Introduction
The World Bank's seminal report investing in health', published in 1993, has already established itself as one of the most influential public health documents of the late 20th century In seeking to draw lessons from the past, it noted that ‘three factors have been important in the dramatic and unprecedented mortality declines of the past hundred years … These factors are income growth, improvements in medical technology, and public health programs combined with the spread of knowledge about health’ (World Bank 1993, p 34)- When, as here, the past is used as a guide to the present, much rests on the truth of the interpretation offered. The purpose of this chapter is to examine underlying determinants of mortality change in adults in high income countries such as Australia, and, in the light of this, firstly, to suggest a re-formulation of the explanatory factors used in the 1993 World Development Report and finally to reflect briefly on some implications of this discussion for the social origins of health inequalities.
The chapter starts with an exploration of the complexities of the relationship between economic development and health improvement, noting both the health-favouring and health-damaging potentials of increased incomes. The underlying theme is that gains in health have often depended on complex institutional adaptations to the effects of economic development - with the measures found necessary to overcome the increased transmissibility of infection associated with rapid urbanisation in the 19th century providing the classic example. At the beginning of the 21st century, important adverse health effects of economic development remain to be solved.
Consideration then moves to the upward shift through the 20th century in the life expectancy attainable at given levels of real income. This points to the fundamental importance of increases in practical knowledge, which have enhanced capacities for health protection and improvement. The paths by which increases in knowledge may act to improve health are shown to be diverse and complex. Medicine therefore needs to be understood as an institution in which the whole of society participates and not merely as a vehicle for the professional deployment of 'medical technology'.
The argument pushes towards a rather abstract model in which health improvement is seen to depend on the interacting effects of increases in knowledge and economic and institutional development.