In these COVID times, nothing should be timelier than a historical comparison of epidemic disease control in two countries with advanced public health systems, Britain and the United States, yet which have struggled badly to contain the COVID pandemic. Charles Allan McCoy is perhaps unfortunate in that his books appeared just as the COVID pandemic took off, so he was unable to include it in his analysis. Still, he is able to consider epidemic disease control measures in the two countries from cholera in the early nineteenth century through to SARS, Ebola and Zika in the twenty-first century.
McCoy adopts the perspectives and methods of historical sociology for his comparison. In particular, he applies theories of path dependency and biopower to seek to make sense of the diverging approaches to disease control in the two countries over the nineteenth and twentieth centuries. In brief, his thesis is that Britain adopted a sanitary/social approach to disease control in the first half of the nineteenth century shaped by the miasmic theory of disease prevailing at the time. By contrast, he argues that the US adopted a more militaristic approach based on border controls and quarantine in second half of the century related to the increasing dominance of the germ theory of disease. In each case, he contends that once the policy had been set, feedback loops of response-formation cycles further embedded the initial approach.
In this reading, four factors then help explain the differences in response-formation cycles in the UK and the US. First, there were different levels of centralisation in each country (with the UK more centralised and the US decentralised). Second, medical authorities held different understandings of the diseases they faced (with UK consensus on miasma vs. US splits between miasma and contagion theory in the first half of the nineteenth century). Third, there were different degrees of imagining citizenry as a ‘social body’ (UK public health viewing the population as a social body vs. US focus on the private actions of individuals). Finally, there was voluntary organisations pressure to develop a coherent response to disease in the UK versus voluntary civic organisations focus limited to local support in the US.
The crux of McCoy’s argument is summed up late in the book: ‘One of the deep historical lessons learned by the British public health system is that the best way to manage an outbreak is through social unification and mutual support. This lesson is very different from what the United States learned by using compulsory quarantine, that is, society is best protected by isolating individuals that threaten the health of the majority’ (p.176).
Herein lies my difficulty with the book. To my mind, McCoy’s presentation of the history of British public health throughout the book is excessively idealised, and does not convey the complex, messy and contested nature of public health in Britain over the two centuries. From early on in the book, he refers to Britain taking ‘an integrated approach to disease control – considering its social, political and economic effects … For Britain, an outbreak of disease is a social problem that requires the coordination of the different elements of society’ (pp. 32–33). Similarly, ‘the British disease control system expanded to consider not only the physical condition of the working-class districts but also the social conditions of the working classes. Health officials began to consider how social problems of poverty, overcrowding, working conditions, the quality of working-class homes, and the lack of “wholesome” food and water influenced rates of disease’ (p. 72).
It is true that from the mid-nineteenth century, the British sanitary approach was concerned with environmental issues such as overcrowding, food and water quality. In addition, some public health leaders such as local medical officers of health were concerned with the underlying issues of poverty and inequality but this was by no means universal, and this did not remain constant over time. McCoy several times approvingly quotes Arthur Newsholme, Medical Officer for the Local Government Board 1909–1918, who spoke of the interconnectedness of public health and poverty, but does not mention his successor George Newman as Chief Medical Officer to the new Ministry of Health who took a much more individualistic approach to public health and downplayed the importance of poverty. Particularly during the economic depression of the 1930s, the Ministry of Health under Newman continued to ignore the evidence of malnutrition caused by poverty, preferring instead to emphasise such individualistic interventions as nutritional education for working class housewives.
Similarly, the book gives no sense of the vicissitudes of the British public health system over the period. For example, there is no mention of the wilderness years without an effective public health function from the abolition of the medical officer of health role in 1974 to the renewal in the late 1980s under the Chief Medical Officer Donald Acheson, nor the British government neglect and budget cuts from the mid-2010s which left the public health system unprepared for the COVID pandemic. There is also little evidence that British public health education campaigns were as effective or influential as McCoy at times suggests. Finally, McCoy overlooks the recent work by Roberta Bivins and others on the coercive and racist approaches to migration, ethnic minorities and health in post-war Britain that have more in common than he would appear to realise with the US approaches he critiques.
Overall, McCoy appears to have a more detailed knowledge of the history of public health in the US than in Britain. His main thesis on the role of path dependency in shaping the respective histories is thought provoking and provides a potentially useful framework for such a comparative historical analysis; however, a nuanced weighing of the evidence to substantiate his thesis is unfortunately lacking, at least on the British side of the comparison.
