In Western Europe the early twentieth century saw a significant growth in the public provision of health care, much of which was administered and financed at the level of municipal and county government. For Marjaana Niemi this expansion of health provision is not an unproblematic story of medical science marshalled in the public interest. Instead the perspective of this book is that the strategies of policymakers perpetuated class hierarchies and patriarchal norms, and subjected vulnerable groups to surveillance and demeaning interventions. Her position is nicely captured in the Habermas-tinged concluding sentence: ‘the very (legal) means which secure freedom are often the means through which freedom is put in jeopardy’ (p. 188).

The book opens with a really impressive survey of the literature on public health in the urban context, then sets out a conceptual framework shaped by the sociology of science and feminist theory. Scientific advance, Niemi argues, was deployed by municipal doctors and politicians who claimed its authority to legitimize their actions. However, the timing and implementation of such policies reveal that they were determined by existing power relationships of class and gender. The theme is explored through a comparative urban study, focusing on Birmingham in England and Gothenberg in Sweden. Rather than surveying the whole gamut of public health activity she limits her field to two key areas: maternal and child welfare, and tuberculosis. Her methodology is qualitative documentary analysis, drawing principally on municipal reports and committee minutes, and also some voluntary sector records.

The comparison between the two cities is not based on an equivalence of size or economic structure. Birmingham, the manufacturing giant of the West Midlands, had a population of one million by 1930, while the commercial and industrial centre of Gothenberg numbered 280,000 (1940). However, both were ‘second cities’, with broadly similar demographic indicators, and thus offer scope for exploration of the ‘full complexity of decision-making’ (p. 23). The first striking point of comparison lies in the relative strength of the municipal health establishment in Gothenberg, where public provision dominated the hospital sector and local taxes sustained medical incomes. In Britain the mix of providers, which privileged private practice and voluntary hospitals, meant that public health doctors lacked the same status and influence, and the integration of hospital policy was more difficult.

Turning to the debates about infant mortality, Niemi shows how in Birmingham the issue of poverty was downplayed in favour of concern about the behaviour of poorly educated slum dwellers, with particular opprobrium reserved for families which did not conform to the male breadwinner model. The policy response was a focus on health visiting and clinic services to educate women on purportedly optimal mothering practices, such as breast-instead of bottle-feeding. In Gothenberg the research findings were produced in a different context: social zoning was less clear-cut and female labour force participation was essential to the urban economy. Thus the science led to a different policy outcome, with maternity hospital investment on a far greater scale than in Britain. The case of tuberculosis similarly demonstrates how expert knowledge which challenged dominant power structures was disregarded. In both cities the causal role of poverty and poor housing was overlooked in favour of a strictly microbial understanding, which legitimized surveillance and segregation of TB patients. Again there were different paths, with Gothenberg moving more rapidly to adopt the BCG vaccine. Here Niemi extends Bryder's earlier analysis, arguing that the prior commitment of financial and professional capital to institutional and educative responses explains Britain's later take-up of vaccine therapy.

In sum the book makes an important contribution both to science studies and to the history of municipal health care. Two reservations may be entered, however. First, is Niemi comparing like with like? The Birmingham evidence is geared heavily towards the perspective of the public health department and we learn little of the part played by the voluntary sector and Poor Law in the debates discussed. The omission of Dudley Road Hospital (Birmingham's allegedly progressive Poor Law infirmary) is odd, given the argument about contrasting hospital policies. Nor are the claims for the city's lacklustre performance in slum clearance supported by detail from housing department sources. Second, although this study is fiercely critical of several municipal health policies, the fact remains that the period saw a major improvement in population health. Niemi is not concerned to explain this, alluding briefly to McKeown and suggesting that its cause is simply unknowable. Instead she presents statistics of declining TB and infant mortality rates principally to assert the hollowness of civic triumphalism, given that both cities pursued quite different strategies. However, since she does not show conclusively that these health improvements really were occurring independently of policy prescriptions, it remains impossible for the reader to calibrate the value of the ‘freedoms’ lost and won in the process.