusion that a great deal is indeed due to unequal access.

In addition, there is evidence that (1) the quality of primary care physicians who treat African Americans may not be as good as the quality of other primary care physicians, 93 and (2) even when whites and African Americans have similar types of health care coverage (for example, Medicare) and are admitted to hospital, the care they receive differs. Notwithstanding the importance of Medicare as an integrative force in health care, 94 the fact remains that studies of Medicare fee-for-service and managed care programs reveal “differences in care patterns … for cancer treatment, treatment after acute myocardial infarction, use of surgical procedures, hospice use, and preventive care.” 95

As David Barton Smith 96 has shown, this is largely the result of lax enforcement of requirements for equal treatment in facilities receiving federal monies, though differences in Medigap coverage may also play a role. After a brief burst of enthusiasm for civil rights following the passage of Medicare, the federal enforcement of equal treatment in hospitals declined. There are a number of reasons why this occurred, according to Smith. Among them were a diminished commitment to civil rights enforcement in the Executive Branch, growing preoccupation with cost containment and shrinking the federal bureaucracy, and organizational changes within DHHS. The result has been continuing disparities in the treatment of African Americans and whites.

## Mortality of Canadians and White Americans.

Figure 3-6 shows that the differences between the life expectancy of Canadians and white Americans emerged in the 1970s and have widened since then. Significantly, the differences between social insurance coverage in the two countries emerged in the 1950s, when Canada developed broader protection than the United States. Both countries by then had industrial accident, pension, and unemployment insurance, but, in addition, in 1944 Canada had developed a system of family allowances. The gap in social insurance opened much wider after Canada implemented a universal health insurance program in 1972, 97 in contrast to the (p. 72 ) far from universal programs, Medicare and Medicaid, created in the United States in 1965.

Additionally, Canada’s social insurance programs are more redistributive than America’s, and the result has been much greater income equality in the former than the latter country. Although between 1974 and 1985 income inequality widened in both Canada and the United States, the trend in Canada reversed in the following decade while it persisted in the United States. In the period 1985 to 1997, Canadian patterns of income taxation and transfer payments were far more redistributive than those in the United States. 98

After the implementation of universal health insurance in Canada, a number of studies were done of the consequences regarding health care utilization. The results were mixed. Some studies showed inequalities in utilization and health status to have persisted, 99 but for the most part utilization has increased, especially among the poor. 100 Although waiting times for elective and semiurgent procedures have lengthened since the 1970s, the degree to which the increase has reduced life expectancy, as contrasted with quality of life, is not significant. 101 Moreover, the differences among socioeconomic groups with respect to avoidable hospitalizations are far greater in American than Canadian cities; 102 the risk of inadequate prenatal care is greater for poor American women than for poor Canadian women; 103 survival from some heavily technology-dependent conditions, e.g., end-stage renal disease, is better in Canada than in the United States; 104 and among hospitalized victims of myocardial infarction, Americans have more technologically intense interventions than Canadians, but the same 1-year survival. 105 On the other hand, survival from hip fractures is worse in Manitoba than in New England, 106 though comparisons with adjacent U.S. states may have been more appropriate. In general, however, most causes of death as well as mortality differences among income groups have declined since the 1970s. 107 Furthermore, the use of U.S. services by Canadians is too miniscule to have a measurable impact on cause-specific mortality or life expectancy. 108

Several comparative studies 109 of the association between income and survival rates from various cancers in American and Canadian cities reveal that:

1. 1. There were few if any differences in survival of different income groups in Canada but substantial differences in the United States.

2. 2. People with cancer who came from poor populations in the United States had worse survival than equally poor people in Canada. This was as true for poor whites as it was for poor African Americans.

3. 3. Survival among the wealthiest groups in Honolulu was better than for the wealthy in Toronto, but, for the most part, differences between upper income groups in the two countries are neither statistically nor substantively significantly different.

4. 4. Cancer survival patterns in Honolulu were more nearly like survival in Toronto than was any other American city. Because Hawaii is the one (p. 73 ) American state that has attempted, though with only partial success, to implement universal medical insurance, the evidence suggests that the differences in cancer survival documented in these studies are primarily the result of differences in access to health services.

Similarly suggestive evidence of the importance of universal coverage comes from a comparison of changing Canadian and American mortality rates from 1980 to 1984 to 1995 to 1996, from causes of death amenable to intervention by the health care system. Douglas Manuel and Yang Mao 110 have shown the following:

1. 1. Breast cancer, Hodgkin’s disease, and peptic ulcer declined equally and were essentially indistinguishable in each country.

2. 2. Asthma deaths increased in the United States and declined in Canada.

3. 3. Death rates from cervical cancer, hypertension/cerebrovascular disease, ischemic heart disease, tuberculosis, and appendectomy, cholecystectomy and hernia declined in each country, but more rapidly and to lower levels in Canada than the United States.

