Part 3: Start a Story with a Seed [1850 - 1970]
Cultural Evolution as a Praxis of Public Health is a series exploring the role played by Western cultural narratives in our current social problems. Over four posts, it questions our notion that the forward march of technological progress is a force of social salvation, using bodily health as a metric for success. It asks what it would take to change our cultural narrative, and what a more effective Western cultural narrative might look like.
As the good ship Humanity chugs along toward runaway climate change, I'm feeling a heavy drag of inertia in my bones. Inertia - the physical force that keeps an object traveling along its present course. This is a big vessel, and it is hard to turn.
Now, it doesn't help that there are sociopaths and sadists actively pulling in the wrong direction. [1,2] So has it always been. But enough ballast from regular folks is the only thing that ever turns the ship, and we don't yet have enough.
Millions or even billions, I think, suspect that on our present course we're bound for trouble. But in order for that wide a swath to start rowing in the same direction, they might first need an inkling of what that direction is. Letting go of a present bearing without a new course yet in mind is hard to do. It's risky: it could leave you adrift. So I'm wondering how we might alight upon and spread the good news of a new direction, to help more well-meaning folks start rowing together.
Old Story or New?
We took a good look in Part 1 of this series at the course that Western culture has been on for the past several thousand years. We looked at the dawn of agriculture, at the start of divisions of labour and more complex forms of politics, at successive phases of technological innovation and successive waves of conquest. For so long, our cultural bearing has been dead ahead toward more of this kind of progress. With human ingenuity as our compass, we believed, we could overcome any limits.
Looking at the data, though, it's clear to see that this proud story we've told of ourselves is exactly wrong. Through most of our culture's history, we were healthier physically and socially when we lived closer to the whims and vagaries of the natural world than we've become through our efforts to overcome them. 
But what about today? Health and wealth have risen precipitously for the majority of Westerners in the past 150 years. In the early 19th century, life expectancy in England and Wales was a measly 40 years. By 1931, English and Welsh could expect to live to more than 60. Today, in the U.K., it's 81, and in Canada the same. [4,5] Our societies are rich beyond imagination. Shouldn't our own modern lives validate the grand narrative that civilization and technology can sustain us and save us, even if it took a little while to get here? Don't our recent gains finally vindicate the story we tell ourselves that civilization is salvation?
Today, we're going to take a closer look. I'll tell you straight out: we're going to discover that that is not the case at all. Rather than the success of the old story, the rise in living standards in the modern West was brought about by the birth of a new one. As the great infectious diseases were brought to heel, and life expectancy vastly extended, a new idea of the purpose of civilized society was being planted en masse.
Every new cultural story begins from the seed of a new idea -- a purpose, a goal, an identity to organize around. It points to a new direction, a way to turn the ship. What we'll see today is that the new direction that was set in the modern era is something we've already discussed. In fact, it's been hiding in plain sight the whole time. It is health and social welfare: the notion that societies should exist first and foremost to serve the well-being of all of their members.
The primacy of health and social welfare was the entire basis for our challenge to the progress story. I introduced it as a yardstick in Part 1 without any explanation, as though it were self-evident to equate social welfare with social success. And if you didn’t bat an eyelash when I did so, that’s a testament to how deeply this purpose for society -- this new story seed -- has been planted in our culture. Because it wasn’t always this way. The French and American Revolutions, for example, introduced their ambitions of equality among citizens as revolutionary ideas, set against the 'glory of the kingdom' goals they sought to displace.
Of course, large gaps remained between the lived realities in those eras and the stated social goals. Some held the goals close at heart, while others resisted or ignored or subverted them. What we'll learn, as we chart the course of the rise of living standards in the West, is what it takes to make a new story seed take hold and propagate -- to bring it from ideal to action. And we'll think through what it would take to keep growing that story seed long enough to change a whole culture's course. Let's go.
The Rise in Living Standards
At the start of the 19th century, Europeans were beset by nasty diseases - smallpox, cholera, typhoid, tuberculosis, and on. The story of civilization says that medical science was born in this era, that it created antibiotics and vaccines, and that we started living long and healthy lives because of it. Meanwhile, as the powerful economic engine of the Industrial Revolution hit its stride, it brought us better nutrition, more leisure, and more stuff. But look more closely at what happened when, and the story falls apart entirely.
