Health and the Rise of Civilisation 
by Mark Nathan Cohen.
Yale, 285 pp., £22.50, October 1989, 0 300 04006 7
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Nutrition and Economic Development in the 18th-Century Habsburg Monarchy: An Anthropomorphic History 
by John Komlos.
Princeton, 325 pp., $45, November 1989, 0 691 04257 8
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Early in the 18th century, the populariser of Newton and fashionable physician George Cheyne advanced his own medical ‘inverse square law’: the health of nations varied in inverse ratio to the wealth of nations. The greater the progress this country had made – in material goods, urbanisation, leisure and civility – the greater the visitations of sickness upon her people. An entirely new name was needed for this phenomenon: the ‘English Malady’ described a chronic degenerative nervous disorder, commonly culminating in suicide. Civilisation, Cheyne contended, had always been the cradle of sickness. Egypt and Greece had often been praised for inventing medicine, but such credit was out of court. Earlier societies had had no need of doctors, for they had suffered little disease. It was sedentary cultural centres and the civilising process itself which had bred sickness.

Cheyne was neither a social radical nor a political reformer: he did not use his disquiet about the price of ‘progress’ or the ‘diseases of civilisation’ as a stick to beat his contemporaries. But he was succeeded by one who did just that: Jean-Jacques Rousseau. In his early Discourses, Rousseau condemned his times, claiming that as material culture, political society and the arts and sciences had advanced, poverty and oppression had mushroomed, and pristine salubrity turned into sickness.

Ever since Rousseau formulated his perverse paradoxes, we have been on our guard against critics who discern in progress mainly a multiplication of miseries: ill-health, hunger and impoverishment. We tend to see their kind – from Sixties hippies, through Ivan Il-lich, to the Greens – as peddlers of pastoral or moralists of mortification. The urge to expose such myth-spinners should not short-circuit an authentic argument, conducted with epidemiological facts and figures. To put it bluntly, have things been getting better or worse?

It is not the least virtue of Mark Nathan Cohen’s revaluation of the ‘diseases of civilisation’ question that he does not push a simple solution. He offers a qualified pessimism about the past, and a question-mark for the future. Cultural anthropology and economic history have generally told uplifting tales of the transition from savagery to civilisation. The life of the hunter-gatherer was nasty, brutish and short, as in the Hobbesian stereotype of the state of nature. Then, thanks to hom. sap’s superior capacities, collective development and technological ingenuity begat agriculture in the Neolithic age, permitting the better exploitation of nature, and leading to improved nutrition and greater security. Sedentism spurred the division of labour, bringing further efficiencies: the arts improved and commerce spread, increasing wealth and diversifying diet. More sophisticated socio-political organisation afforded additional protection against nature and better welfare provision. Eventually, science, technology and industrialisation brought affluence to the ‘developed world’, just as it is destined to bring affluence to the underdeveloped world.

It is in this conventional wisdom, argues Cohen, an archaeologist, that the myth-making lies. Its premises are belied by anthropologists’ evidence of hunter-gatherer peoples – pygmies, aborigines, eskimoes – and by archaeologists’ reconstructions of our own early forebears. Concentrating on the !Kung San of the Kalahari and the Hadza of Tanzania, Cohen argues that these wandering bushpeople generally enjoy an adequate diet – low in calories but rich in protein and rather varied. There is little sign of serious malnutrition or deficiency diseases. In fact, the bushpeople enjoy relatively disease-free existences. This is thanks to a combination of factors: the dryness of their environment, transhumance (they move on before their own fecal waste becomes a health hazard), isolation from other potential disease-transmitters. Archaeological evidence – above all, the inferences made by paleopathology from early bones and teeth – corroborates these findings. Our Stone Age ancestors do not seem to have been decimated by smallpox, measles, typhoid, or most of the other bacterial and viral epidemics which proved lethal later on.

This situation was not to last. Skeletal analysis from Neolithic times onwards squares with studies of impoverished sedentary peoples in today’s Third World to suggest that agricultural intensification, denser populations and the growth of extensive trade networks amount to a familiar case of the ‘failure of success’. Life in insanitary settlements, lived in intimate proximity to domesticated animals, surrounded by vermin, insects and micro-organic parasites, multiplied the range of diseases to which populations succumbed: water, air and vector-borne infections (malaria, dysentery, schistosomiasis and so forth) became the pitiless destroyers they remain to this day in many parts of the world.

With the coming of agriculture, even the food problem may have worsened. How do we unravel this paradox? It can be argued that sedentism increases the vulnerability to climatic disasters – nomads just move on. In the long run, tilling the soil, accompanied as it usually is by the intrusions of trading, tribute, taxation and other political extortions, tends towards monoculture. And monocultures carry further environmental hazards in their wake. They often encourage dietary imbalances of one kind or another, which lead to pellagra, marasmas, kwashiorkur, scurvy and other deficiency diseases.

Above all, however, it is population pressure which becomes the evil demon. Hunter-gatherer groups are stable and healthy so long as they remain tiny: today’s surviving bands seem to enjoy salutarily low fertility. It was probably population growth which necessitated the invention of agriculture, with its higher yields. This permitted, or encouraged, further demographic growth, but parasites and vectors typically survive and thrive only among dense human aggregations and pestilence was the chief consequence of – and check on – growth.