These observations, too, suggest that the Canadian system of comprehensive care, free of charge at the point of service, and with a greater emphasis than in the United States on primary care, may be generally more effective than the American system for the total population. In light of the great inequalities between whites and African Americans, however, the question is whether the differences between the two countries are accounted for by the high rates of death among African Americans, or whether these differences affect white Americans as well? The lower life expectancy of white Americans than Canadians since the 1970s and the results of the analyses of cancer survival both suggest that there should be differences in most of the causes of death amenable to intervention by the health care system.

The data displayed in Figure 3-8 are comparisons of age-adjusted death rates of Canadians 111 and white Americans from the same causes as those described previously when African American and white rates were compared. In virtually every case, Canadians have lower rates than white Americans. The exceptions are breast cancer, all respiratory diseases in children, and peptic ulcer, where the rates are very similar or the same. Moreover, among conditions in which the rates are declining, they tend to be declining more rapidly among Canadians. These are hypertension and cerebrovascular disease, Hodgkin’s disease, appendectomy, cholecystectomy and hernia, cervical cancer, and chronic rheumatic heart disease. Ischemic heart disease has declined at about the same rate in each population. HIV/AIDS increased more rapidly and to higher levels among white Americans than Canadians, and in the 1990s fell more rapidly. Nonetheless, the rates are still higher in the United States. Diabetes is increasing in both populations as well, but far more rapidly among white Americans than among Canadians.

Figure 3-8. Avoidable mortality of white Americans and all Canadians, 1980–1998/9. (Age-adjusted mortality rates using U.S. standard population.)

These comparisons strongly suggest that the Canadian health care system, though not without serious problems, 112 serves the interests of Canadians better than the U.S. health care system serves the interests of white Americans, not to mention African Americans. Not only has Canadian per capita income been 70% to 73% of U.S. income since 1970, but Canadian per capita health expenditures are less than half those of the United States. 113 In current U.S. dollars in 1999, per capita health expenditures in Canada were U.S.$1939 (p. 75 ) compared to U.S.$4271 in the United States. 114 Thus, both efficiency and quality as defined by the Working Group on Preventable and Manageable Diseases in the 1970s are greater in Canada than in the United States.

# Conclusion

The historical and contemporary evidence indicates that the standard of living, whether measured as height or as income, is not invariably positively (p. 76 ) associated with life expectancy. This is because the health of populations is responsive to many more factors—including personal and public health services—than are summarized by the measures conventionally used. Much depends upon the context, epidemiological, sociopolitical, as well as economic. For example, height is inversely associated with some causes of death (respiratory and cardiovascular) and positively associated with others (some forms of cancer and, as shown in Appendix 2 , tuberculosis). Thus, the prevailing epidemiological regime will shape the relationship between this measure of the standard of living and overall mortality, even as the overall standard of living may help shape the prevailing epidemiological regime.

Similarly, while only a wealthy society, such as England was in the nineteenth century, may have been able to make the initial investments necessary to develop and install clean water supplies and sewer systems, once the technology and trained engineers were available, poorer populations could adopt those innovations at much lower cost. This appears to be what happened within Europe and the United States in the nineteenth century and more broadly internationally in the twentieth century.

Finally, political culture and institutions have a profound effect that may well be more significant than the standard of living as measured by income per capita. This is the lesson to be drawn from the comparison of mortality rates in the United States and Canada. Given the existing technologies, the ability to make services universally accessible can have a measurably beneficial impact upon the health of the population.

The standard-of-living debate has been too narrowly conceived. It is based upon the assumption that if income rises for everyone, even if unequally, everyone will benefit. For some purposes this may be true, and, indeed, income has proven itself over and over again to be a useful indicator of social status and social difference. When considering the health of populations, however, it may also be seriously misleading for, as Edgar Sydenstricker pointed out when he first advocated the use of income as a measure of the adequacy of the social environment in public health, the social environment included “tradition, superstition, and mores; modes of living, fads, and fashions; standardization of ideas and attitudes by the press, movies, radio, and schools; cultural factors, such as the esthetic idea of posture or a religious regimen of diet or of personal cleanliness.” 115 As we will see in the next chapter, it is a lot to ask of any single indicator that it adequately reflect the impact of all of these on the health of populations.

## Notes:

(1.) William Blake, “London” in “Songs of Innocence and of Experience.” In The Complete Poetry and Selected Prose of John Donne and The Complete Poetry of William Blake. New York: Modern Library/Random House, 1941. This is the first draft of the poem.

(2.) For a more detailed discussion, see S.J. Kunitz, “The personal physician and the decline of mortality.” In R. Schofield, D. Reher, and A. Bideau, eds., The Decline of Mortality in Europe. Oxford: Oxford University Press, 1991.