Of that great and historic reduction in infectious disease, most of it took place before effective antibiotics and vaccines were invented.  The first antibiotic drug arrived in 1935, and most of the vaccines appeared through the 1940s and '50s. By then, the Roaring Twenties had come and gone, and tuberculosis just wasn't something you thought about much anymore. Medical science delivered the knockout punches, but the fight had already been mostly won. [9-14]
And won by whom, or what? While the microbiologists were studying germs, another group of scientists was at work as well. Only instead of peering into microscopes, they were taking to the streets. They were the first epidemiologists. The word epidemiology means the study of epidemics. Epidemic, from Ancient Greek, means among the people.  That's where they were: they were mapping, neighbourhood by neighbourhood and town by town, where and when diseases struck and spread.
They found more disease near polluted water sources, and so they lobbied for sewer systems and filtration. They found worse health in poor urban neighbourhoods than in rich ones, so they fought for crowding regulations in factories and homes. Years later, microbiologists would explain their successes -- that cholera thrives in feces-fouled water, and tuberculosis spreads in poorly-ventilated air.  The epidemiologists kept going. They fought for and won the provision of public baths, paved streets, maternity services, and universal education. Backed by social science and spurred on by success, these early activists for social welfare powered a century of change.
The work fed into broader social movements for unionization and income redistribution and, alongside many new allies, paved the way for the welfare state. Their research provided a concrete point of focus for working class consciousness, while their political advocacy convinced the middle classes to embrace the first widespread progressive taxation and public investment programs. On the basis of this new story seed -- that societies exist for the benefit of all of their members -- a broad, cross-class consensus was established and maintained for stable institutions charged with equitable distribution and mass welfare.  It vastly reduced the burden of infectious disease, sent life expectancy rates soaring, and reversed the age-old declining trend in human health. 
And what of the prosperity brought by the Industrial Revolution? As archaeologist Mark Nathan Cohen made clear from cases throughout human history, having more resources in a society does not translate automatically into welfare for the majority of citizens. Resources contribute to mass welfare only when they are broadly shared.  In the case of the Industrial Revolution, resources were at first concentrated in very few hands, and the conditions of their production -- crowded cities, pollution, long hours of work for little pay -- bred misery for the majority. As a society, it fits the historical pattern of inequality and disease exactly. But in this era, the epidemiologists intervened, and they altered the usual outcome.
The evidence is clear, and the academic consensus wide: this political organizing and these social reforms, and not the technologies of vaccines and antibiotics, are responsible for most of the great gains in health and welfare we associate with modern life. [20,21]
How to Choose a Story
In time, the vaccines and antibiotics -- the pride of the old progress story -- did arrive, and when they did, they drew the rates of infectious disease in the West down from relatively low to near zero. It may not have much mattered for our health whether they or the public health measures had arrived first: both, in the end, were effective.
But their separation in time offers us a chance to ask interesting questions about how we tell the story of our culture. The public health measures and the vaccines take part in very different stories of health and disease. By this random quirk in history, that the public health measures arrived so long before vaccination, we've been able to watch how a new kind of story -- the one represented by public health reforms -- performs all on its own, and it opens a window onto narrating our way of life another way. Let's watch how it happens.
Vaccines and antibiotics enact the familiar civilizational progress story. They made use of ingenuity and technology to keep us safe from dangerous, nature-based critters -- denizens of the primordial muck -- that we couldn't control or contain. The efficacy of these medical measures helped to establish a belief that the chaos of the natural world was the source of our poverty and sickness. It valourized a faith that more technological progress and more civilization would lift us over and above it.
The public health measures worked for a very different reason — not because they carried the progress of civilization forward, but precisely because they challenged it. As epidemiologists compiled their maps of disease, they discovered that the epidemics were spreading in lockstep with the Industrial Revolution. You can follow its headway in the health data, town by town, throughout England and Wales. You can track them in tandem clear across France, and later, as industrialization spread to Germany, Australia, and Japan, you can watch as the infectious diseases arrive there too. The correlation was so common and so close, in fact, that this suite of sicknesses came to be popularly known as the diseases of civilization. 