Malthus is thus in a sense vindicated by Cohen’s temperate and tentative synthesis. Human ‘development’ from caveman to combine-harvester is better seen not as pure progress – spontaneous and unalloyed betterment – but as a series of rather desperate holding operations designed to meet urgent demographic demands, each subject to the law of diminishing returns. ‘Progress’ has its costs. Yet, as John Komlos argues in his subtle ‘anthropometric’ account of economic development in the 18th-century Habsburg Empire, the real point about the history of the West over the last couple of centuries is that Malthusian crises have been held at bay, perhaps rendered a thing of the past: population pressures have provoked progress. As may be inferred from the diminishing height of recruits into the Austrian Army, the nutritional status of Habsburg subjects was deteriorating during the 18th century even as population levels rose: a scenario surely ripe for classic positive Malthusian checks, as had occurred so devastatingly during the 14th and, to a lesser degree, the 17th centuries.

Yet this was not the outcome. Intelligent measures advanced by Maria Theresa and Joseph II, relaxing feudalism and opening labour markets, stimulated economic activity; advances in production met the dangers of the population surge, for rising wealth enabled food to be bought in from outside. Central Europe successfully industrialised, albeit with a stunted and disease-susceptible work-force, and industrialisation proved an antidote to Malthusian immiseration.

Much the same happened, although on a more spectacular scale, in Georgian England, where, in addition, the cheap grain of the 1730s and 1740s meant that the population surge began from a sound nutritional base, allowing the nation to take full advantage (through labour accumulation and economies of scale) of rising numbers. The higher productivity and income brought by rapid industrialisation afforded, at long last, an escape from the Malthusian trap. Or, rather, it permitted England to export her potential Malthusian crisis to Ireland, whose economy was rendered increasingly subservient to English food needs with catastrophic results in the mid-1840s.

In other words, as both Cohen and Komlos perceive, Malthus’s scientistic biologism provides an impoverished economic framework, in that it omits the political dimension. From prehistorical times onwards, the worsening plight of the destitute, malnourished and diseased has been the product not just of nature but of human powers. Increasing internal social stratification enabled the rich and strong to seize the benefits of a larger cake. Latterly, precisely as happened in Ireland in the age of the Great Famine, colonialism has replicated this process on a global scale, with the developed nations creating underdevelopment. Komlos’s more optimistic reading invites us to dwell on the superior productivity of modern technologies and economies: Cohen’s bleaker vision insists that we remind ourselves that these modern systems have operated in circumstances in which myriad mouths have to be fed, there is a gross maldistribution of resources (agribusiness) and terrifying disease mobility. European colonial powers found from the first that germs were more effective than guns as weapons for subjugating peoples overseas.

In today’s world, population is rising faster than ever, having doubled twice this century and being likely to do so again before 2030; and the traditional trinity of Malthusian positive checks (war, famine and disease) has been joined, by a fourth, unknown to the dismal parson: eco-disaster. Should we therefore conclude that civilisation does not merely bring its own special diseases and discontents but is inherently pathogenic? Here, as Cohen sensibly concludes, the evidence is harder to assess. There seems to be no reason to demur from his finding that even in the more spectacularly ‘advancing’ or ‘advanced’ systems – Europe as it developed from Medieval through to early industrial times – threats of deadly famine, or at least of dearth and malnutrition, became – and long remained – grave, and wave upon wave of epidemics drove morbidity and mortality to appalling peaks. After all, commercial and colonial powers did not merely export lethal diseases, such as measles and smallpox: they also imported plague and cholera. Over the course of several centuries, rural displacement, high-density urbanisation and proletarianisation proved a bonanza for pathogens. George Cheyne and all the 19th-century prophets of doom were perhaps right, and even Rousseau’s ideological axe-grinding cannot be dismissed.

Yet, as Komlos insists, the familiar dismal Malthusian equation of demographical pressure with famine and epidemics does not seem to have been inescapable, either biologically or politically. A simple historical juxtaposition may be illuminating. In the 18th and 19th centuries, when urbanising Europe was reeling from epidemic body-blows, Japan seems to have stayed astonishingly healthy – to some degree because of isolation from world trade, but more, it seems, because of effective, custom-sanctioned, preventive health habits.

In any case, populations adjust. From the mid-19th century, in a manner which Malthus failed to predict, population pressure began to slacken in the advanced nations, while at the same time a decline in the mortality rate began to be apparent. These trends were probably not the result of any revolutionary medical breakthroughs, but were rather the product of growing affluence and improved public health conditions. James Riley has recently argued, in Sickness, Recovery and Death, that this transition was itself ambiguous, best regarded as a move from a ‘high death culture’ into one of ‘high sickness’. For all the ingenuity of his reasoning, this view seems wide of the mark: it appears that we can all now expect to lead longer, more able-bodied and healthier lives than our predecessors. In other words, it seems that some peoples have been fortunate enough to make the transition full circle from the so-called healthy ‘affluent bushman’ to the healthy ‘affluent Westerner’. In both instances, though under quite distinct circumstances, limits to fertility seem to have facilitated such blessings. This apparent escape from the Malthusian treadmill affords some hope for the future; it is one all peoples should be entitled to enjoy.

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