(3.) R.W. Fogel, “The conquest of high mortality and hunger in Europe and America: Timing and mechanisms.” In P. Higonnet, D.S. Landes, and H. Rosovsky eds., Favorites of Fortune: Technology, Growth and Economic Development Since the Industrial Revolution. Cambridge: Harvard University Press, 1991, pp. 33–71, pp. 59–60.

(4.) For a review, see B. Harris, “Health, height, and history: an overview of recent developments in anthropometric history.” Social History of Medicine 7: 297–320, 1994.

(5.) R.W. Fogel, “New sources and new techniques for the study of secular trends in nutritional status, health, mortality, and the process of aging.” Historical Methods 26: 5–43, 1993, p. 19.

(6.) Ibid. pp. 20–21.

(7.) R. Floud, K. Wachter, and A. Gregory, Height, Health and History: Nutritional Status in the United Kingdom, 1750–1980. Cambridge: Cambridge University Press, 1990.

(8.) D.L. Kuh, C. Power, and B. Rodgers, “Secular trends in social class and sex differences in adult height.” International Journal of Epidemiology 20: 1001–1009, 1991.

(9.) Life expectancy data are from E.A. Wrigley R.S. Davies, J.E. Oeppen, and R.S. Schofield, English Population from Family Reconstitution, op. cit. p. 614. Human Mortality Database. University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany). Available at www.mortality.org. Data were downloaded on November 8, 2004.

(10.) G. Kearns, “The urban penalty and the population history of England.” In A. Brandstrom and L-G Tedebrand, eds., Society, Health and Population during the Demographic Transition. Stockholm: Almqvist and Wiksell International, 1988.

(11.) D.J.P. Barker, C. Osmond, and J. Golding, “Height and mortality in the counties of England and Wales.” Annals of Human Biology 17: 1–6, 1990.

(12.) H.T. Waaler, “Height, weight and mortality: the Norwegian experience.” Acta Medica Scandinavica, Supplementum 679, 1984. G. Davey Smith et al., “Height and risk of death among men and women,” P. Allebeck and C. Bergh, “Height, body mass index and mortality: do social factors explain the association?” Public Health 106: 375–382, 1992. A.M. Nystrom Peck and D. H. Vagero, “Adult body height, self perceived health and mortality in the Swedish population.” Journal of Epidemiology and Community Health 43: 380–384, 1989. G. Davey Smith, M.J. Shipley, and G. Rose, “Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study.” Journal of Epidemiology and Community Health, 44: 265–270, 1990.

(13.) G. Davey Smith et al., “Height and risk of death among men and women,” op. cit. , p. 102.

(14.) R. W. Fogel, “New sources and new techniques for the study of secular trends …”

(15.) P.G. Lunn, “Nutrition, immunity, and infection.” In R. Schofield, D. Reher, and A. Bideau, eds., The Decline of Mortality in Europe. Oxford: Oxford University Press, 1991, pp. 131–145.

(16.) J. C. Riley “Height, nutrition, and mortality risk reconsidered.” Journal of InterdisciplinaryHistory 24: 465–492, 1994.

(17.) Unfortunately, published height data are not as readily available or plentiful for the last quarter of the nineteenth century as they are for earlier in the century. Using other kinds of data, however, Millward and Bell have argued that economic factors and maternal health are a better explanation of the decline of mortality in the last third of the nineteenth century than are public health interventions. They show that investments in public health, measured by local government finances and loans for capital improvements for water works, sewers, and roads, increased rapidly in the early twentieth century, after the decline in infant mortality had begun. Thus, they claim, improvements in the late nineteenth century could not have been sufficient to influence profoundly the decline of infant mortality in their selected cities that began so dramatically in the 1870s. They also argue that the gradual decline in infant mortality which occurred in the last 30 years of the nineteenth century were the result of improvements in maternal health and nutrition and declining fertility rates. See F. Bell and R. Mill-ward, “Public health expenditures and mortality in England and Wales, 1870–1914.” Continuity and Change 13: 221–249, 1998. R. Millward and F. Bell, “Economic factors in the decline of mortality in late nineteenth- and twentieth-century Britain.” European Review of Economic History 2: 263–288, 1998. And R. Millward and F. Bell, “Infant mortality in Victorian Britain: the mother as medium.” Economic History Review LIV: 699–733, 2001.

(18.) For a helpful review, see B. Harris, “Public health, nutrition and the decline of mortality: the McKeown thesis revisited.” Social History of Medicine 17: 379–407, 2004. Harris offers a qualified defense of McKeown’s thesis, concluding that it is difficult to precisely quantify the contribution of nutrition to the decline of mortality.

(19.) S. Szreter, “The importance of social intervention in Britain’s mortality decline c. 1850–1914: a re-interpretation of the role of public health.” Social History of Medicine 1: 1–37, 1988. I shall not deal with a critique of Szreter’s paper, or with Szreter’s reply. See S. Guha, “The importance of social intervention in England’s mortality decline: the evidence reviewed.” Social History of Medicine 7: 89–113, 1994. And S. Szreter, “Mortality in England in the eighteenth and nineteenth centuries: a reply to Sumit Guha.” Social History of Medicine 7: 269–282, 1994.