Epidemiologists employed their disease maps to ask pointed questions about the conditions in which people were living. They looked for social factors that were common in places of sickness and scarce where there was health. Their maps proffered real-time, scientific evidence that the causes and consequences of the 'progress' of their age was harming bodily health. Medical statistics became a cipher for unlocking the code of how and where the Industrial Revolution was making people ill, and public health policy a toolkit for rendering it habitable.
Epidemiology set up health and social welfare, then, as a check against conventional progress. Beside the Victorian story of civilizational progress, there were now the beginnings of a possible alternative: that civilization should exist not primarily for the sake of abstract progress, but for the social welfare of the majority.
How to Move Past 'Progress'
Civilization, and the progress story we tell about it, have given us a great deal of trouble. And yet, as archaeologist Mark Nathan Cohen reminds us, agriculture and civilized life came about for a reason: rising population pressures were making it hard to support everyone through hunting and gathering alone. In all likelihood, we could not go back now to the hunting and gathering life en masse if we wanted to, successful though it was then and remains now for many contemporary cultures. There are just too many of us on this planet.  The rise of the social-welfare story, though, points us toward another way through.
Cohen’s skeletal record tells us that our social problems come largely from how far we have distanced ourselves from the rhythms of the natural world, in diet, lifestyle, social hierarchy, and more.  The progress narrative has us reinforce this specific basic problem: by engendering pride in our sense of detachment from earthly limits, it encourages us to draw the gap between nature and our culture farther still. When 19th-century epidemiologists used health and disease as a barometer for what was wrong in our way of life, they introduced a method for moving in the opposite direction. The public health reforms were act of conscious adaptation. The movement showed us that it was possible to re-integrate with our environment again, and that enormous gains in welfare could result.
A critical examination of these gains of the modern age lays waste to the notion that we must choose between headlong, self-destructive progress and cultural stasis. The problem is not progress and change, but the specific mythological insistence that progress means outsmarting and conquering natural limits. The early epidemiologists gave us a starting proof that it is possible for us to re-invent ourselves in harmony with those forms instead.
Where the old story says that more high-tech and specialized control will overcome our problems, this new story suggests that any invention that is out of step with the rhythms of life will produce a host of new problems. In the old story, our problems come from unruly nature nipping at our heels, but in the new, they more likely issue from the dust we kick up in our own footfalls. This or that high-tech whiz-bang, marvellous though it may be, will always be chasing the underlying current of social issues flowing from our disconnection from a more organic ecological state. Through the lens of this new story, the very technology, order and ingenuity we deploy as we run to defend ourselves against a dangerous world has in fact put us on a treadmill -- where each solution gives rise to a ramifying series of problems, looping back around in front of us again. The old story hums to the rhythm of Silicon Valley's techie buzz, but there is anxiety at the heart of it: we are running just to keep up.
For the whole of civilized life, we have been running to keep up. Our culture's proudest achievement -- the advent of agriculture -- was but one more patch for a pressing social problem, never getting to the root.  In the modern era, industrial capitalism and medical science have solved particular problems before them, but they have not addressed this more fundamental issue, which runs, and chases us, on a much longer arc: that the further our culture has split itself from the rest of life around it, and the more we have stratified our societies and subdivided the functions of work, and the more we have forgotten what it means to know the land, the less healthy and well we then have become.
The old progress story doesn't admit to this paradox at the root of civilization, and this is its crippling flaw. A new story, informed by the evidence plain in our bodies and bones, would, and must. If the old story defines progress as rising above the whims and exigencies of nature, a new story would use all the tools of technology and culture to re-integrate with them instead.
What our ailing bodies have been trying to tell us is that there are limits. Limits to growth. Limits to understanding, and to intelligence. Limits to the distance we purport to put one person above another. Limits to the distance we put between ourselves and the bases of life. Medical statistics, as we have seen, give our bodies a collective voice. If we listen well enough, the patterns map the way toward where and what those limits are, and suggest ways to adapt our lives to thrive within them. Epidemiology does not say that there is one right way to live, but it does say is that there are wrong ways. Good epidemiology keeps score, and Mother Nature decides. First she makes you sick, and then she makes you extinct. Those are the rules of living here, and we are not exempt.
