| Book Review | Health and History, 9.1

Book Review

Differing Approaches to Public Health History: A Review Essay

Criena Fitzgerald, Kissing Can Be Dangerous: The Public Health Campaigns to Prevent and Control Tuberculosis in Western Australia, 1900–1960 (Perth, WA: University of Western Australia Press, 2006). ISBN 1 920694 78 1 (hardcover), ISBN 978 1 920694 78 4 (paperback). vii + 264pp

Patrice Bourdelais, Epidemics Laid Low: A History of What Happened in Rich Countries (Baltimore, MD: Johns Hopkins University Press, 2003). ISBN 0 8018 8294 X (hardcover), ISBN 0 8018 8295 8 (paperback). xiv + 176pp

Scott H. Podolsky, Pneumonia Before Antibiotics: TherapeuticEvolution and Evaluation in Twentieth-Century America (Baltimore, MD: Johns Hopkins University Press, 2006) ISBN 0 8018 8327 X. x + 254pp.

While these three books fall within the ambit of public health history, their approaches, methodologies and narratives are as far apart as the three continents from which they emanate—Australia, Europe and America. Yet all have something to contribute to the discipline.

Criena Fitzgerald's book on the antituberculosis campaigns in Western Australia from 1900 to 1960 emerged from her PhD thesis from the University of Western Australia, where she is currently a postdoctoral fellow. The title of her book Kissing Can Be Dangerous and the delightful cover photo indicate its social history orientation. Taken from a 1948 health education pamphlet, the title epitomises the public health approach to the disease in the early-twentieth century, following Robert Koch's 1882 identification of the tubercle bacillus and the new understanding of the infectious nature of the disease. Not only could kissing spread germs, but it could lead to immorality and the frequenting of unsafe public places, predisposing people to tuberculosis. Fitzgerald explains that in the early-twentieth century the antituberculosis campaign was premised on controlling behaviour. Yet, equating tuberculosis with uncleanliness, immorality and intemperance had the effect of stigmatising those with the disease, making the social consequences of the disease sometimes worse than the physical symptoms themselves. It was also counter-productive for the public health campaign as it led people to hide their infection. Doctors colluded with patients to conceal their disease from public health authorities, as reporting them held no obvious benefits for doctors and affected their relationship with patients. However, this public and medical approach to the disease changed in the 1940s and 1950s when tuberculosis was reframed and became 'everyone's business.' A Tuberculosis Act in 1948 provided federal funds to address the social and economic needs of the tuberculosis patient, while a mass X-ray campaign was launched in the 1950s for early detection. Those who complied were 'good Western Australians'; sufferers from tuberculosis were now regarded as safe while those who had not had an X-ray were considered unsafe. The postwar campaign succeeded, Fitzgerald argues, because it addressed social inequalities caused by the disease and because it had been accepted as a community concern.

In her introduction Fitzgerald states that she is not attempting a comparative history, either with other states of Australia or with other countries, although she does reference studies from elsewhere where appropriate. However, she should have provided a justification for the narrow focus on one Australian state, beyond the fact that this was the subject of the PhD thesis. A discussion of what was unique or distinctive about Western Australia and also the ways in which it reflected broader policies (for Australia at least) would have given it a wider appeal to an international audience. Clearly there are features which were distinctive, such as its status as a health resort for tuberculosis sufferers, its sparse and scattered population and its mining industry—all of which are explored to some extent but not set in an international or even a national context.

Fitzgerald draws on oral histories of patients and doctors to construct her social history, as well as archival research. By contrast, Epidemics Laid Low: A History of What Happened in Rich Countries, by Patrice Bourdelais, professor at the École desHautes Études en Sciences Sociales in Paris, is a synthesis based exclusively on secondary sources. While Fitzgerald's study focuses on one disease in one Australian state over a period of sixty years, Bourdelais's book spans all infectious diseases and all Western European states. His story starts with the bubonic plague of the Middle Ages and finishes with the late-twentieth-century AIDS epidemic. Addressing broad public health policies and the scientific discoveries which affected them, Bourdelais's is a top-down study; there is little room for patients' experiences here.

