Opinion, Berkeley Blogs

A history of health and health inequalities

By Claude Fischer

Water Treatment

The increasing delay of death for Americans over the last century or so has been extensive and consequential, probably in many profound ways that we do not fully appreciate. In the late 19th century, a newborn white boy would be expected to live, on average, to about 40; now, such a newborn can be expected to live into his late 70s. A ten-year-old then could expect to reach his late 50s and a ten-year-old can now expect to reach his mid-70s. Girls live longer and nonwhites shorter lives, but the trends have been dramatically upward for them, as well. Moreover, Americans’ health, while they lived, also improved markedly.

Water Treatment

How did this happen? Historians have excavated old health records and applied new techniques to parse out why better health and lower mortality occurred. In a just-published review of the topic, appearing in the Journal of Economic Literature, UCLA economic historian Dora Costa describes how the United States extended its people’s lives in different ways in different eras, depending in part on the nature of the health threat and on public will.


Costa describes four eras of health. First, up to the early 1800s, European-Americans were relatively healthy, tall, and long-lived, because they enjoyed a bountiful and nutritious natural environment, were an ocean away from the European plagues, and lived scattered enough so that epidemics were not as much a problem as in the old countries.

From about the 1830s to 1880s, conditions significantly worsened, with crowding in cities, immigration-borne diseases, and strains on food resources. Shorter lives and shorter Americans resulted.

The third era, the 1880s to about 1930, was marked with breakthroughs in science, technology, and public health that radically reduced disease and deaths, especially for young children. Clean water and effective sanitation were critical, as probably also were other public programs such as school vaccinations, milk inspections, air pollution controls, and mosquito abatement. Americans became taller and longer-lived. (The spread of smoking, by the way, would undercut some of this progress.)

The fourth era, the one that continues, has seen further advances in health and life spans, largely at advanced ages, but mainly in the form of what might be called private scientific means – medication for both acute and chronic conditions, medical devices, and surgery.


Costa also looks carefully at class differences in mortality and health. In the first, healthful period there appears to have been little inequality in health. In the second period, inequalities widened mainly because the poor lived in the most disease-ridden quarters and had the least means to buy soap, store fresh food, or have a private toilet. In the third period, the era of major public health interventions like water and sewage treatment, inequalities shrank dramatically. It was the poor who most needed and were most relieved by this new infrastructure.

1918 public-health poster

Now, in the fourth period, inequalities appear to be growing “because the new health-producing technologies [are] private goods requiring income to purchase and education (or its correlates) to use effectively.” The level of education matters more, in part because the less-educated have been likelier to smoke, but perhaps also because the new treatments, such as handling one’s diabetes, require more skill to maintain.

(A 2015 National Academies of Sciences report highlight the issue that this widening – the life expectancy of the well-off is rising substantially while that for the less well-off is rising slowly, if at all – means that the affluent will end up with yet more lifetime Social Security and Medicare benefits compared to the poorly-off who won’t have lived long enough to fully collect.)


Costa stresses that critical third era when local governments borrowed heavily to build public health facilities. That spending disproportionately helped the poor, immigrants, and blacks. The reason native-born, middle-class Americans supported such expenditures, she argues, is because, in the dense cities around 1900, they too were threatened by water-born diseases and by contact with the ill.

“The well-to-do were not more generous about health spending in the past, they were more self-interested because of fear of infectious disease. As chronic disease replaced infectious disease, health care has become more of a private good and is not necessarily viewed [by the well-off] any differently from other types of welfare spending” (italics added).

Costa points out, however, welfare-like interventions regarding health, such as adding people to Medicaid or otherwise subsidizing their access to the health system, do not, studies suggest, show substantial improvements in the health of the poor. (The programs seem to do a better job of protecting people from health-triggered financial crises.)

It may be (my suggestion) that allowing disadvantaged Americans a bit better access the current health system is not nearly as effective as would be some wholesale rebuilding of the health and health-care environment in the United States, a latter-day version of building the water and sanitation systems of the late 1800s.

Cross-posted from Claude Fischer's blog, Made in America: Notes on American Life from American History.