From Myth to Method
To tell a different kind of story, as we discussed in Part 1, you start by choosing a different kind of goal. But what happens from there? The welfare of the majority had been set down as a social purpose, as we discussed, in the French and American Revolutionary declarations of independence, but there was a long way left to go before realizing them. How did the 19th-century epidemiologists take that seed of a new story and make it start to take root?
The 19th-century epidemiologists developed the story by setting up the new goal as a yardstick for social success, and measuring their societies against it. They mapped the gaps between goal and reality and argued for correcting them. In order to make this new kind of case, they perfected the political use of a new kind of method: medical statistics. To take population-wide statistics was to declare that every life counted for something. It was to contend that you could better gauge the state of society by taking its average than by gazing at the images at its peak. Once upon a time, a resplendent king could carry the majesty of the people on his upright body, but medical statistics could make clear that everyone else paid the price in theirs.
It was to state further that the optimal distribution of resources in society is not a matter of opinion. Through its methods of measurement, epidemiology can take certain supposedly moral questions of how we ought to live, and settle them in biological fact. In retrospect, statistics became a tool for collapsing the age-old storytelling fallacies of riches and empire that made us think we were living better than we were.
Once epidemiologists were able to point toward social failings with some precision in this way, they were in a strong position to propose ways to address them. Their specificity in measurement turned an ideal into a grounded program of social policy actions, which social movements could rally around and governments could act upon. In this way, the epidemiologists moved the social-welfare narrative forward from imagination to advocacy. Through a method of measurement and a program of action, the story seed took root.
Though statistics are no guarantee of justice, the fact is that once a national census is considered a basic tool of governance, the expected role of that government has changed. Today, as our societies veer back toward ruinous inequality, we have an established social infrastructure for blowing the old mythology’s cover. The Occupy movement, for instance, could pierce our renewed conquest-and-riches images with a statistic as its rallying cry. It could demonstrate to the public that the systems in place today do not serve the welfare of the majority. When statistics were taken away from Canadians by the Harper government, through cancelling the long-form census there was a national outcry. And after Trudeau returned them -- on his second day of office -- census-takers filled them out so eagerly that they crashed the servers.[29,30] Returning the census was as much a substantive policy initiative as it was an act of applied mythology -- a praxis of storytelling. When we look at such social-welfare-oriented acts and feel that they say something about who we are, or who we aren't, or who we want to be, then the beginnings of a competing story have been born.
But let’s back up a step on the rosy devotions. Buried in the last paragraphs paean to statistics was this little clause that you might have nearly missed: we have veered back toward ruinous inequality. That's not an afterthought. That's a big deal. Things were on a decent track for 100 years, and then the channel changed. The welfare state started giving way in the 1970s to the rise of neoliberalism, and the fledgling new story slipped back into second place. How did it happen? That is something that a praxis of new storytelling needs to be able to answer for.
In our third and final post in this series, we’ll look into how and why epidemiology and its allied social movements lost their influence over the past 40 years. As we do, we’ll find out what it takes to keep a story on track, so that it can go on developing to maturity. These are vital questions, because we have unfinished business as a society.
- J'ai dormi sous l'eau - AIR (5:43)
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 Hall, Shannon. "Exxon Knew about Climate Change Almost 40 Years Ago." Scientific American. 26 October 2015. Accessed 6 August 2016. Link.
 Bump, Philip. "Jim Inhofe's Snowball Has Disproven Climate Change Once and for All." Washington Post. 26 February 2015. Accessed 6 August 2015. Link.
 Cohen, Mark Nathan. Health and the Rise of Civilization. New Haven: Yale University Press, 1989.
 Szreter, Simon (1988). The Importance of Social Intervention in Britain’s Mortality Decline c. 1850-1914: A Re-Interpretation of the Role of Public Health. Social History of Medicine (1), p. 12. Data are for England and Wales.
