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Lecture Notes - Health & Society (7332A005AY)
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Health and Society, Readings Week 1J. P. Mackenbach – A History of Population Health. Rise and Fall of
Diseases in Europe: Chapter 1: Introduction
• Utopia means ‘nowhere’ and was coined by Thomas More in his book (1516).
– p. 1
• It is remarkable how much of More’s utopian health vision has been realised
in the 20th century. – p. 1
• Over the past three centuries, health of Europeans improved enormously. This
can be see most clearly in the increase in the length of life. – p. 2
o This increase is accompanied by enormous changes in people’s
health. – p. 4
• Many diseases have disappeared, other diseases that took their place occur
at higher ages than the diseases of the past. – p. 4
• The total number of life-years increased, but also the numbers of years that
Europeans can expect to live in good health. – p. 4
o Recently, also the number of years that we can expect to live in ill-
health has also increased. – p. 4
▪ This is the result of increased survival of patients with chronic
diseases. – p. 5
▪ → Resulting in a faster increase in total life expectancy than in
healthy life expectancy. – p. 5
• “Specific causes of death have risen and fallen over time, and it is only
because ‘falls’ ultimately had the upper hand that life expectancy could rise.” –
pp. 5-6
o One of the main findings of this book. – p. 6
• General explanation for the rise of disease: (1) Human efforts to improve their
living conditions, often → (2) required or allowed them to undertake new
activities, → (3) which later turned out to be health-damaging. – p. 6
o E.g., long-distance trade brought the plague into Europe. – p. 6
• General explanation for the decline of disease: (1) The drive for better living
conditions not only brought new health risks, → but (2) also created the
necessary conditions for reducing these risks. – p. 6
• Economic development and population health did not always move parallel in
Europe. – p. 6
• The acceptance of measures to reduce health risks also often required socio-
cultural change, and the effective implementation required institutions able to
deliver them on large scale, such as an effective public health sector and an
accessible health care system. – p. 6
o Political enterprise. – pp. 6-7
o National boundaries and political events (revolutions) often coincided
with sharp break-lines in population health. – p. 7
,• The epidemiologic transition theory:
o Proposed by Egyptian-American epidemiologist Abdel Omran (1925 –
1999). – p. 7
o It describes the mortality component of the demographic transition. – p.
7
o “Long-term shift […] in mortality and disease patterns whereby
pandemics of infection are gradually displaced by degenerative and
man-made diseases as the chief form of morbidity and primary cause
of death”. – p. 7
o The shift occurs in three stages:
▪ “The age of pestilence and famine” in which life expectancy
vacillat[es] between 20 and 40 years and mortality [is] high and
fluctuating. – p. 7
▪ “The age of receding pandemics” in which life expectancy
increases steadily from about 30 to about 50 years and
epidemic peaks become less frequent or disappear. – pp. 7-8
▪ “The age of degenerative and man-made diseases” in which life
expectancy rises gradually until it exceeds 50 years and
mortality eventually approaches stability at a relatively low level.
– p. 8
o Omran recognised that in Western Europe and North America the shift
started early and took about 100 years. → The ‘Western’ or ‘classical’
model of epidemiological transition. – p. 8
▪ Rising living standards as an important driver of population
health. – p. 8
o In other countries, notably Japan and Eastern Europe, the transition
started later but proceeded more quickly. → The ‘accelerated’ model. –
p. 8
▪ Public health and medical technologies more important drivers.
– p. 8
o Omran’s picture not accurate. – p. 8
• Two studies investigating the steep rises in life expectancy and national
income:
o Thomas McKeown (1912 – 1988):
▪ Decline in mortality as the result of the decline in infectious
diseases. – p. 9
▪ Infectious disease mortality decline for the most antedated the
introduction of specific medical interventions (e.g., antibiotics). –
p. 9
▪ The decline of mortality from infectious diseases in England and
Wales mostly due to a decline of air-borne diseases, and not
water-borne diseases (on which most public health interventions
were targeted). – p.9
, ▪ → Neither medical care or public health interventions could
account for the decline in mortality.
