The Prevalence of Syphilis in England and Wales on the Eve of the Great War: Re-visiting the Estimates of the Royal Commission on Venereal Diseases 1913-1916.

Public fears of widespread venereal disease led in 1913 to the appointment of The Royal Commission on Venereal Diseases (RCVD). In 1916 its Final Report offered only a single cautious and somewhat imprecise summary statement about the likely prevalence of venereal diseases in England and Wales. Although the significance of contemporary attitudes to venereal disease has attracted a good deal of historiographic attention, no historian or demographer has since investigated this aspect of the Royal Commission's work. This article critically re-examines the most important quantitative evidence presented to the Royal Commission relating to the years immediately prior to the First World War. It utilises this evidence to produce new estimates of the probable prevalence of syphilis among adult males, both nationally and among certain geographical divisions and social groups in the national population; and also to offer a comment on the likely prevalence of gonorrhoea.

"We weren't the sort that wanted intimacy every night": Birth control and abstinence in England, c.1930-60.

This article presents an exploration of qualitative evidence on the relationship between birth control and abstinence from an oral history project, which interviewed middle and working-class English men and women, who had married between the late 1920s and the early 1950s. Among the working classes the assumption that men were responsible for birth control choices and the disadvantages that contraceptive methods of all types posed, combined with the fear of pregnancy, acted as a disincentive to have sex and resulted in forms of partial abstinence. Among the middle classes, women had much more access to birth control information and as a consequence a greater range of methods was used, including more female methods. However, the reluctance of couples to discuss sexual matters, and some continued preference for male methods meant that while condoms were the most regularly used middle-class male method, both withdrawal and abstinence were also in evidence. Moreover, although partners were more likely to discuss birth control at the start of their marriages, they were less likely to agree that contraception was a male responsibility and there was greater potential for conflict over contraceptive methods, not infrequently resulting in abstinence. The evidence suggests that sexual and contraceptive practices in marriages in England at the end of the secular fertility decline do not present a picture which straightforwardly correlates with the assumptions represented by the popular thesis that this period of increased fertility control was closely associated with the rise of companionate marriage.

The way forward.

Good public-health decisionmaking is dependent on reliable and timely statistics on births and deaths (including the medical causes of death). All high-income countries, without exception, have national civil registration systems that record these events and generate regular, frequent, and timely vital statistics. By contrast, these statistics are not available in many low-income and lower-middle-income countries, even though it is in such settings that premature mortality is most severe and the need for robust evidence to back decisionmaking most critical. Civil registration also has a range of benefits for individuals in terms of legal status, and the protection of economic, social, and human rights. However, over the past 30 years, the global health and development community has failed to provide the needed technical and financial support to countries to develop civil registration systems. There is no single blueprint for establishing and maintaining such systems and ensuring the availability of sound vital statistics. Each country faces a different set of challenges, and strategies must be tailored accordingly. There are steps that can be taken, however, and we propose an approach that couples the application of methods to generate better vital statistics in the short term with capacity-building for comprehensive civil registration systems in the long run.

Civil registration systems and vital statistics: successes and missed opportunities.

Vital statistics generated through civil registration systems are the major source of continuous monitoring of births and deaths over time. The usefulness of vital statistics depends on their quality. In the second paper in this Series we propose a comprehensive and practical framework for assessment of the quality of vital statistics. With use of routine reports to the UN and cause-of-death data reported to WHO, we review the present situation and past trends of vital statistics in the world and note little improvement in worldwide availability of general vital statistics or cause-of-death statistics. Only a few developing countries have been able to improve their civil registration and vital statistics systems in the past 50 years. International efforts to improve comparability of vital statistics seem to be effective, and there is reasonable progress in collection and publication of data. However, worldwide efforts to improve data have been limited to sporadic and short-term measures. We conclude that countries and developmental partners have not recognised that civil registration systems are a priority.

Health by association? Social capital, social theory, and the political economy of public health.

Three perspectives on the efficacy of social capital have been explored in the public health literature. A "social support" perspective argues that informal networks are central to objective and subjective welfare; an "inequality" thesis posits that widening economic disparities have eroded citizens' sense of social justice and inclusion, which in turn has led to heightened anxiety and compromised rising life expectancies; a "political economy" approach sees the primary determinant of poor health outcomes as the socially and politically mediated exclusion from material resources. A more comprehensive but grounded theory of social capital is presented that develops a distinction between bonding, bridging, and linking social capital. It is argued that this framework helps to reconcile these three perspectives, incorporating a broader reading of history, politics, and the empirical evidence regarding the mechanisms connecting types of network structure and state-society relations to public health outcomes.

Industrialization and health.

Throughout history and prehistory trade and economic growth have always entailed serious population health challenges. The post-war orthodoxies of demographic and epidemiological transition theory and the Washington consensus have each encouraged the view that industrialization necessarily changes all this and that modern forms of rapid economic growth will reliably deliver enhanced population health. A more careful review of the historical demographic and anthropometric evidence demonstrates that this is empirically false, and a fallacious oversimplification. All documented developed nations endured the 'four Ds' of disruption, deprivation, disease and death during their historic industrializations. The well-documented British historical case is reviewed in detail to examine the principal factors involved. This shows that political and ideological divisions and conflict-and their subsequent resolution in favour of the health interests of the working-class majorities-were key factors in determining whether industrialization exerted a positive or negative net effect on population health.

The population health approach in historical perspective.

The origin of the population health approach is an historic debate over the relationship between economic growth and human health. In Britain and France, the Industrial Revolution disrupted population health and stimulated pioneering epidemiological studies, informing the early preventive public health movement. A century-long process of political adjustment between the forces of liberal democracy and propertied interests ensued. The 20th-century welfare states resulted as complex political mechanisms for converting economic growth into enhanced population health. However, the rise of a "neoliberal" agenda, denigrating the role of government, has once again brought to the fore the importance of prevention and a population health approach to map and publicize the health impacts of this new phase of "global" economic growth.

Rethinking McKeown: the relationship between public health and social change.

Thomas McKeown was a rhetorically powerful critic, from the inside, of the medical profession's mid-20th-century love affair with curative and scientific medicine. He emphasized instead the importance of economic growth, rising living standards, and improved nutrition as the primary sources of most historical improvements in the health of developed nations. This interpretation failed to emphasize the simultaneous historical importance of an accompanying redistributive social philosophy and practical politics, which has characterized the public health movement from its 19th-century origins. Consequently, the current generation of public health practitioners are having to reconstruct such a politics and practice following its virtual dismantlement during the last 2 decades of the 20th century.