Book review

R.W. Fogel, The Escape from Hunger and Premature Death, 1700–2100: Europe,

America and the Third World, Cambridge University Press, Cambridge, 2004, ISBN

0-521-00488-8.

Robert Fogel has been at the forefront of developments in Cliometrics and in what has

subsequently come to be known as ‘anthropometric history’ for much of the last half-

century, and he was awarded the Nobel Prize for Economics (jointly, with Douglass North)

in 1993 for his work on railroads and slavery. In this book, he draws on a vast amount of

research in both economics and biodemography to provide a new framework for examining

the relationship between changes in diet and nutrition, public health and medicine and the

improvement of human health in Britain, France and the United States since the beginning

of the 18th century. He also seeks to extend this work by examining the implications of

these historical changes for our understanding of demographic change in both developing

and developed countries in the century to come.

Although this book is based on a series of lectures which were originally delivered at

Cambridge University in 1996, and also draws on some previously published material, it is

also quite a short book, and some sections draw on work which is still ongoing. In some

places, readers are referred to a forthcoming publication with which this reviewer is also

associated.

The underlying message of The escape from hunger is both simple and powerful. Fogel

argues that the majority of the people living in Britain and France in the 18th century

existed on a diet which was barely sufficient for the satisfaction of their basic physiological

needs. The inhabitants of these two countries (and by inference other Europeans) ‘adapted’

to their straitened circumstances by being significantly smaller than their 21st-century

descendants, but this ‘adaptation’ also meant that they were more likely to die at younger

ages. The ‘escape from hunger’ was therefore an essential precondition, not only for the

reduction of infant and childhood mortality, but also for the reduction of mortality from

chronic conditions among those aged 60 and above.

One of the main sources of inspiration for this research was the work of the

epidemiologist, Waaler (1984). Hans Waaler examined the relationship between height,

weight and mortality among 1.7 million Norwegian adults who were weighed and

measured as part of a national radiological survey between 1963 and 1975, and showed that

there was a close association between the two anthropometric variables and the risk of

dying at each age. During the late-1980s and early-1990s, John Kim used these data to

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construct ‘Waaler surfaces’ which illustrate ‘how height and weight are related to the risk

of both poor health and mortality’ (p. x), and these ‘surfaces’ form the epidemiological

bedrock of Fogel’s analysis.

This book also rests on the central contention that a large proportion of the population of

Britain and France during the course of the 18th century was suffering from ‘chronic

malnutrition’. Clark et al. (1995, pp. 222–223) estimated that the average value of the diet

consumed by labourers’ families at the end of the 18th century was equal to 1508 calories

per person per day, whilst Shammas (1984, pp. 356–358; 1990, p. 134), using the same

source, calculated that the average individual consumed 1734 calories per day in the south

of England and 2352 calories in the north. Fogel estimates that the average number of

calories available to the population as a whole in 1800 was equivalent to 2237 calories per

day, but this is still well below the figures obtained for more recent periods (p. 9).

It is also worth pointing out that, even though Fogel places diet and nutrition at the heart

of his analysis, this is not a crude restatement of the kind of nutritional argument which has

often been associated with the work of Thomas McKeown. In the first place, Fogel makes

an important distinction between the amount of food available to the population and the

nutritional value which may be derived from it, and he recognises that environmental

factors, such as sanitation and the quality of drinking water, can have a substantial bearing

on nutritional status. Secondly, he also acknowledges that the processes of industrialisation

and urbanisation introduced new hazards of their own which represented a major barrier to

health improvement. ‘The modernisation of the 19th century was a mixed blessing for

those who lived through it’ (p. 19), and the sanitary revolution which kicked off towards the

end of the 19th century was an essential starting-point for the dramatic improvements in

health and longevity which characterised the 20th century (pp. 37, 42).

Although the first half of the book is primarily concerned with the historical experience

of Britain, France and the United States, Fogel is also concerned to examine the

implications of his analysis for those countries which are undergoing development today.

One of his most important insights is that we may be in danger of underestimating the

extent of chronic malnutrition in the modern world if we assume that nutritional standards

in most of the developed countries have already reached optimal levels (pp. 47–49).

However, this argument is tempered by an appreciation of the fact that we now know much

more about the technology of health improvement than our predecessors knew in the

middle of the 19th century, and this leads Fogel to conclude that it should be possible for

today’s poorest countries to achieve significant progress in a much shorter period of time

than that required by the industrial ‘pioneers’ (pp. 51–54).

The Food and Agriculture Organisation of the United Nations (2003) has recently

estimated that there were nearly 800 million undernourished people at the end of the 1990s,

and the problems faced by these people are rather different to those faced by the majority of

the inhabitants of the world’s wealthiest countries. In The Fourth Great Awakening, Fogel

(2000) argued that the majority of people living in the United States had largely escaped

from the shadow of material poverty, and that future generations would need to spend a

much smaller proportion of their time meeting their basic physical needs. In the present

volume, he argues that the two great ‘growth industries’ of the 21st century will be leisure

and health care. In the case of the latter, he anticipates that we will need to devote fewer

resources to the provision of health services for people below the age of 65, but that there is

Book review148

likely to be an increase in the demand for life-saving and life-enhancing technologies at

older ages (pp. 66–88).

In the final two chapters, Fogel turns his attention to the problem of equity in health care

and the future of longevity. In Chapter 5, he suggests that instead of seeking to extend the

coverage of health insurance schemes, United States authorities should give greater priority

to the provision of prenatal and postnatal care, health education, school health screening

and community clinics, together with increased support for international vaccination

programmes (pp. 104–106). However, there may be a tension between some of the

arguments advanced in this chapter and those in the previous chapter. If the main source of

growth in the demand for health services in the future is likely to be associated with the

demand for new forms of health care at older ages, at what point will it become necessary to

ensure that these services are also made available to the widest spectrum of the whole

population?

The book’s final chapter is both brief and to the point: How long can we live? As Fogel

points out, demographic observers from Louis Dublin onwards have often erred on the side

of caution when predicting future trends in longevity, but current researchers, such as

Oeppen and Vaupel (2002), have cast off the shackles of pessimism to suggest that average

levels of life expectancy at birth are set to rise dramatically over the next 50 years. If these

observers are correct, the world of the future could start to look very different, even from

the one which Fogel has surveyed in the course of these pages.

References

Clark, G., Huberman, M., Lindert, P.H., 1995. A British food puzzle 1770–1850. Econ. Hist. Rev. 48, 215–237.

Fogel, R.W., 2000. The Fourth Great Awakening and the Future of Egalitarianism, Chicago.

Oeppen, J., Vaupel, J., 2002. Broken limits to life expectancy. Science 296, 1029–1031.

Shammas, C., 1984. The eighteenth-century English diet and economic change. Explorations Econ. Hist. 21, 254–

269.

Shammas, C., 1990. The Preindustrial Consumer in England and America, Oxford.

United Nations Food and Agriculture Organisation, 2003. The State of Food Insecurity in the World, Rome.

Waaler, H., 1984. Height, weight and mortality: the Norwegian experience. Acta Med. Scand. Suppl. 679, 1–51.

Bernard Harris*

School of Social Sciences, University of Southampton

Southampton SO17 1BJ, UK

*Tel.: +44 23 80 59 25 67; fax: +44 23 80 59 38 59

E-mail address: bjh2@soton.ac.uk

18 March 2005

Book review 149