▪ → Thus, he thought the alternative explanation to be nutrition. –
p. 9
o Samuel Preston (1943):
▪ The ‘Preston-curve’ related national income to average life
expectancy at birth. – p. 10
• People in richer countries on average live longer than
people in poorer countries. – p. 10
▪ The upward shift in the curve explained more of the global rise
in life expectancy between these points in time than rising
national incomes. – p. 10
▪ Preston thought that other factors such as public health
programs, maternal and child health services, and antibiotics
probably accounted for a sizable part of the rise in life
expectancy between the 1930s and 1960s. – pp. 10-11
• Mackenbach identifies five types of developments that underlie the long-term
improvements in population health:
o 1) Changes in human health as a result of changes in living conditions
which happen without any human involvement. – p. 11
▪ E.g., climate changes. – pp. 11-12
o 2) Changes in human health as a result of changes in human
behaviour or of man-made changes in living conditions, which are
actively pursued but for reasons completely unrelated to health. – p. 12
▪ E.g., changes due to the shift from an industrial to a service
economy. – p. 12
o 3) Changes in human health as a result of changes in human
behaviour or of man-made changes in living conditions, which are
pursued for reasons indirectly related to health. – p. 12
▪ E.g., changes in agricultural methods or for reasons of
cleanliness. – p. 12
o 4) Changes in human health as a result of public health interventions.
These are changes in human behaviour or living conditions, which are
pursued for reasons directly related to health, but involve actions
outside medical care. – p. 12
▪ E.g., changes in smoking in response to health education
campaigns. – p. 12
o 5) Changes in human health as a result of medical care. These are,
like category 5, by definition pursued for reasons directly related to
health, but involve actions in an individual contact between a health
care professional and a patient seeking care. – p. 12
▪ E.g., changes in survival rates from cancer due to improvements
in cancer treatment. – p. 12
, • Of these categories, only the changes under category1 are ‘completely
spontaneous’. – p. 12
• Of these categories, only the changes under category4 and category5 are
definitely ‘intentional’. – p. 12
• Of these categories, category2 and category3 are somewhere in-between
‘spontaneous’ and ‘intentional’. – p. 12
o However the changes made in these categories are considered ‘man-
made’. – p. 12
▪ This also explains how changes in population health are so
closely related to economic, political, and socio-cultural
conditions. – p. 12
• An ‘inconvenient truth’ is that the fastest advances in population health
occurred under conditions of political oppression. – p. 14
o The same applies to economic underpinnings: economic growth was
partly dependent on the exploitation of colonies and the massive
burning of fossil fuels. – p. 14
o Furthermore, human population numbers have increased and as a
result other living species have suffered. – p. 14
• “This book is unashamedly ‘Eurocentric’.” – p. 16
• The political map of Europe ahs changed repeatedly. – p. 16
• This book’s starting point is the early 18th century. – p. 17
• Population health: the people’s health. – p. 18
o Two main things societies do to protect and enhance the population
health:
▪ 1) Public health. – p. 18
▪ 2) Delivering medical care. – p. 18
▪ → But there are several other factors. – p. 18
• Public health: the art and science of preventing disease, prolonging life, and
promoting health through the organised efforts of society. – p. 18
o Includes activities such as food inspection, vaccination programs,
tobacco control policies, road traffic safety measures, etc. – p. 18
• As a result of people’s more frequent contacts with the health care system
and the greater accuracy of diagnostic methods, less disease goes
undetected now. – p. 20
o This warns us against taking the 20th century rise of diseases like
ischaemic heart disease and cancer at face value. – p. 20
J. P. Mackenbach – A History of Population Health. Rise and Fall of
Diseases in Europe: Chapter 2: Long-Term Trends in Population Health
• Mackenbach starts his analysis by looking at mortality trends because death
usually follows disease, and therefore mortality rates tell us about the
frequency of disease. – p. 25
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