History as a Determinant of Health
The social, economic, and environmental conditions that shape the health of populations are not just the products of contemporary circumstance; they are part of an historical continuum. The effect that historical factors like war, economics, intellectual movements, and mass migration can have on the long-term health of populations argues for a consideration of the past itself as a determinant of health. With this in mind, and in keeping with the aspirations of SPH Narrative Month to “represent and reflect on the structures that affect health,” a Note on how the past influences the present, and how an understanding of history can help us create a healthier world.
Wither history? The arc of history can teach us much, particularly—as it relates to the concerns of public health—by fostering an understanding of how factors that may not seem germane to health at a fixed historical moment are often deeply relevant in the long run. Consider the rise of US life expectancy during the 20th century. In 1900, life expectancy in this country was about 47 years. It is now about 79 years. What accounts for this shift? To someone with the dramatic technological breakthroughs of the last century fresh in mind as they consider the latter half of that century, the answer would likely seem easy: better drugs and treatments. It is not difficult to see why this opinion might prevail—from vaccines, to surgical procedures, to advances in genomics, the 20th century was undeniably a time of amazing medical progress, and this progress has certainly helped to prolong life. However, a broader look at the history of the period suggests that the fundamental difference was made by steady improvements in living standards—initially catalyzed by the Industrial Revolution—better nutrition, and signal achievements in public health. An historical perspective therefore helps us to recognize what has mattered most over time, and what might matter today, and in the future.
History also sheds light on the roots of present-day health disparities in the US. This is especially true in the case of American slavery, and the legacy of black marginalization that we continue to live with. The most overt consequence of slavery, our country’s ugly history of racism, has shaped our society in many ways, with direct implications for public health. Take, as one example, the area of housing policy. I have previously argued for the centrality of housing to public health. Housing, and housing affordability, affect everything from our proximity to residential exposures—shaping early childhood development—to the presence of fire hazards, to income. The burden of poor housing has historically been, and remains, disproportionately borne by blacks. About 7.5 percent of non-Hispanic blacks live in substandard housing, compared to just 2.8 percent of whites. This disparity is the result of a mix of government policies and real estate dealings that have created a kind of de-facto segregation in many of our cities. Chicago is a case in point. 500,000 blacks moved to the city between 1916 and 1970 as part of the Great Migration—a period when more than six million blacks moved from the rural South to cities in the North, Midwest, and West to find economic opportunities and escape the restrictions of Jim Crow. During this time, Chicago real estate commissions adopted racially restrictive policies to “contain” the black population in certain parts of the city. In the 1930s, these practices were bolstered by New Deal-era “redlining” policies, which codified racial prejudice into the insurance and lending policies of the federally-funded Home Owners’ Loan Corporation, laying the groundwork for housing disparities that persist to this day. As we work to mitigate these disparities, an awareness of how they arose helps us to see that fair housing is not just a question of promoting smarter, healthier policies; it is a question of correcting an historical injustice.
It is not surprising that history also teaches us how health is shaped on a global scale. Last May marked the 100th anniversary of the Sykes-Picot Agreement, a pact which led to innumerable hardships in the Middle East, creating the conditions for much of the region’s current unrest. Sykes-Picot was a secret post-World War I agreement between Great Britain and France to divide the Arab lands of the defeated Ottoman Empire into “spheres of influence” to be shared by the two countries. Notably, the agreement established the rough outlines of what would become Syria and Iraq (Figure 1).
The borders of the agreement were drawn with little consideration for the political or cultural composition of the people who were to live in them, setting the stage for decades of sectarian conflict. The failure of the agreement, and the unstable political order it inaugurated, continue to characterize much of the Middle East, from the war in Syria to the activities of ISIS. The population health consequences of such conflict can be devastating, threatening the mental and physical health of thousands, even millions. War also means refugees, who, in addition to the xenophobia they often face, have their own distinct health challenges, including the problems of post-traumatic stress disorder (PTSD) and unsafe conditions in refugee camps. The history of Sykes-Picot argues, I think, for greater awareness of how seemingly abstract geopolitical decisions can have powerful ramifications for the health of populations, emphasizing the ineluctable role of politics in shaping the health of populations.
Finally, there is value in studying history as it relates to public health itself, enriching our perspective and helping us to think critically about our field. The CDC’s “10 Great Public Health Achievements”—a resource I have referred to frequently in these Notes—is an excellent place to start. By providing a brief history of public health successes, such as the story of immunization in the last century and the widespread reduction of motor vehicle deaths through policy changes and education campaigns, we are able to learn about public health at its best, gaining both inspiration and practical insights. Our study of history is incomplete, however, if it does not also take into account the failures that, at times, characterize the work of any large-scale, intergenerational effort. In the case of public health, this is amply represented by the Tuskegee Study, which followed a cohort of nearly 400 syphilitic black men over the course of 40 years in Alabama, without ever informing them that they had the disease or providing treatment. The study, which ruined the lives of many of the participants, remains a blot on the record of public health, never to be forgotten, catalyzing future discussions of medical ethics and the enduring challenge of racism in the US. A study of all aspects of our history in public health, both negative and positive, can help us better see that public health is a deeply human affair, full of triumphs and blunders; high ideals, and, occasionally, profoundly misguided actions. This can perhaps help us move well beyond our present moment, putting what we do today in clearer perspective.
At SPH, we engage with history in a number of ways. The work of Professor Michael Grodin—in particular his study of Jewish medical resistance during the Holocaust—teaches us about public health’s response to perhaps the darkest chapter in our history, and how we might think about questions of religion and morality under the most harrowing of circumstances. Professor David Jones has done much to illuminate the history of poverty, through his exploration of the legacy of Robert Kennedy and the social determinants of health in the Mississippi Delta. Through our Racial Justice Talking Circles, we are empowered to consider the historical factors that shape our own privilege, working towards a more nuanced grasp of the present through a better understanding of the past. This speaks to the responsibility of public health to bear witness, not only by acknowledging past events, but by communicating how our history informs the present moment in immediate, ever-unfolding ways.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Robert A Knox Professor, Boston University School of Public Health
Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.
Previous Dean’s Notes are archived at: http://www.bu.edu/sph/tag/deans-note/