5 Diseases and the European Mortality Decline, 1700-1900

In his study of world population published more than 50 years ago, A. M. Carr-Saunders (1936) ob­served that the population of western Europe had begun to increase by the early eighteenth century, if not earlier, as a result of a growing gap between births and deaths.

For the purposes of this discussion the conditions, of which note must be taken, may be classified into four groups, though the boundaries between them are indefinite and though there is much overlapping: (1) political, that is conditions in relation to the maintenance of external and internal order; (2) social, including the state of knowledge in relation to the production and use of food, and to the making and use of clothing; (3) sanitary, that is conditions relating to housing, drainage, and water-supply; (4) medi­cal, including both the state of knowledge concerning the prevention and cure of disease and its application to the public at large.

Because Carr-Saunders was dealing with the pe­riod after 1700, he thought that the first category - social order - no longer applied because conditions in England and the rest of northwestern Europe were by that time comparatively stable and orderly. Thus, the other three categories were of most value in explaining the mortality decline in northwestern Europe in the eighteenth and nineteenth centuries. Under (2) he included the adoption of root crops, the improvement of gardening, and the use of cotton for clothing, which improved personal cleanliness. Un­der (3) he included the improvement of towns and their water supplies, the paving and cleaning of streets, and the substitution of brick for timber.

He then pointed out that in the countries of south­western Europe (excluding France) mortality did not begin to decline until the 1890s, probably as a result of the late introduction of improvements in catego­ries (2), (3), and (4). Finally, in eastern Europe the course of mortality showed some resemblance to that of southwestern Europe, but began to decline even later, when the same three causal categories were first introduced.

In general, writers before Carr-Saunders had taken a similarly broad approach. After World War II, however, the situation changed. In an article on a century of international mortality trends, George Stolnitz (1955) observed the following:

Increasing life chances are almost always explained by reference to two broad categories of causes: rising levels of living on the one hand (income, nutrition, housing, liter­acy), and on the other technological advances (medical science, public health, sanitation). The usual approach has been to regard these sets of factors as more or less coordi­nate, with little attempt to assess their relative impor­tance. At the same time there has been considerable em­phasis on their interdependence, a common observation being that the developing and application of disease con­trol techniques would have been very different in the absence of widespread social change. Both of these views, which evolved largely on the basis of Western mortality experience, have also been traditional explanations of the contrasting patterns found in other parts of the world. Only recently has their adequacy been seriously ques­tioned, mainly as a result of developments in Latin America-Africa-Asia. The introduction of new disease­control methods in this region, usually unaccompanied by any important shifts in socio-economic conditions, has led to drastic mortality declines in the last few years.

The measurable reduction in mortality rates fol­lowing the introduction of antibiotics and pesticides led not only to revisionist views of the past accom­plishments of medical technology. It led as well to a major reshaping of the biomedical research and edu­cation establishment in the United States in the decades following World War II, at a time when the United States had emerged as the dominant force in scientific research in the West.

Both the intellectual and institutional changes evoked a response from others with different ways of explaining historical and contemporary disease pat­terns. We may call theirs a “holistic” approach, for it emphasized the significance of the social context, economic forces, and modes of life, and placed less weight on medical factors. For example, in 1955 Thomas McKeown and R. G. Brown wrote that the medical interventions usually invoked to explain de­clining mortality in eighteenth-century England could not possibly have had the effect attributed to them. In fact, some may have done more harm than good, as R. Dubos (1959) also pointed out.

Others have argued that, at worst, hospitals and dispensaries, inoculations for smallpox, and “man­midwives” had no discernible effect and may have been beneficial. McKeown (1976), in The Modern Rise of Population, has suggested that improved nu­trition in the eighteenth century initiated the de­cline. Others have their favorite “first causes” as well: J. Riley (1987) has suggested environmental improvements, and W. H. McNeill (1976), among others, has advanced the increasing genetic resis­tance to infectious diseases of European populations.

It is likely that the mortality decline proceeded in stages, with certain classes of diseases being reduced in sequence (Omran 1971). The first to be reduced were pandemic and epidemic diseases not responsive to the nutritional status of the host.

By the early 1700s the great pandemics of plague, as well as subsistence crises, had receded from west­ern Europe. As Carr-Saunders (1936) had suggested, this was largely the result of the growing stability of governments. More recently M. W Flinn (1981) has elaborated this point, suggesting that a number of factors were responsible for the diminution of mortal­ity from wars, famines, and plague. There was, he suggests, a change in warfare: a shift to naval and colonial wars, the development of a science of mili­tary hygiene, greater discipline of armies, and in­creasing isolation of armies from civilian populations (all of which would have contributed to a decline in typhus, among other causes of death). There was also a diminution of subsistence crises, attributable to the spread of new crops, the opening (in eastern Europe especially) of new lands, improved transportation, and more sophisticated “social administration” and famine relief. There was, finally, a diminution of plague in western Europe, which a number of observ­ers have attributed to increasingly effective quaran­tine procedures, for example, the Hapsburgs' cordon Sanitaire along the boundary of their empire with the Ottoman Empire. All of these measures were a reflec­tion of growing efficiency in the administration of increasingly large states (Flinn 1981).

