It is strikingly difficult to review a book about long-term trends in population health and demography during a generation-defining pandemic. Looking back decades from now and studying the same demographic phenomenon that Johan P. Mackenbach examines in his new book, A History of Population Health: Rise and Fall of Disease in Europe, COVID-19 may be either a blip on an otherwise noteworthy trend or a curve in a new direction. We know that today Europeans are living longer than ever before, and doing so in better health, even if they spend more time in old age dealing with chronic health issues.

Mackenbach's longue durée, Braudel-inspired, and erudite book wades into scholarly territory that will be familiar to readers of Journal of British Studies. In the 1970s, Egyptian-American epidemiologist Abdel Omran and British physician Thomas McKeown proposed influential, if controversial, theories about what caused the epidemiological transition in Western Europe and North America that saw the decline of both mortality and fertility in the late nineteenth and early twentieth century. McKeown had argued, readers will recall, that the Western world saw major demographic changes, including the decline of the major infectious diseases and the rise of life expectancy, largely as a result of a rising standard of living, particularly improved nutrition.

There was significant pushback to McKeown's claims in the 1980s and 1990s, by historians such as Simon Szreter, Anne Hardy, Graham Mooney, and by Mackenbach himself, who argued that the rise of preventive medicine and public health played a much larger role in the epidemiologic transition than McKeown had acknowledged. Economic growth, most scholars agree today, does not directly or inevitably lead to improvements in population health.

A History of Population Health, then, is an attempt to resuscitate a not-yet extinguished but somewhat fizzled debate about the rise and fall of disease and the role of human agency. To forewarn readers, this is a dense, sometimes unwieldy, and prohibitively expensive book; it is more synthetic than original, and it is highly quantitative at the expense of narrative and interpretation. Mackenbach's central claim will be familiar to those who have read his prior work in this area: “human agency,” he argues, “accounts for both the rise and fall of disease” (vii). Changes in life expectancy, the decline of the major infectious diseases, and the rise of chronic health conditions are inherently, he argues, political outcomes. Democratic countries in Europe, Mackenbach shows, and those that implemented a public health system that works and access to medical care, account for the long-term regional differences between western, northern, southern, and eastern Europe. Health outcomes, it will surprise very few, are the result of political choices. This is far from a startling conclusion, but it is one that will be tested during the COVID-19 pandemic. Indeed, Mackenbach's book will provide an important starting point for future research on the role of politics and public health in curbing COVID-19.

Mackenbach organizes the book into three parts. Part one, “Long Term Trends: A Bird's Eye View,” examines the big-scale patterns of life expectancy for Europeans between the eighteenth and the twenty-first centuries. Part two, “Zooming in: The Rise and Fall of Disease,” turns to a series of case studies of specific health problems, from famine and plague to tuberculosis and heart disease. The final section, part three, “Synthesis and Outlook,” returns to a broad approach, asking the central question of the book, “What was the role of human agency?” through a regional comparison of European countries. Regional differences matter, even if the broader trends point in a similar direction. Northern European countries outpaced their southern and eastern European counterparts in terms of rising life expectancy.

A History of Population Health is a book about big patterns of European demographic history. At times it even feels encyclopedic, especially in part two's listing of specific diseases. Mackenbach has very little to say about public health intervention other than that it was critical for long-term changes in Europeans’ overall health over the past three hundred years. In discussing the impact of public health, or “public hygiene” in part one, Mackenbach falls back on older, largely abandoned narratives about the impact of the bacteriological revolution. The book nonetheless offers a salient, important reminder that thinking about questions of population health have often been conflated with the activities of public health. Teasing out the two, he shows, offer important zoomed-out perspectives on long-term change.

Much of the early literature on the epidemiological transition focused on Britain, the first industrialized nation and one that saw a precipitous decline of the major infectious diseases by the early twentieth century. Scholars of British history will find that Mackenbach decentralizes Britain from these broader narratives of demographic change, even if specific political decisions, such as the late nineteenth century introduction of compulsory notification of infectious diseases, led to important changes in the health landscape of Britain. The comparative nature of A History of Population Health makes this an important reference work, and the extensive bibliography is a veritable goldmine for anyone interested in population health.