(20.) S. Szreter, “Economic growth, disruption, deprivation, disease, and death: on the importance of the politics of public health for development.” Population and Development Review 23: 693–728, 1997, p. 710.

(21.) e.g., Szreter, “The importance of social intervention,” op. cit. , p. 21.

(22.) A. Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine 1856–1900. Oxford: Oxford University Press, 1993.

(23.) F. Bell and R. Millward, “Public health expenditures and mortality in England and Wales, 1870–1914.”

(24.) R. Woods, The Demography of Victorian England and Wales. Cambridge: Cambridge University Press, 2000. pp. 355–356.

(25.) G. Davey Smith and J. Lynch, “Social capital, social epidemiology and disease aetiology.” International Journal of Epidemiology 33: 691–700, 2004.

(26.) S. Szreter, “Debating mortality trends in 19th century Britain.” International Journal of Epidemiology 33: 705–709, 2004.

(27.) S. Szreter and G. Mooney, “Urbanization, mortality, and the standard of living debate: new estimates of the expectation of life at birth in nineteenth-century British cities.” Economic History Review 51: 84–112, 1998, p. 107. For a slightly earlier period, see P. Huck, “Infant mortality and living standards of English workers during the Industrial Revolution.” The Journal of Economic History 55: 528–550, 1995.

(28.) J. Vogele, Urban Mortality Change in England and Germany, 1870–1913. Liverpool: Liverpool University Press, 1998, p. 93.

(29.) Ibid. , p. 213. See also the earlier paper by J.C. Brown, “Public reform for private gain? Public health and sanitary infrastructure in German cities 1877–1910.” Paper presented at the annual meeting of the Social Science History Association, Chicago, November, 1988. And J.C. Brown, “Coping with crisis? The diffusion of waterworks in late nineteenth-century German towns.” The Journal of Economic History XLVIII (No. 2): 307–318, 1988.

(30.) For a somewhat different explanation of the differences between England and Germany, see E.P. Hennock, “The urban sanitary movement in England and Germany, 1838–1914: a comparison.” Continuity and Change 15: 269–296, 2000.

(31.) A.S. Wohl, Endangered Lives, op. cit. , pp. 170–171. G. Kearns, “Private property and public health reform in England 1830–70.” Social Science and Medicine 26: 187–199, 1988. Szreter, “Economic growth, disruption, deprivation, disease, and death,”

(32.) A. Hardy, The Epidemic Streets, op. cit. , p. 268.

(33.) J.C. Brown, “Public health reform and the decline of urban mortality: the case of Germany, 1876–1912.” Paper presented at the annual meeting of the Population Association of America, March, 1989.

(34.) W.R. Lee and J.P. Vogele, “The benefits of federalism? The development of public health policy and health care systems in nineteenth-century Germany and their impact of mortality reduction.” Annales de Demographie Historique No. 1, pp. 65–96, 2001. Similar differences have been observed among French cities. S.H. Preston and E. van de Walle, “Urban French mortality in the nineteenth century.” Population Studies 32: 275–297, 1978.

(35.) R.J. Evans, Death in Hamburg: Society and Politics in the Cholera Years 1830–1910. Oxford: Oxford University Press, 1987.

(36.) M.R. Haines and H.J. Kintner, “The mortality transition in Germany, 1860–1935. Evidence by region.” Historical Methods 33: 83–104, 2000.

(37.) The Swedish data come from: L.G. Sandberg and R.H. Steckel, “Was industrialization hazardous to your health? Not in Sweden!,” and R.H. Steckel and R. Floud, “Conclusions,” both in R.H. Steckel and R. Floud, eds., Health and Welfare during Industrialization. Chicago: The University of Chicago Press, 1997.

(38.) Sandberg and Steckel, “Was industrialization hazardous to your health?” p. 143. See also P. Skold, “The key to success: the role of local government in the organization of smallpox vaccination in Sweden.” Medical History 45: 201–226, 2000.

(39.) This occurred in France as well as Germany. J.-P. Goubert, The Conquest of Water: The Advent of Health in the Industrial Age. Princeton: Princeton University Press, 1986.

(40.) Steckel and Floud, “Conclusions,” op. cit. p. 424.

(41.) P.W Ewald, “The evolution of virulence.” Scientific American April, 1993, pp. 86–93. And Evolution of Infectious Disease. New York: Oxford University Press, 1993.

(42.) D.M. Fox, “Populations and the law: the changing scope of health policy.” Journal of Law, Medicine & Ethics 31: 607–614, 2003, p. 608.

(43.) F.B. Smith, The People’s Health 1830–1910. Canberra: The Australian National University Press, 1979, pp. 414–415.