Thus, by 1700, the start of the period under consid­eration, a major transformation in mortality was well underway. The great waves of mortality were ebbing and, by the mid-eighteenth century, death rates were stabilizing - albeit at high levels. Not until about the turn of the nineteenth century, how­ever, did they begin a definite decline.

These observations refer primarily to northwest­ern Europe. Eastern Europe and the Balkans, and to a lesser degree southern Europe, still suffered from high and fluctuating mortality rates, as can be seen in the devastating plague epidemic that afflicted Moscow in the 1770s (Alexander 1980). Indeed, it was in the eighteenth century that mortality in northwestern Europe began to diverge from that of the rest of Europe. These large regional differences will be dealt with first, followed by mortality in northwestern Europe.

It is beyond the limits of this essay to account for the rise of urban industrial societies in northwest Europe during the eighteenth century, and more ru­ral, agricultural societies elsewhere. That both pro­cesses were somehow related is generally agreed, though precisely how is much less clear. Certainly as cities grow, they must draw on a hinterland of in­creasing size for agricultural produce. Just why rings of production within nations or across Europe (and the globe) acquired the characteristics they did in the eighteenth and nineteenth centuries is a sub­ject of disagreement. Clearly, ease of transport and magnitude of demand are important variables (Dodgshon 1977).

Whatever the cause, it appears that in the eigh­teenth century agricultural production was differen­tiated across Europe such that the east central, east­ern, and southern areas were devoted largely to the production of staples on large estates, worked by an impoverished peasantry. In contrast, agriculture in northwest Europe was characterized largely by mixed dairy and arable activities on farms of 20 to 50 hectares (Abel 1980), usually worked by individ­ual families and servants.

Family organization and household size differed significantly among regions of Europe as well, again for reasons that are poorly understood. North­west European family organization tended to be neolocal, and household size to be smaller than else­where in Europe, where households were large and complex in organization.

It has been said that mortality stabilized in north­western Europe during the eighteenth century as a result of growth of stable states, and that elsewhere rates tended to fluctuate widely as epidemics per­sisted into the nineteenth century. Nonetheless, even in the more peripheral regions of Europe, there seems to have been a diminution of pandemics and famines as compared with their occurrence in previ­ous centuries. The diseases that remained were en­demic. They included named diseases such as tuber­culosis, typhoid, scarlet fever, measles, as well as various forms of pneumonia, enteric infections, and, in children, the so-called pneumonia-diarrhea com­plex. Even smallpox, which in the past had caused such fearsome epidemics, became in the course of the eighteenth century and even more in the nine­teenth, increasingly a disease of children rather than of young adults, a result of both the growth and integration of populations and inoculation and vacci­nation. Most of these diseases were made more le­thal by the malnourished state of the host, although smallpox seems to have been an exception.

There were several ways in which agricultural and household organization affected this constella­tion of airborne, foodbome, and waterborne diseases. For example, early marriage associated with early childbearing increased the risk of infant death. Large households were likely to be crowded, and density increased the risk of contracting airborne infections as well as the opportunity of spreading body lice (vectors of typhus) in particularly unsani­tary conditions. Indeed, typhus continued to be com­mon in the civilian populations of Russia and the Balkans well into the nineteenth century.

The pattern of agriculture that persisted in the peripheral regions of Europe throughout the nine­teenth century - agricultural wage laborers or serfs working on large estates devoted to monocropping - required the exploitation of female labor. In addition to imposing physiological stress on women, it pre­vented them from breast feeding for as long as might have been desirable. Moreover, the fact that dairying was not common probably meant that, when infants were weaned, they were put on a very modified adult diet rather than one that included a large amount of nonhuman milk. Under such circumstances, so- called weanling diarrhea was probably very common. Weanling diarrhea is a lethal syndrome in which a malnourished child develops diarrhea and in which diarrhea may precipitate malnutrition. Diarrhea may or may not be caused by malnutrition, but mal­nutrition increases the likelihood that an episode of diarrhea will be fatal.

Studies in Russia at the end of the nineteenth century showed that infant mortality increased dur­ing the summer, when mothers often worked long hours in the fields, generally leaving their children at home, where they could not be nursed. In addi­tion, the practice of using a pacifier rather than breast feeding increased the chances both of malnu­trition and of the acquisition of infections, since the pacifier was “a rag covering crumbled bread or rolls, wet dough, or milk kasha - a device ripe with bacte­ria, especially when combined with milk or, as was the custom, prechewed by an adult” (Frieden 1978). Medical reformers who attempted to change these practices frequently met resistance from people for whom domestic arrangements within an extended family reinforced traditional beliefs and child­rearing practices.

