History rarely repeats itself in any exact sense, but the research of professional historians can offer much to contemporary public health and other policy practitioners.1 History provides a rather longer time frame and a wider context for understanding the causes of a current problem, and these can both be crucial to its satisfactory resolution. History is alive to the importance of context, the precise sequence of events, and differences of perceptions and power that generate conflicts and misunderstandings. Historians locate the present within a dynamic flow of structures, relationships, and attitudes that have a momentum that needs to be researched and acknowledged.2 Well-intended, methodologically rigorous, and supposedly theoretically sound public health or development policy interventions applied in ignorance of these historicist factors are often doomed to fail or generate unfortunate unintended consequences when implemented.
Furthermore, although they may fail to consult relevant studies by professional historians, all policy interventions do make implicit background assumptions about historical change. Typically, the assumption is made either that history is irrelevant (because history is somehow stuck in the past) or that history is a familiar, easily knowable linear trajectory, termed the demographic, the health, the epidemiological, or the epidemiologic transition. Studying professional history can emancipate policy practitioners from these misleadingly simplistic assumptions.
Historical research has the capacity to spring very significant surprises. It can transform the imaginative resources available to policymakers, forcing both a reconsideration of the validity of current approaches and a reassessment of the feasibility of radical alternatives.
The Institute for Public Policy Research prize-winning essay that Hilary Cooper, Ben Szreter, and I wrote exemplifies this. The commonplace assumption today that universal welfare systems are a product only of the mid-twentieth century, established after “modernization,” when Western liberal democracies became rich enough to support this “luxury,” is entirely wrong. The causation goes in the other direction. In England, the epicenter of modern economic growth circa 1780 to 1850, the population had, uniquely, already enjoyed universal social security and health care for two centuries. These policies endowed its “modern” economic growth with voluntary labor mobility, hence more prosperity than any other country.
THE ELIZABETHAN POOR LAW
Although now largely forgotten or unknown, the Elizabethan Poor Laws of 1598 and 1601 established the world’s first universal social security and welfare system: an absolute entitlement to life-preserving “relief” for every subject, primarily in the form of payments in kind or cash and medical attention. Poor Law funding, administration, and legal oversight were radically devolved. Each of the approximately 10 000 Anglican parishes of England and Wales had to establish a fund that would support orphans, widows, the old and disabled, the ill, and the involuntarily unemployed all year round in response to demand. It was funded by a progressive principle of taxation on the value of land in every parish.3
England soon became the first nation in Europe to be free from the age-old devastating insecurity of famine. From a position of economic backwardness in the late 16th century, it began to outperform the rest of Europe, which it did for the next 250 years. The economy urbanized rapidly as labor streamed from the countryside to towns and cities to take better-paying artisanal and manufacturing jobs, safe in the knowledge that the elder generation was provided for in the rural parishes. This labor mobility was crucial for England’s sustained economic growth, powered by a 350% urbanization rate circa 1600 to 1800—compared with just 10% to 25% elsewhere in Europe.4 The endpoint was the steam-driven Industrial Revolution and an unprecedented peak in labor productivity growth, at over 1% per annum, sustained from 1850 to 1873.
POLICY ORIGINS OF RELATIVE ECONOMIC DECLINE
The succeeding policy, the 1834 Victorian Poor Law, was a harshly deterrent system of workhouses and hard labor in which husbands and wives were separated so they could not reproduce at the expense of the community. The individualist teachings of Adam Smith, Thomas Malthus, Benthamite utilitarianism, and providential evangelicalism formed the governing ideology of the new policy, which justified the British state’s failure to intervene decisively when more than a million died in 1845 to 1851 in Ireland’s famine, the worst such event in modern European history.5
Another consequence of the failure after 1834 to nurture its own working class was the decline, from the 1870s, of productivity growth in Britain—as a result of which the country lost its world-leading place to the United States and Germany. By contrast, these countries were early adopters, respectively, of universal secondary education and, especially in Germany, national social insurance for their populations. UK productivity did not recover until the first-ever majority Labour government of 1945 reimplemented the universal welfare provisions that had initially powered the Industrial Revolution, establishing the National Health Service, family allowances, national insurance, universal pensions, and secondary education for all.
HISTORICAL LESSONS FOR PUBLIC HEALTH POLICY
Two important lessons, of many, from British history should inform contemporary public health policies.
First, if it had been clearly understood in the critical period of 1975 to 1985 that Britain’s history demonstrated that the provision of a universal social security and primary health care system had fundamental importance for growing the economy, the Alma Ata Declaration, calling for such systems to be put in place in all less-developed countries, might have been followed through on.
Instead, because the declaration made its case solely on humanitarian grounds, as Packard and others have shown, this proved to be insufficient when its opponents argued that developing countries’ finances were too constrained for such humanitarian “generosity.”6 Consequently, the World Bank, through the 537 adjustment loans it made to 109 countries in the 1980s and 1990s, pursued an entirely opposite policy of “selective” primary health care, only—imposing user fees wherever possible, to simulate a US model of commercialized medicine.7 Because of resurgent neoliberal economics, represented at the World Bank by Chief Economist Anne Krueger, this policy embodied beliefs similar to those of Smith, Malthus, and their followers when they replaced England’s Elizabethan Poor Laws in 1834. According to neoliberal doctrine, developing economies should be opened up for free trade. Moreover, publicly funded and publicly provided services were deemed a costly “burden” impeding the growth of market economies. If the lessons of Britain’s economic history had been properly understood, it would have been more obvious that these neoliberal policies were a misleadingly one-sided view of the relationship between welfare and growth.
Furthermore, the health and mortality consequences of these policies, for Africa in particular, have been as catastrophic in some cases as the Victorian Poor Law was for the Irish peasantry in the 1840s. Economic growth in emerging nations, meanwhile, has been slow, uneven, and inegalitarian—especially compared with countries in East Asia that resisted taking the conditional loans of the World Bank and instead, like Britain had earlier, invested heavily in economic security and primary health care for their populace before embarking on projects to stimulate growth of a market economy.
Second, Britain’s history confirms that societies that assiduously protect their population’s positive health, education, and security from the vagaries of accident, illness, old age, and downsizing in a market economy can grow their economies most productively. The austerity policy of the UK government since 2010 is not only immoral (because it forces the vulnerable to bear the brunt of subsidizing remedial policies for the 2008 financial crash, which was caused by the actions of others, mainly financiers) but also completely misguided because it ignores historical evidence. History shows that welfare systems are not a luxury. If they are reduced or eliminated then the economy suffers, as well as the public’s health.
ACKNOWLEDGMENTS
Hilary Cooper and Ben Szreter coauthored the 20 000-word essay “Incentivising an Ethical Economics,” which was joint winner in July 2019 of the inaugural £100 000 Institute for Public Policy Research Economics Prize, the world’s third largest economics prize.
I would like to thank the anonymous referees for their thoughtful comments.
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.
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