(44.) R. Haines and R. Shlomowitz, “Explaining the modern mortality decline: what can we learn from sea voyages?” Social History of Medicine 11: 15–48, 1998.

(45.) R. Spree, Health and Social Class in Imperial Germany. Oxford: Berg Publishers, 1988, p. 151

(46.) G.V. Rimlinger, Welfare Policy and Industrialization in Europe, America, and Russia. New York: John Wiley & Sons., 1971.

(47.) International Labour Office, Compulsory Sickness Insurance: Comparative Analysis of National Laws and Statistics. Studies and Reports, Series M (Social Insurance) No. 6, Geneva, 1927.

(48.) C.R. Winegarden and J.E. Murray, “The contributions of early health-insurance programs to mortality declines in pre-World War I Europe: Evidence from fixed-effects models.” Explorations in Economic History 35: 431–446, 1998.

(49.) For two specific diseases (typhoid and diphtheria), Jorge Vogele has failed to find significant correlations between the availability of medical practitioners per 1000 population and mortality rates. See Vogele, Urban Mortality Change in England and Germany, op. cit. pp. 195–196.

(50.) D.T. Rogers, Atlantic Crossings: Social Politics in a Progressive Age. Cambridge: Harvard University Press, 1998, p. 61.

(51.) W.H. Dawson, Social Insurance in Germany, 1883–1911: Its History, Operation, Results. London: T. Fisher Unwin, [1912] 1979, p. 202.

(52.) Ibid. , pp. 183–185.

(53.) Ibid. , p. 254.

(54.) Ibid. , p. 203.

(55.) J.P. Mackenbach, “The contribution of medical care to mortality decline: Mc-Keown revisited.” Journal of Clinical Epidemiology 49: 1207–1213, 1996.

(56.) E. Sydenstricker and W I. King, “A method of classifying families according to incomes in studies of disease prevalence.” Public Health Reports 35: 2829–2846, 1920, p. 2829,

(57.) Ibid. , p. 2830, italics in original. See also S.D. Collins, Economic Status and Health: A Review and Study of the Relevant Morbidity and Mortality Data. Treasury Department, United States Public Health Service, Public Health Bulletin No. 165. Washington, D.C.: U.S. Government Printing Office, 1927.

(58.) E. Sydenstricker, Health and Environment. New York: McGraw-Hill, 1933, pp. 13–15.

(59.) C.K. Wu and C.-E. A. Winslow, “Mortality, prosperity and urbanization in United States Counties,” American Journal of Hygiene 18: 491–542, 1933. J.H. Watkins and A.G. Evans, “Mortality changes as related to prosperity and urbanization in United States counties.” American Journal of Hygiene 26: 449–471, 1936.

(60.) G. St.J. Perrott and S.D. Collins, “Sickness and the Depresssion: a preliminary report upon a survey of wage-earning families in Birmingham, Detroit, and Pittsburgh.” Mil-bank Memorial Fund Quarterly 11: 281–298, 1933, and “Sickness and the Depression: a preliminary report upon a survey of wage-earning families in Baltimore, Cleveland, and Syracuse.” Milbank Memorial Fund Quarterly 12: 28–34, 1934. G. St. J. Perrott, E. Sydenstricker, and S.D. Collins, “Medical care during the Depression: a preliminary report upon a survey of wage-earning families in seven large cities.” Milbank Memorial Fund Quarterly 12: 99–114, 1934. G. St.J. Perrott and S.D. Collins, “Relation of sickness to income and income change in 10 surveyed communities.” Public Health Reports 50: 595–622.

(61.) L.P. Herrington and I.M. Moriyama, “The relation of mortality from certain metabolic diseases to climatic and socio-economic factors.” American Journal of Hygiene 28: 396–422, 1938. I.W. Moriyama and L.P. Herrington, “The relation of diseases of the cardiovascular and renal systems to climatic and socio-economic factors.” American Journal of Hygiene 28: 423–436, 1938. L.P. Herrington and I.M. Moriyama, “The relation of mortality from certain respiratory diseases to climatic and socio-economic factors.” American Journal of Hygiene 29: 111–120, 1939. C.A. Mills, “Climate and metabolic stress.” American Journal of Hygiene 29: 147–164, 1939.

(62.) S. H. Preston, “The changing relation between mortality and level of economic development.” Population Studies 29: 213–248, 1975. See also R.A. Easterlin, “Industrial revolution and mortality revolution: two of a kind?” Journal of Evolutionary Economics 5: 393–408, 1995 and R.A. Easterlin, Growth Triumphant: The Twenty-first Century in Historical Perspective. Ann Arbor: University of Michigan Press, 1996, p. 77.