Germany provides another example of the associa­tion between peasant life on large estates and mor­tality. In eastern Prussia the growth of Junker es­tates devoted to grain monoculture gave rise to a peasant class that needed to exploit women in order to subsist, the result being, as in Russia, an inability to breast feed properly and a high rate of infant mortality. In western Prussia, by contrast, land re­forms in the early nineteenth century led to a wider distribution of peasant landownership, a greater va­riety of crops, and greater ownership of livestock by more people. Thus, spontaneous abortions and in­fant, perinatal, and maternal mortality were all lower in the West than in the East (Kunitz 1983).

Similar regional differences were observed in It­aly, where the south was distinguished from the north by a high proportion of Iatifundia and high crude mortality rates. Interestingly, however, in this case infant mortality did not differ from one region to another. No explanation for the lack of difference is available; rates all over Italy continued to be among the highest in Europe right to the present century. Indeed, in one particularly poor “latifondo” region in Calabria, the crude mortality rate aver­aged about 50 per 1,000 in the latter part of the nineteenth century. In one commune of this area between 1861 and 1875, the average annual crude mortality rate had been about 60 per 1,000 and the infant mortality rate averaged about 500 per 1,000 live births. There was no natural increase in the population (Kunitz 1983).

There are no available data from nineteenth­century Spain that permit a distinction to be made between areas of Iatifundia and areas where peas­ants owned their own land. Similarly, nineteenth­century data from the Balkans are somewhat sparse. Crude mortality rates in Croatia were almost 40 per 1,000 between 1800 and 1870 and began to decline significantly only in the 1870s. Rates were lower in Slovenia, probably reflecting the greater influence of Austria. Data from Serbia are available from 1860, with rates ranging from 27 to 33 per 1,000 between 1860 and 1890 (Gelo 1982-3). It is likely that mortality stabilized gradually over the century as the Ottoman Empire instituted reforms modeled on those of Western governments, including efforts to control plague. The fact that it stabilized at high rates was undoubtedly due to continuing backward­ness, for throughout the area feudal or Semifeudal relations persisted for much of the nineteenth cen­tury. In the Hapsburg lands, where servile obliga­tions were formally revoked in 1848, the state devel­oped Semifeudal relationships between members of its bureaucracy and the peasantry, but in Bosnia- Herzegovina, under Hapsburg domination from 1878, and in Macedonia, feudalism persisted until 1918. In Serbia the state and money lenders were the chief forces dominating the peasantry (Kunitz 1983).

Turning now to a consideration of mortality pat­terns within northwestern Europe during the eigh­teenth and nineteenth centuries, we have already observed that mortality had stabilized and even be­gun to decline in the eighteenth century. This was primarily a rural phenomenon. Urban mortality re­mained high well into the nineteenth century, though a widely shared definition of urban is some­times difficult to arrive at.

The points made about the consequences for mor­tality rates of agricultural and household organiza­tion in the peripheral regions of Europe suggest, by way of contrast, why mortality in the rural parts of northwestern Europe declined more rapidly. House­holds were smaller and presumably less crowded; marriage and therefore childbirth occurred at later ages; dairying became increasingly common and was practiced year round beginning in the eigh­teenth century; there seems to have been less exploi­tation of female labor; increasing emphasis was placed on breast feeding of infants and young chil­dren; and when weaning occurred, infants were likely to be given cows milk rather than a watered- down version of adult table foods. The result was lower rates of infant, child, and crude mortality in rural northwestern Europe than elsewhere.

In contrast, urban mortality in northwestern Eu­rope throughout most of the nineteenth century was often as high as in the high-mortality countries of Europe; rates in some cities seem actually to have increased in the first part of the nineteenth century. The issue of whether urban mortality did in fact in­crease is bound up with the so-called standard of living debate (Woods and Woodward 1984). On one side are the “pessimists” - usually to the left of the political spectrum - who claim with Friedrich Engels that industrial development resulted in a deteriora­tion of living conditions of the working class. On the other side are the “optimists,” who claim that develop­ment made life better for all and that in some regions of Europe industrial development averted a subsis­tence crisis, so severe was rural poverty (Komlos 1985). As almost always happens, there is a middle position, whose advocates in this case claim that ur­ban mortality did increase but that it was never as high as it had been in the seventeenth and eighteenth centuries, when epidemics could run amok (e.g., Arm­strong 1981).

