Health, civilization and the state: a history of public health from ancient to modern times

to be purchased collectively either through social or private insurance. Doctors sought to monopolize access to the resulting funds, which required "walking a tightrope between markets and government". Government help was needed to eliminate competition but no control over the profession was to be ceded in return. Hence the evolution of powerful self-regulating bodies such as the GMC and the AMA and, above all, the Association of Insurance Doctors in Germany. Governments themselves benefited from professional selfregulation because issues of rationing could be disguised as clinical judgements and hereby delegated to doctors. This deal started to break down in the 1970s as a result of political and economic change. Decreasing economic growth and increasing public articulacy required more overt action from governments. Simultaneously, disasters such as thalidomide, instances of professional incompetence and the greed of the medical supply industry tarnished the reputation of scientific medicine. In particular, after the introduction of Medicare and Medicaid in the US in the 1960s, the cost of health care exploded to the point where neither employers nor government were prepared to foot the bill. Greater intervention was delayed because of governments' need to develop their regulatory capacity: but increased regulation came with the Prospective Payment System for Medicare in 1983, the Thatcherite reforms in Britain and the 1993 Seehofer reforms in Germany. Moran provides an illuminating guide to these historical developments in all three countries. Siting medical developments in their full political and economic context also adds an important dimension to the debate over present-day reform; and the centrality of the US to these reforms is explained by both the depth of its own crisis which spawned innumerable initiatives and their diffusion as a result of American pre-eminence in the world market for both pharmaceuticals and medical equipment. Above all, Moran shows how a more open and contested system of governance has been established since the 1980s, although both the medical profession and industries have proved adept at capturing-in part, at least-the regulatory machine and thereby safeguarding their interests. The opacity of the language used is important for this latest accommodation-as it was from the start when greater regulation was introduced, most notably by Reagan and Thatcher, in the name of deregulation.