(63.) D.D. Rutstein, W. Berenbert, T.C. Chalmers, C.G. Child, 3rd, A.P. Fishman, and E.B. Perrin, “Measuring the quality of medical care: a clinical method.” New England Journal of Medicine 294: 582–588, 1976, p. 582. Italics in original.

(64.) Ibid. , p. 583.

(65.) E. Nolte and M. McKee, Does Healthcare Save Lives? Avoidable Mortality Revisited. London: The Nuffield Trust, 2004, p. 30. Much of the discussion in the following paragraphs is based upon the literature reviewed in this publication.

(66.) Ibid. , p. 43.

(67.) Ibid. , p. 42.

(68.) J. Billings, L. Zeitel, J. Lukomnik, T.S. Carey, A.E. Blank, and L. Newman, “Impact of socioeconomic status on hospital use in New York City.” Health Affairs 12: 162–173, 1993. A.B. Bindman, K. Grumbach, D. Osmond, M. Komaromy K. Vranizan, N. Lurie, J. Billings, and A. Stewart, “Preventable hospitalizations and access to health care.” Journal of the American Medical Association 274: 305–311, 1995. J. Billings, G.M. Anderson, and L.S. Newman, “Recent findings on preventable hospitalizations.” Health Affairs 15: 239–250, 1996.

(69.) See, for example, P. Braverman, R. Oliva, M.G.G. Miller, R. Reiter, and S. Egerter, “Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986.” New England Journal of Medicine 321: 508–513, 1989. G.L. Lindberg, N. Lurie, S. Bannick-Mohrland, R.E. Sherman, and P.A. Farseth, “Health care cost containment measures and mortality in Hennepin County’s Medic-aid elderly and all elderly.” American Journal of Public Health 79: 1481–1485, 1989. D.R. Calkins, L.A. Burns, and T.L. Delbanco, “Ambulatory care and the poor: tracking the impact of changes in federal policy.” Journal of General Internal Medicine 1: 109–115, 1986. C.A. Miller, “Infant mortality in the U.S.” Scientific American 253: 31–37, 1985. N. Lurie, N.B. Ward, M.F. Shapiro, and R.H. Brook, “Termination from Medi-Cal—does it affect health?” New England Journal of Medicine 311: 480–484, 1984. N. Lurie, N.B. Ward, M.F. Shapiro, C. Gallego, R. Vaghaiwalla, and R.H. Brook, “Termination of Medi-Cal benefits: a follow-up study one year later.” New England Journal of Medicine 314: 1266–1268, 1986.

(70.) J.E. Wennberg, J.L. Freeman, R.M. Shelton, and T.A. Bubolz, “Hospital use and mortality among Medicare beneficiaries in Boston and New Haven.” New England Journal of Medicine 321: 1168–1173, 1989.

(71.) E.M. Sloss, E.B. Keeler, R.H. Brook, B.H. Ooperskalski, G.A. Goldberg, and J.P. Newhouse, “Effect of a health maintenance organization on physiologic health.” Annals of Internal Medicine 106: 130–138, 1987.

(72.) E.B. Keeler, R.H. Brook, G.A. Goldberg, C.J. Kamberg, and J.P. Newhouse, “How free care reduced hypertension in the Health Insurance Experiment.” Journal of the American Medical Association 254: 1926–1931, 1985.

(73.) J. McKinlay and S. McKinlay, “The questionable contribution of medical measures to the decline of mortality in the U.S. in the twentieth century.” Milbank Memorial Fund Quarterly 53: 405–428, 1977. S. Wing, “The role of medicine in the decline of hypertension-related mortality.” International Journal of Health Services 14: 649–665, 1984. J.B. McKinlay, S.M. McKinlay, and R. Beaglehole, “A review of the evidence concerning the impact of medical measures on recent mortality and morbidity in the United States.” International Journal of Health Services 19: 181–208, 1989.

(74.) Nolte and McKee, Healthcare, op. cit. , p. 56.

(75.) W.H. Barker and J.P. Mullooly, “Stroke in a defined elderly population, 1967–1985: a less lethal and disabling but no less common disease.” Stroke 28: 284–290, 1997.

(76.) W.H. Barker, J.P. Mullooly, and K.L.P. Linton, “Trends in hypertension prevalence, treatment, and control in a well-defined older population.” Hypertension 31 [part 2]: 552–559, 1998.

(77.) In terms of purchasing power parity, the figures have been more nearly similar.

Year

United States

Canada as a % of the U.S.

1980

$11,500$13,020

88%

1990

$19,400$23,440

82.7%

2000

$27,170$34,100

79%

Source: The World Bank, World Development Report, 2002. CD-ROM.

(78.) A more complete discussion of the differences in mortality reported in this section is to be found in S.J. Kunitz, with I. Pesis-Katz, “Mortality of White Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies.” Milbank Quarterly 83: 5–39, 2005.

(79.) M.R. Haines and R.H. Steckel, eds., A Population History of North America. New York: Cambridge University Press, 2000, pp. 696–697.