Bourdelais provides an account of 'the politics of the struggle against epidemics,' and 'the multiplicity of factors which produced this progress,' including the policies of national and local governments, public demands, the role of doctors, scientific discoveries and access to care. In doing so he ranges across several nation states, though with a special emphasis on France. Also striking is the language he uses, adopting the military metaphors of his protagonists, the public health reformers through the ages. For example, he includes in his 'list of twentieth-century medical achievements' the 'defeat' of rubella (p.123). He concludes that factors which led to the great progress in 'rich' countries remain unavailable today in poorer countries. He sees the developing world as being in a similar situation to nineteenth-century Europe and advises the developed world to address the problems of these poorer countries.

Like Fitzgerald, Bourdelais writes that public health measures were accompanied by a degree of social control, with reformers setting out 'to improve the habits and morality of the working class, as well as their respect for cleanliness, their life-style preferences, their childcare practices, and their social life' (p.153). He tells us that 'Prostitutes were the object of a powerful social stigma, as were people with syphilis and even people with tuberculosis; such people were blamed for their illnesses, which were seen as the result of unhygienic behavior.' However, he puts a different spin on it from Fitzgerald when he admonishes that 'not one country experienced a reduction in infectious disese mortality without first having a public health policy that imposed numerous constraints and involved changes in life-styles. It's as simple as that!' (p.153) One wonders about the implications of this statement for his conclusion about the need to support current immigrant groups and the poorest countries to promote global health.

Scott Podolsky's study, Pneumonia before Antibiotics, is not about 'rich' and 'poor' countries over the centuries, but concentrates exclusively on twentieth-century America. He provides a history of a set of specific therapeutic interventions, the treatment of pneumonia before the advent of antibiotics in the 1940s. While the subject matter is therapeutics, it qualifies as a public health history because, as he explains, the antipneumonia treatment was translated into a public health issue in the 1930s. A lecturer in the Department of Social Medicine at Harvard Medical School and an internist at Massachusetts General Hospital, Podolsky deals with one disease entity like Fitzgerald, but is more interested in scientific and medical debates than with social and cultural aspects. The disease he has chosen to focus on is also quite different from tuberculosis, as he explains. One notable difference is the attention, or lack of attention, paid to this disease by historians, in stark contrast to the voluminous studies of the history of tuberculosis. Historical inquiry into pneumonia has focused upon penicillin as the great breakthrough. Little heed has been paid to the prepenicillin era, yet Podolsky argues that this was a very formative period in the treatment of the disease. His sources consist of the published literature from the scientific and medical communities and archival records left by key individuals, such as infectious disease specialists, insurance company executives and pharmaceutical agents. Like Fitzgerald and unlike Bourdelais, Podolsky's study is based on primary research and the text is supported by extensive endnotes.

While Bourdelais covers heavily traversed grounds in public health history, though providing his own insights along the way, Podolsky thus examines a forgotten or unexplored aspect of medical history. He investigates the development and use of antipneumococcal serotherapy in America from the 1890s to the 1940s. He argues that this foreshadowed the medical profession's focus on therapeutic specifics, which was so pronounced in the postwar antibiotic era. The antipneumocococcal antiserum trials also served as an important though historically neglected foundation for the later and more extensive chemotherapy trials. Podolsky makes an important point about public health history when he notes that pneumonia was construed as a community health program in the 1930s but not in the 1940s, indicating the politically-constructed nature of what constitutes public health. His study also throws light on the antibiotic revolution itself. Antipneumococcal serotherapy was deemed revolutionary in the years and even months before the arrival of the sulfa drugs, as it was founded on the tenets of applied immunology and justified by controlled clinical trials. While the arrival of chemotherapy and antibiotics have been historically regarded as revolutionary, Podolsky shows that at the time they were perceived as attractive alternative specifics rather than as revolutionary approaches to pneumonia. Yet by the end of the 1940s antipneumoococcal serotherapy had been relegated to the dark ages of medicine, if it was remembered at all.

These three studies thus provide contrasting approaches to the history of public health and health policies. Bourdelais provides the broad sweep and an evaluation of past trends, focusing on the work of famous scientists, their discoveries, and their application. By contrast to Bourdelais' 'macro-history,' Fitzgerald's work can be described as 'micro-history.' This gives her the opportunity to explore the social and cultural ramifications of disease and public health interventions, and in this way contribute to the large and growing number of historical studies of tuberculosis. Podolsky explores an under-researched disease entity, though unlike Fitzgerald he focuses largely on medical and scientific debates. Comparing these three histories shows how varied public health history can be, in subject matter as well as approach and methodology.

LINDA BRYDER

UNIVERSITY OF AUCKLAND

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