Health Policy

Landed Gentry and Health


“The title of our lands is free, clear, and absolute, and every proprietor of the land is a princess his own domains, and lord paramount of the fee.” 

Jesse Root, 1798, Chief Justice of the Connecticut Supreme Court

When it came to social hierarchy and family position, land was the ultimate measure of success and influence in Great Britain. But by the time of the American Revolution, our Founders were already fast at work dismantling Primogeniture (“the right of succession belonging to the firstborn child, especially the feudal rule by which the whole real estate of an intestate passed to the eldest son.”) It had already largely disappeared in New England, and was gone in the southern colonies by 1800.

In its place, the colonists envisioned a “free and mobile market,” where land could be traded like money and other goods. To do so, the original land grants and “feudal tenures” were obliterated, and their legal documents swept clean by the new law of the land. The decisions on ownership were made locally, empirically and by “common wish” of those in power.

Property was meant to be traded, fast and furious, but most of all put to “productive use” in a young nation obsessed with rapid growth. As legal historian, Lawrence Friedman, suggested, “In land lay the hope of national wealth; for countless families, it was their chance to make some money. The land, once it was cleared of the native peoples (by hook or by crook), and properly surveyed, was traded with speed and fury. Speculation in raw lands was almost a kind of national lottery.”

Secure possession of land rapidly and dramatically segregated the “have’s” from the “have-not’s.” By the end of the century, industrialization and urbanization, fueled by Black flight from white southern segregationists and immigration from Europe and Asia, had escalated the growth of cities lacking required housing and infrastructures to support health and safety. The scientific revolution, a new Sanitary Movement, and the beginnings of government regulations together began to address infectious diseases and unsafe food and water.

A century later, urbanization (primarily as a source of jobs and access to power) has lost none of its appeal. Consider the fact that in 2012 there were about 7.0 billion global inhabitants with 49% rural and 51% urban. In 2023, we topped 8.0 billion, but 57% are now urban. By 2030, we’re projected to reach 9.0 billion with 2/3rds living in cities. The cities themselves are growing in number and size. There are now 512 cities worldwide, primarily on coastal plains, with populations over 1 million.

Under ideal circumstances, this urban migration to concentrated land dwellings could serve our human population well – with jobs, clean air and water, transportation, housing and education, health care, safety and security. But without investment and planning, they can be a harbinger of poor health, and ultimately a death trap.

Recognizing this threat, urban geographers and public health professionals are increasingly collaborating in the creation of a common language and set of measures or determinants to gauge the success of governmental investment and action. One area of recent common focus is  “urban land tenure insecurity” as a contributor or determinant of poor health outcomes.

The researchers are attempting to put together a complex puzzle to answer the question, “Do variations in land tenure security and variations in health outcomes relate to each other?” What urban geographers have already established is that “livelihood, well-being and quality of life” are elevated by housing security in “formal settlements.” These sites have laws that ensure rights of dwellers as a hedge against homelessness, and a range of services that promote “employment, housing security, political participation, education, protection from environmental risks, and access to primary health care.”

In contrast, informal settlements place inhabitants at risk on multiple levels. First, by definition these sites lack the planning and infrastructure to support the populations who have congregated in this location. Second, the uncertainty of basic safety and security (literally “a roof over your head”), and the implied threat of forced displacement and instantaneous mobility, makes “setting” down roots much less likely. This undermines investing in community and support systems necessary for physical health. Finally the stress and disruption ever-present in these informal settlements ensures high burdens of mental health disease.

Land, then, does remain the “ultimate measure of success”  in modern times. But the success and influence engendered in secure housing and settlement has little to do with “overlords”, but much to do with access – to secure housing, healthy food, clean air and water, a job and transportation, recreation, and human relationships. And all of the above are enhanced by access to settled neighborhoods with access to health care.

Mike Magee MD is a Medical Historian and author of CODE BLUE: Inside the Medical Industrial Complex.

Categories: Health Policy

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