(80.) Comparison of racial differences in avoidable deaths have been the subject of several previous articles. See, for instance, S. Woolhandler, D.U. Himmelstein, R. Sil-ber, M. Bader, M. Harnly and A.A. Jones, “Medical care and mortality: racial differences in preventable deaths.” International Journal of Health Services 15: 1–22, 1985.

(81.) W.W. Holland, ed., European Community Atlas of “Avoidable Death”, Vol.1, Oxford: Oxford University Press, 1991, p. 1. Italics added.

(82.) M.D. Wong, M.F. Shapiro, W.J. Boscardin, and S.L. Ettner. “Contribution of major diseases to disparities in mortality.” New England Journal of Medicine 347: 1585–1592, 2002.

(83.) All the mortality data come from the Centers for Disease Control (http://wonder.cdc.gov) with the exception of perinatal mortality. D. Hoyert, “Perinatal mortality in the United States.” Vital and Health Statistics 20 (25), 1995.

(84.) R. Farley and W.R. Allen, The Color Line and the Quality of Life in America. New York: The Russell Sage Foundation, 1987, pp. 42–43.

(85.) M.B. Wenneker and A.M. Epstein, “Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts.” Journal of the American Medical Association 261: 253–257, 1989. A.M. Gittelsohn, J. Halpern, and R.L. Sanchez, “Income, race, and surgery in Maryland.” American Journal of Public Health 81: 1435–1441, 1991.

(86.) Farley and Allen, The Color Line, op. cit. , pp. 42–43. Ewbank, “History of Black mortality and health before 1940,” op. cit. , p. 123.

(87.) L. Tabar, M-F Yen, B. Vitak, H-H. T. Chen, R.A. Smith, and S.W. Duffy, “Mam-mography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening.” The Lancet 361: 1405–1410, 2003.

(88.) B.A. Jones, E.A. Patterson, and L. Calvocoressi, “Mammography screening in African American women: evaluating the research.” Cancer 97 (supplement): 258–272, 2003.

(89.) K.M. McConnochie, M.J. Russo, J. McBride, P. Szilagy, A.M. Brooks, and K.J. Roghmann, “Socioeconomic variations in asthma hospitalization: excess utilization or greater need?” Pediatrics 103: e75, 1999.

(90.) M.D. Wong et al. “Contribution of major diseases to disparities in mortality,”

(91.) M.D. Wong et al. “Contribution of major diseases to disparities in mortality,”

(92.) A.M. Gittelsohn, J. Halpern, and R.L. Sanchez, “Income, race, and surgery in Maryland,”

(93.) P.B. Bach, H.M. Pham, D. Schrag, R.C. Tate, and J.L. Hargraves, “Primary care physicians who treat Blacks and Whites.” New England Journal of Medicine 351: 575–584, 2004.

(94.) T.R. Marmor, “Review essay of Atlantic Crossings and Shifting the Color Line.” Public Opinion Quarterly 64: 110–113, 2000.

(95.) B.A. Virnig, N. Lurie, Z. Huang, D. Musgrave et al., “Racial variations in quality of care among Medicare + Choice enrollees.” Health Affairs, 21: 224–230, 2002.

(96.) D.B. Smith, “Addressing racial inequality in health: civil rights monitoring and report cards.” Journal of Health Politics, Policy, andLaw, 23: 75–105, 1998.

(97.) R.T. Kuderle and T.R. Marmor. “The Development of Welfare States in North America.” In P. Flora and A.J. Heidenheimer, eds. The Development of Welfare States in Europe and America. New Brunswick, N.J.: Transaction Books, 1982, pp. 83–85.

(98.) M. Wolfson, “Income inequality in Canada and the United States.” The Daily, Statistics Canada, July 28, 2000, http://www.statcan.ca/Daily/English/000728/d000728a.htm. M. Wolfson and B. Murphy, “Income inequality in North America: does the 49th parallel still matter?” Canadian Economic Observer August 2000, pp. 1–24.

(99.) E. Wood, A.M. Sallar, M.T. Schechter, and R.S. Hogg, “Social inequalities in male mortality amenable to medical intervention in British Columbia.” Social Science and Medicine 48: 1751–1758, 1999. J.R. Dunn and M.V. Hayes, “Social inequality, population health, and housing: a study of two Vancouver neighborhoods.” Social Science and Medicine 51: 563–587, 2000. S. Dunlop, P.C. Coyte, and W. McIsaac, “Socio-economic status and the utilization of physicians’ services: results from the Canadian National Population Health Survey.” Social Sciences and Medicine 51: 123–133, 2000. R. Wilkins, J-M Berth-elot, and E. Ng, Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Supplement to Health Reports, Vol. 13. Ottawa: Statistics Canada, 2002.

