How Healthy Was Primitive Man? : HEALTH AND THE RISE OF CIVILIZATION<i> by Mark Nathan Cohen Ph.D. (Yale University Press:$29.95; 320 pp.; 0-300-04006-7) </i>

Was there an Eden? Rousseau thought so; he admired the noble savage and wrote that in a “state of nature” men were strong of limb, fleet of foot and clear of eye. He contrasted this natural condition of health with the proliferating diseases of civilization and was “tempted to believe that in following the history of civil society we shall be telling that of human sickness.”

Anthropologist Marshall Sahlins concurred: He described technologically primitive hunter-gatherers as living in “the original affluent society.” Of course, the opposing view had its proponents. Thomas Hobbes wrote that the life of primitive man “was poor, nasty, brutish and short,” and more recently, Lewis Henry Morgan described human cultural evolution as a progression from “savagery” to “barbarism” and finally to our current enlightened state of “civilization.”

Can such conflicting views be reconciled? If not, what really did happen in history? Mark Nathan Cohen’s “Health and the Rise of Civilization” provides challenging, thought-provoking and, for most of us, unexpected answers to these questions. Cohen’s highly regarded “The Food Crisis in Prehistory” and “Paleopathology at the Origins of Agriculture,” the latter co-edited with George Armelagos, have established him as a leading medical anthropologist with special expertise in the health consequences associated with the shift from hunting and gathering to agriculture.

In his current book, Cohen uses health as a reasonably quantifiable measure of the human condition. He traces the progression from our late Stone Age (big-game-hunting ancestors of 25,000 years ago) through the “broad spectrum revolution” (which, in the Old World, began about 15,000 years ago); the “Neolithic Revolution,” during which the shift from foraging to agriculture occurred, about 10,000 years ago; the development of large-scale “civilized” societies beginning perhaps 5,000 years ago, and finally to the modern industrialized states of the present.

Rousseau and Sahlins notwithstanding, most of us maintain a Hobbesian perspective of the progression--John A. J. Gowlett’s “Ascent to Civilization” pretty well sums it up in a single book title. We live longer than our preagricultural ancestors did and our childhood mortality rate is lower. We have immunizations, antibiotics, anesthesia, open-heart surgery and MRI scanners. Surely our health is superior; how could anyone argue otherwise?

Cohen can. He skillfully blends insights from the fields of epidemiology (the analysis of factors governing health and disease in contemporary societies), medical anthropology (actual field studies of health among recently investigated hunters and gatherers) and paleopathology (the use of skeletal and mummified remains to evaluate the health of prior societies). These related, yet independent disciplines permit “triangulation.” Each, by itself, is imperfect, limited, biased; but when data from all three fields tend to support common conclusions, the resulting interpretation of past events is hard to dispute.

Cohen’s analyses probably will upset beliefs, images and illusions that many of us hold. It appears likely that farmers worked harder and were less healthy than were the foragers who preceded them. Then why did the “Neolithic Revolution,” the shift from hunting to farming, occur. Cohen postulates that game animals were becoming ever scarcer and that increasing population produced growing constraints on group mobility. Bands that previously had ranged widely to utilize seasonally available plant and animal resources now competed with other groups that wanted those same resources. In the end, people adjusted to the new circumstances by adopting a sedentary rather than nomadic existence and by increasing the productivity of the land they were able to hold--they became farmers.

Changes of this magnitude had to affect human health: Foragers walk away from their refuse, but it accumulates in sedentary communities--especially ones with rudimentary or nonexistent sanitation facilities. The resulting boost in the prevalence of infectious disease was exacerbated by increased community size: Epidemic diseases cannot persist in cultures composed of small, mobile bands. In addition, trade, necessitated when people became confined to fixed locations that couldn’t provide all requisite resources, promoted dissemination of epidemic infections still further.

Nutritional quality declined even as quantity increased. In most locations, animal husbandry failed to provide the dietary protein that hunting had previously afforded. Concentration on a smaller number of vegetable crops suitable for the community’s geographical location necessarily limited dietary breadth in comparison with that available to wide-ranging nomadic foragers. Furthermore, farmers are more vulnerable to climatic vagaries: Hailstorms, droughts, floods, late freezes and so forth can produce famine more readily for agriculturists than for foragers--a contention Cohen documents by analysis of dietary stress markers in skeletal remains.

The Neolithic Revolution’s social and political consequences were of even greater import. Agriculture necessitated coordinated, future-oriented group activities. These, together with increased community size, led to the emergence of formal leaders--chiefs, or “big men.” The same factors also promoted the development of status hierarchies foreign to band-level hunting and gathering societies in which interpersonal relationships are essentially egalitarian. Despite our pride in the Declaration of Independence, men were more equal before the Neolithic Revolution than after the American.

Cohen proceeds to make similar analyses for the shift from small- scale agricultural communities to the larger, commonly recognized civilizations that began to appear about 5,000 years ago, and also the changeover from agriculture to industry that occurred roughly 200 years ago. In each case, his observations are perceptive, balanced and insightful. Perhaps the central theme is that the health implications of these societal upheavals have been unevenly stratified. For the elite in most locations, health and longevity have slowly and fitfully improved. However, for the majority, and especially for people in disadvantaged geographical locations, health indicators suggest that overall welfare failed to achieve preagricultural levels until the 19th Century. In the world’s poorer developing nations, people are almost certainly less well-off even today.

Even affluent individuals in the world’s most “advanced” industrialized nations suffer from chronic degenerative diseases--heart attacks, strokes, cancer, diabetes, obesity, osteoporosis and hypertension--which the best available evidence suggests were uncommon, rare, or practically unheard-of for hunters and gatherers. Cohen marshals impressive and convincing data from multiple disciplines to support this conclusion.

The book is divided into three sections. The narrative text of 142 pages is followed by an 82-page appendix of footnotes--readers of the prestigious periodical Science will be familiar with this arrangement. Finally, a 46-page bibliography provides documentation and further reading for individuals who, like myself, are stimulated by the book’s ideas. Cohen’s style is scholarly but clear and easily readable, not at all stiff and technical. Even the footnotes are straightforward and helpful, rather than arcane or excessively academic.

In my opinion, “Health and the Rise of Civilization” is certain to become a classic--a prominent and respected source on this subject for years into the future. It should be of value for historians, anthropologists, and physicians interested in epidemiology or preventive medicine.

Are there any qualifications? Of course, but they’re hardly derogatory. Cohen might have broadened the scope of his work. For example, the place of women in society has varied with the “rise” of civilization just as health has. Many anthropologists believe that men and women were near equals, both socially and economically, before the emergence of agriculture. Thereafter women generally became second-class citizens or totally disenfranchised to the status of mere property.

Subsequent fluctuations in women’s status have roughly paralleled changes in health. Only in the recent past--and then only in restricted cultural circumstances--have women reclaimed the near equality that appears to have been their birthright. I wish Cohen had addressed this topic with the same perceptive, even-handed scholarship that characterizes his writing; the results would have been welcome amid the unscientific, largely politicized pro- and anti-feminist diatribes now extant.

Reservations aside, this is a marvelous book. It’s a well-written, scrupulously documented, finely reasoned treatise that will shake up prejudices, blast icons and broaden horizons. If you want to read something that will make you think, reflect and reconsider, Cohen’s “Health and the Rise of Civilization” is for you.