 The health and welfare gains of the modern age, of course, have been deeply inequitably distributed. They were funded in part by the plunder of colonies, internationalizing the class inequality that has plagued civilization throughout its history. And a large urban underclass exists in the Global North still. I spent a long time grappling with how to make sense of these facts next to the still quite real improvements in welfare that took place among large underclasses in the West. I'm not really sure yet whether or not the modern age represents a change from the pattern of civilization. This is a large blind spot, and I don't think I yet have the information to start to see into it. For now, I decided to press on and present the modern age as a democratic success in the West because I think it can help us choose between two different discourses advanced by different groups of people who claim interest in the welfare of poor and marginalized people. The first is liberal capitalism, which believes that the greatest welfare is advanced by spreading free markets and Western values. The second is a combination of social democracy and popular social movements, and it believes that the greatest welfare is advanced by active policies to manage the distribution of resources, and that this state of affairs is best maintained through a constant presence of movements of the people themselves in the political process. In this piece, I present a historical case that is usually seen as one of the greatest triumphs of the first discourse, and demonstrate how it was actually a triumph of the second. I felt this was important to do, because it helps to clarify which strategy is most likely to extend welfare even further.
 Makari, George. Soul Machine: The Invention of the Modern Mind. New York: W. W. Norton & Company, 2015, p. xiv.
 There is one prominent exception: a smallpox vaccine, generally believed to have been effective, existed since the 18th century. However, this seems to be the sole instance of effective medical therapy of any kind prior to the 20th century, and excluding smallpox entirely from the data does not significantly upset the trends. See McKeown, Thomas and R. G. Record (1962). Reasons for the Decline of Mortality in England and Wales during the Nineteenth Century. Population Studies: (16), 2, pp. 94-122; and Szreter (1988).
 Mackenbach, Johan P (1996). The Contribution of Medical Care to Mortality Decline: McKeown Revisited. Journal of Clinical Epidemiology: (49), 11, pp. 1207-1213.
 McKeown, Thomas and R.G. Brown (1955). Medical Evidence Related to English Popluation Changes in the Eighteenth Century. Population Studies: (9), 2, pp. 119-141.
 McKeown, Thomas and R. G. Record (1962).
 McKeown, Thomas et al (1972). An interpretation of the modern rise of population in Europe. Population Studies: (26), 3, pp. 345-82.
 McKeown, Thomas et al (1975). An interpretation of the decline of mortality in England and Wales during the twentieth century. Population Studies: (29), 3, pp. 391-422.
 Szreter (1988).
 Epidemiology. Online Etymology Dictionary. 2001-2014. Accessed 18 January 2015. Link.
 Szreter (1988).
 Szreter, Simon (2003). The Population Health Approach in Historical Perspective. American Journal of Public Health: (93), 3, pp. 421-31.
 Cohen, Health and the Rise, pp. 26-31, 141.
 Szreter, Simon (2003).
 Colgrove, James (2002). The McKeown Thesis: A Historical Controversy and Its Enduring Influence. American Journal of Public Health: (92), 5, pp. 725-729.
 Szreter, Simon (2003).
 Cohen, Health and the Rise, pp. 130-142.
 Cohen, Mark Nathan. The Food Crisis in Prehistory: Overpopulation and the Origins of Agriculture. New Haven: Yale University Press, 1977.
 Szreter, Simon (2003). The Population Health Approach in Historical Perspective. American Journal of Public Health: (93), 3, pp. 421-31.
 “[Anthropologists and historians] also disagree about whether the adaptive benefits of large-scale management outweigh the costs of exploitation. "That is an empirical question that I will address with medical evidence.” [Emphasis added]. Cohen, p. 30.
 "Statistics Canada (mandatory long-form census)." voices-voix: Defending advocacy and dissent in Canada. 8 August 2014. Accessed 13 August 2016. Link.
 Harris, Kathleen. "Mandatory long-form census restored by new Liberal government." CBC News. 5 Nov. 2015. Accessed 24 July 2016. Link.
 Winsa, Patty. "For Canucks, this census ticked all the right boxes." Toronto Star. 4 May 2016. Accessed 24 July 2016. Link.
 Mackenbach, JP (2009). "Politics is nothing but medicine at a larger scale: reflections on public health's biggest idea." Journal of Epidemiology and Community Health: 63(3), pp. 181-184.