(100.) L. Munan, J. Vobecky, and A. Kelly, “Population health care practices: an epi-demiologic study of the immediate effects of a universal health insurance plan.” International Journal of Health Services 2: 285–295, 1974. A.D. McDonald, J.C. McDonald, V Salter, and P.E. Enterline, “Effects of Quebec Medicare on physician consultation for selected symptoms.” New England Journal of Medicine 291: 649–652, 1974. J. Siemiaty-cki, L. Richardson, and I.B. Pless, “Equality in medical care under national health insurance in Montreal.” New England Journal of Medicine 303: 10–15, 1980.

(101.) C.D. Naylor, “Health care in Canada: incrementalism under fiscal duress.” Health Affairs 18: 9–26, 1999.

(102.) Billings et al., “Recent findings on preventable hospitalizations,”

(103.) S.J. Katz, J.R.W. Armstrong, and J.P. LoGerfo, “The adequacy of prenatal care and incidence of low birthweight among the poor in Washington State and British Columbia.” American Journal of Public Health 84: 986–991, 1994.

(104.) J.C. Hornberger, A.M. Garver, and J.R. Jeffery, “Mortality, hospital admissions, and medical costs of end-stage renal disease in the United States and Manitoba, Canada.” Medical Care 35: 686–700, 1997.

(105.) G.M. Anderson, J.P. Newhouse, and L.L. Roos, “Hospital care for elderly patients with diseases of the circulatory system: a comparison of hospital use in the United States and Canada.” New England Journal of Medicine 321: 1443–1448, 1989. J.V. Tu, C.L. Pashos, C.D. Naylor, E. Chen, S-L Normand, J.P. Newhouse, and B.J. McNeil, “Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada.” New England Journal of Medicine 336: 1500–1505, 1997.

(106.) L.L. Roos, E.S. Fisher, S.M. Sharp, J.P. Newhouse, G.Anderson, and T.A. Bubolz, “Postsurgical mortality in Manitoba and New England.” Journal of the American Medical Association 263: 2453–2458, 1990.

(107.) R. Wilkins, J-M Berthelot, and E. Ng, Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Supplement to Health Reports, Vol. 13. Ottawa: Statistics Canada, 2002.

(108.) S.J. Katz, K. Cardiff, M. Pascali, M.L. Barer, and R.G. Evans. 2002. “Phantoms in the snow: Canadians’ use of health care service in the United States.” Health Affairs 21: 19–31.

(109.) K.M. Gorey, E.J. Holowaty G. Fehringer, E. Laukkanen, A. Moskowitz, D.J. Webster, and N.L. Richter, “An international comparison of cancer survival: Toronto, Ontario, and Detroit, Michigan, metropolitan areas.” American Journal of Public Health 87: 1156–1163, 1997. K.M. Gorey, E.J. Holowaty, E. Laukkanen, G. Fehringer, and N.L. Richter, “An international comparison of cancer survival: advantage of Toronto’s poor over the near poor of Detroit.” Canadian Journal of Public Health 89: 102–104, 1998. K.M. Gorey, E.J. Holowaty, G. Fehringer, E. Laukkanen, N.L. Richter, and C.M. Meyer, “An international comparison of cancer survival: Toronto, Ontario and three relatively resourceful United States metropolitan areas.” Journal of Public Health Medicine 22: 343–348, 2000. K.M. Gorey, E.J. Holowaty, G. Fehringer, E. Laukkanen, N.L. Richter, and C.M. Meyer, “An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii.” American Journal of Public Health 90: 1866–1872, 2000. K.M Gorey, E. Kliewer, E.J. Holowaty, E. Laukkanen, and E.Y. Ng, “An international comparison of breast cancer survival: Winnipeg, Manitoba and Des Moines, Iowa, metropolitan areas.” Annals of Epidemiology 13: 32–41, 2003.

(110.) D. Manuel, and Y. Mao, “Avoidable mortality in the United States and Canada, 1980–96.” American Journal of Public Health 92: 1481–1484, 2002.

(111.) The data are from Statistics Canada 1987–1999.

(112.) D. Blumenthal, C. Vogeli, L. Alexander, and M. Pittman, A Five-Nation Hospital Survey: Commonalities, Differences, and Discontinuities. New York: The Commonwealth Fund, 2004.

(113.) U.E. Reinhardt, P.S. Hussey, and G.F. Anderson, “U.S. health care spending in an international context: why is U.S. spending so high, and can we afford it?” Health Affairs 23: 10–25, 2004.

(114.) World Development Indicators 2002, CD-ROM. Washington, D.C.: The World Bank, 2002. Health expenditures are defined as follows: “Total health expenditure is the sum of public and private health expenditure as a ratio of total population. It covers the provision of health service (preventive and curative), family planning activities, nutrition activities, and emergency aid designated for health but does not include provision of water and sanitation.”

(115.) E. Sydenstricker, Health and Environment, op. cit. , p. 13–15.