sewage plant

The health of the American people has risen and fallen with fluctuations in the health of its poorest. Although more vulnerable in the past, the affluent have generally managed, major epidemics aside, to stay healthier than other Americans. Going back centuries, they regularly had nutritious food, usually clean water, decent shelter, and the ability to leave town in malarial season. The lower classes, particularly their children, were ill in normal times and especially vulnerable to periodic epidemics

One of modern America’s great achievements is the extension of the average life span, from about 40 years for a just-born infant several generations ago to about 80 years now.

sewage plant

That doubling was accomplished largely by improving the health of less fortunate Americans through public health projects. In a new paper, the eminent economic historian Dora Costa provides an overview of America’s health history which emphasizes the importance of those projects in the late 19th century. Reading her essay raises the question, Where are the equivalent public health projects of the early 21st century?


America’s health history is not one of steady progress. In the 18th and early 19th centuries, Americans lived notably longer and healthier lives than Europeans did. That era probably created the enduring image of the big and hearty American, an image that outlasted reality. In the mid-19th-century, Americans’ health deteriorated. Average life spans shortened and average height, a good indicator of childhood health, shrank.

The reasons for this regression are still uncertain but probably entail both higher infection rates in the growing cities and reduced nutrition around the nation. Americans’ health then improved sharply over the course of the twentieth century, although we are now behind Europeans in height and, indeed, probably last among comparable nations in health overall. (See earlier posts, here and here, for details.)

Costa suggests that America’s health history has four phases:

The first period, in the 1700s and early 1800s, was one of a relatively good disease environment and high nutritional availability…. The second period, from the 1830s to the 1880s, was one of a worsening of the disease environment (and perhaps of nutritional availability)…. starkest in urban areas. The third period, from the 1880s to the early 1900s, saw the introduction of a new technology – public health. The new technology was a public good. In contrast, during the fourth period, from the 1930s or 1950s to the present, the new health producing technologies were private goods [drugs, therapies, and “effective health habits”].

While the current, fourth phase is certainly extending lives, health improvements these days are minor compared to those achieved in the third phase, the era of major public health investments. Progress today depends much more on individual initiative and resources. Eventually, new drugs become generic, new treatments become standard practice, and new ideas spread, helping most Americans. But in each case, the well-off are years ahead of others in reaping the benefits. The dynamics of the previous, third phase were quite different.

Health as a public good

In the late 19th and early 20th century, local, state, and federal authorities (and in some cases, philanthropies) invested heavily in public projects that largely eliminated or contained the spread of infections — projects such as sewage systems, water treatment plants, mass vaccinations, milk and food inspections, housing codes, and hookworm and malaria reduction campaigns. Also, relief campaigns in bad times sustained nutrition among the unfortunate. These public initiatives were dramatically effective, propelling Americans to longer and healthier lives in the 20th century.

Costa asks: Why were affluent Americans c. 1900 willing to pay for costly projects that mainly helped the poor, the immigrant, and the black? She speculates that their support was self-interested. The well-off understood, germ theory now being accepted, that by stopping epidemics and reducing the circulation of infections, most of these initiatives helped protect their own families, too.

And, now?

The U.S. now trails the western world in overall health. What are the 21st-century public projects that might improve our health? Universal health insurance, particularly with its provision of preventative care, comes to mind. However, Costa notes that research so far has found that insurance expansion saves Americans money but does not necessarily improve their health.

Another direction is to expand “nanny-state” nudges toward better health behavior. The anti-smoking campaign is a model: higher taxes, public- service advertising, and constricting regulations have reduced smoking and improved health. Would Americans support similar campaigns to discourage sugar and fat consumption or to encourage more exercise? The backlash against former New York Mayor Bloomberg’s effort to restrict sugary sodas suggests not. What about stronger regulation of environmental risks? The recent trend here seems in the other direction, as illustrated by toxic spills into drinking supplies.

Is there a will this century among the better-off to pay for public health projects that would mainly help the less well-off? Politicians have been eager in recent decades to support R&D on major chronic diseases, but most of that work leads to private Big Pharma applications and individual treatments.

Perhaps it falls to the health-cost crisis faced by Medicare and by purchasers of private insurance like major corporations to generate the 21st century willpower needed to improve the wider public health for the public good.

Cross-posted from Claude Fischer’s blog, Made in America: Notes on American life from American history.