In both England and France, urban mortality seems to have begun to decline in the second half of the nineteenth century. The diseases that declined were spread in different ways: through the air (e.g., respiratory tuberculosis), food, or water (e.g., ty­phoid and gastroenteritis of all sorts). Many of them seem to be more lethal if the host is malnourished. Indeed, McKeown (1976) has argued that the decline in deaths from tuberculosis in England was the re­sult of improved host resistance resulting from bet­ter nutrition, whereas the decline of foodborne and particularly waterborne diseases was the result of improvements in public health measures, such as protected water supplies and sewage disposal, which seem to have been introduced with increasing fre­quency in the second half of the nineteenth century. Some diseases such as scarlet fever may have de­creased in virulence as a result of genetic shifts in the microorganism itself. Others, such as diphthe­ria, may have increased in virulence for the same reason. There seems little doubt that, in both urban and rural places, the incidence of smallpox declined dramatically throughout the century as a result of vaccination. And unquestionably the pneumonia­diarrhea complex of childhood declined significantly as well.

It will never be possible to apportion credit with total accuracy to the many preventive measures that contributed to the decline in urban mortality. Public health interventions, changing standards of individ­ual behavior, and improved housing and diets pre­sumably played more or less important roles. Efforts to sort through all of these factors will doubtless raise more questions.

For example, because it has proved difficult to get good direct measures of the standard of living in past times, individual stature, an ingenious indirect mea­sure, has increasingly been relied on (Fogel, Enger- man, and Trussell 1982). It is generally assumed that height is a good reflection of nutritional status. Thus, if better diets were responsible for the stabili­zation of or increase in life expectancy, there should have been an accompanying increase in stature. Un­fortunately, the association is complicated by the fact that height also reflects the impact of disease, particularly gastrointestinal afflictions. Permanent stunting may not occur if the intervals between bouts of childhood sickness are sufficiently long that catch-up growth can take place. In developing coun­tries this is often not the case, however, and it has been said that “infections are as important a cause of malnutrition as is the limited availability of food” (Martorell and Ho 1984).

The same may have been true in eighteenth- and nineteenth-century Europe. Thus, the findings re­garding variations in height among European popu­lations (Floud 1984), between urban and rural popu­lations (Sandberg and Steckel 1987), and within populations over the course of 100 or 200 years (Fo­gel et al. 1982) are difficult to interpret if one wants to use them as a measure of the availability of food. This is important because an increase in height (which began in most western European countries in the nineteenth century) could be interpreted as a reflection of the increased availability of food or a reflection of declining sickness resulting from public health measures and from changes in personal be­havior, or - what is more likely — both.

In England, at least, fluctuations in life expec­tancy diminished by the mid-eighteenth century, sta­bilized at relatively low levels, and then began to increase in the first decades of the nineteenth cen­tury. Height also began to increase in the early nine­teenth century. Unfortunately, regional data on height are not yet available. But these observations can be interpreted tentatively to mean that the stabi­lization of mortality was not caused by improved nutritional status and that, when both height and life expectancy began to increase in the nineteenth century, the effects could have been reciprocal: re­duced sickness contributing to increased height, im­proved nutrition (partially reflected in increased height) making people less susceptible to the lethal effects of the most prevalent infectious diseases. In other words, height is a good measure of the stan­dard of living, but it is difficult to determine whether more food or less disease was responsible for the height increase.

There are several points on which most observers seem to agree. First, the initial recession of pan­demics seems to have been a result of the growth of nation-states. Second, specific curative measures ap­plied by individual physicians to individual patients had little if any impact on mortality, regardless of the comfort or distress they may have caused pa­tients and their families. Third, the recession of a variety of endemic diseases had a mix of causes: environmental cleansing and active public health interventions; changes in personal behavior (more frequent bathing, handwashing, the cessation of spit­ting in public, the covering of one’s mouth and nose when sneezing and coughing); and improvements in living conditions. Fourth, urban mortality in west­ern Europe increased for a generation or two in the early nineteenth century.

There are also significant areas of disagreement. One, the standard-of-living debate, has already been mentioned. Another, which has received less attention, is the degree to which individual behav­ior, as opposed to collective measures, affected mor­tality. McKeown (1976) has argued that, in de­veloped nations, individual behavior is now more significant than environmental conditions in deter­mining health status whereas in the past environ­mental conditions were more important than indi­vidual behavior. There is certainly disagreement with regard to the truth of this assertion. It has been argued, for example, that attitudes toward breast feeding and personal cleanliness had a mea­surable impact on mortality in the eighteenth and nineteenth centuries (Razzell 1974; Fildes 1986).

Another subject of disagreement has to do with the notion that European populations were selected for resistance to a wide variety of infectious diseases. Some claim that this was an important determinant of declining mortality, whereas others deny that it was. What is clear is that the European mortality decline was a momentous phenomenon, not simply for Europeans but for all peoples. Its causes were bound up with the very creation of the world as we now know it and will continue to be a topic of debate for as long as we disagree about why the world is as it is.

Stephen J. Kunitz

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