Wealth and health map

Back in the 1970s, a plan was briefly aired to build a third major airport for London at Foulness, an island on the Essex coast. The development foundered from a combination of environmental and (mostly) economic objections. Two or three centuries ago, Londoners might have balked at the proposal on health grounds. In 1723, the vicar excused himself from residing there, exclaiming: "Foulness is the unhealthiest part of an unhealthy country." Further, the island was inhabited predominantly by men who were "rough, lawless and offensive to decency".

Foulness is one of a number of black spots on Mary Dobson's map of Essex, Kent and East Sussex. The "early modern" of her title takes in a rather larger sweep than is generally accepted, including as it does the whole of the 18th century. Likewise, Dobson's "England" bears some hallmarks of a publisher's marketing department. "Southeast England", which her study primarily encompasses, sounds too much like an exercise in local history. However, the title can be defended on two grounds. First, the late-18th century did see the gradual establishment of the modern demographic regime, and so what came before can be reasonably described as early modern, despite the increasingly secular values associated with the Enlightenment. Second, Dobson's monumental monograph wonderfully assimilates into its own working premises the population history of England, as established by E. A. Wrigley and Roger Schofield and their colleagues in the Cambridge group for the History of Population and Social Structure. And, like any good local or regional study, it challenges some of the accepted national generalisations, while reinforcing our basic picture of England's demographic performance before the first census of 1801.

Unlike Wrigley and Schofield, however, Dobson concentrates almost exclusively on mortality: baptism-burial ratios feature crucially in her analyses, but fertility as a motor for the population rise that began around the mid-18th century is never assessed. Instead, she concerns herself with other factors - economic, climatological, geographic, social, medical and psychological - that might explain why Foulness and Romney Marsh were such unhealthy places and the High Weald of Kent and Sussex comparatively healthy.

Dobson's book is divided into three parts. Part one establishes the importance of place as a determinant of health. Dobson argues that the tradition of medical topography needs to be taken more seriously by historians. In particular, she sketches the historical geography of southeast England to show how, within Kent, there was a gradient running southeast to northwest, from the Romney Marshes, where there was wealth but no health, to the Weald, where there was health and wealth, on to the Kent Downs, where there was health but little wealth.

Part two is about people: mostly people in their demographical collective, but also (rare in demography) integrating qualitative sources and anecdotes of individuals.

The bedrock of Dobson's monograph rests on her sensitive analyses of the surviving parish records of southeast England. This quantifies her assertions about the role of geography, while the data permit her to cast doubt on simple economic assumptions about the correlation of prosperity and longevity. For one thing, too many unhealthy parishes had high wages. For another, factors such as good water supply, isolation, or height above sea level, affected demographic performance. Some communities also changed dramatically during the period. By the end of the 18th century, for instance, parishes in Romney Marsh were as healthy as some upland neighbours.

Dobson exposes one of the major reasons for this change in the third part of her volume, which is concerned with disease. She demonstrates beyond reasonable doubt that malaria ("ague", "marsh fever") had significant consequences for demographic history. Her chapter on malaria is a tour-de-force in combining modern medical knowledge with a sensitive exposition of the ways in which this disease crippled the human spirit.

But "healthy" is a relative term and all communities in early modern England experienced years when more people were buried than baptised. In examining the more general epidemiological history, Dobson has exploited a vast range of printed and manuscript sources, which fuel her subtle discussion of the major epidemiological causes of death between 1600 and 1800.

The strength of this big book lies in its mix of geography, demography and historical epidemiology and in the fact that Dobson has brought such a wide range of contemporary sources to bear on her subject. She recognises the cogency of earlier observers, even if their intellectual and medical frameworks were strikingly different from those we now employ. And she stresses that human activity - smallpox inoculation, drainage works, systems of welfare and charity - must be taken seriously in our understanding of how people in 1800 were, on the whole, healthier than their forebears of two centuries earlier.

Towards the end of the book, Dobson briefly cites the classic monograph of Fernand Braudel on the Mediterranean Basin in the age of Phillip II. Dobson's work may lack some of Braudel's imaginative power, but in its subtle mix of geography and material culture, it possesses many of the qualities that characterise that great historical monument.

W. F. Bynum is professor of the history of medicine, Wellcome Institute, London.