A History of Population Health

Front matter

CONSORZI PROVINCIALI AMTITVBERCOLARI.

BRITE | RODOPI

A History of Population Health

PART 1 Long-term Trends: A Bird’s Eye View

2 Long-term Trends in Population Health 25 Changes in Over-all Population Health 25 Changes in Disease Patterns 39 Epidemiologic Transition 2.0 48

3 Understanding Trends in Population Health 57 Theories of Population Health 57 Economic, Political and Sociocultural Conditions 69 Public Health and Medical Care 90

PART 2 Zooming in: The Rise and Fall of Diseases

4 Health Problems of Pre-industrial Societies 121 Violence and Hunger 121 Great Epidemics 135

5 Health Problems of Industrializing Societies 149 Communicable Diseases 149 Maternal, Infant and Perinatal Mortality 182 Other Health Problems of Industrializing Societies 198

6 Health Problems of Affluent Societies 217 Chronic Diseases 217 Injuries 261 A New Plague 271

PART 3 Synthesis and Outlook

7 Why? 27 Why Did European Population Health Improve? 279 Why Did Some Countries Rush Ahead or Lag Behind? 291

8 Outlook 324 Feathers of Icarus 324 The Way Ahead 329 By Way of Conclusion 334

Suppl. Part 1, Chapters 1-3 341 Suppl. Part 11, Chapters 4-6 358 Suppl. Part 111, Chapters 7-8 374

Bibliography 377 Index 424

CONTENTS

Preface

This is a book about long-term trends in the health of Europeans, and about how and why diseases have come and gone. It is about the role of politics and biology, and about everything in-between, from religion to medical care and from tobacco control to the Industrial Revolution. Starting in the early 18th century and ending in the 2010s, it puts the spectacular changes in life expectancy and morbidity patterns into perspective, and tries to identify the deeper causes of the dramatic variations between European countries. Its main conclusion is that most diseases are man-made, that ‘human agency’ accounts for both the rise and fall of disease, and that between-country differences in political, sociocultural and economic conditions have profoundly influenced population health.

The idea for a book like this arose long ago, in 1984, when I read Fernand Braudel’s La Méditerranée — an integrated history of the whole Mediterranean area during the reign of Philip 11 of Spain (1527-1598) — while I was sitting under a cypress tree in the South of France. Full of admiration I thought by myself: how wonderful would it be to paint such a broad canvas on the history of health? It took more than three decades before I felt capable of giving it a try, and even now it is easy to see the enormous gulf between Braudel’s depth and breadth and my more modest achievement. Nevertheless, I hope readers with a similar interest in ‘big picture’ histories will be interested in the result.

While working on this book, I received generous support from many colleagues. After stepping down as head of the Department of Public Health of Erasmus MC in Rotterdam, I was allowed to spend the years remaining until my retirement on writing a book (I actually wrote two ... the other one appeared in 2019 under the title Health inequalities: persistence and change in European welfare states). The Stichting Maatschappelijke Gezondheidszorg financially supported the production of this second and more ambitious book.

A special word of thanks goes to Marina Karanikolos (London) who helped me with collecting and analysing the mortality data. David Leon (London), Mart van Lieburg (Rotterdam), France Meslé (Paris) and Frans van Poppel (The Hague) read the manuscript and provided me with lots of detailed and useful comments. In various stages of writing, I also received useful suggestions from (in alphabetical order) Evgeny Andreev (Moscow), Virginia Berridge (London), Timo Bolt (Rotterdam), Francisco Bolumar (Madrid), Jan Willem Coebergh (Oegstgeest), Martin Gorsky (London), Martin McKee (London), Wilma Nusselder (Rotterdam), Sevket Pamuk (Istanbul), Diego Ramiro (Madrid), Enrique Regidor (Madrid), Paula Santana (Coimbra), Sergey Shishkin (Moscow),

VIII PREFACE Sergey Timonin (Moscow), Jacques Vallin (Paris), Anatoly Vishnevsky (Moscow), and Vasiliy Vlassov (Moscow). I am also grateful to three anonymous reviewers for their comments.

Of course, all the remaining errors — and there are likely to be some, in view of the vast terrain I had to cover — are entirely mine.

Rotterdam, December 2019 Johan Mackenbach

Illustrations nw fp WwW N

19 20 m

A WwW N

Plates

Cabet’s utopian principles. Title page of Voyage en Icarie, 1848 3

Europe in the 18th century 17

Lucille Randon, a.k.a. Soeur André. The oldest person in Europe, 2019 30 Savonerie [Soap factory] as explained in the Encyclopédie, 1771 94 European public health history on zoth century postage stamps 106 Alexander Fleming on a stained glass window in St. James’s Church (London), 1952 114

La Guerre [War]. Painting by Pablo Picasso, 1951 122

Three men burying famine victims during Leningrad’s siege, 1942 132 “The louse and death are friends.” Russian poster warning against typhus, 1919 144

Cholera victims being carried away in Palermo, 1835 150

“Do not trust appearances.” Spanish poster warning against syphilis,

1938 166

A woman suffering from chronic pellagra. Watercolour, ca. 1925 199 Miners during their lunch-break in a coal mine in Limburg, 1945 209 Map of cardiovascular disease mortality in Europe, 1990 218

“Iwas really something.” Painting of a woman dying from Alzheimer’s, 2015 256

A poor depressed man prepares to hang himself, 1826 259

Sjukdomarna [Diseases] registered by a parish priest in Varnhem, Sweden, 1773 294

“Social-democratic party demands state pension.” Dutch election poster, 1929 301

Map of illiteracy levels in Europe, 1930 306

“Against the kulak’s howl.” Soviet poster promoting collective farming, 1928 318

Figures

Trends in life expectancy in Europe, 1730-2015 4 Trends in over-all mortality in Europe, 1720-2015 26 Trends in life and health expectancy in the Netherlands, 1850-2010 38

Trends in cancer incidence in Europe, 1953-2011 44 m.

ILLUSTRATIONS

The origins of disease 62

National income and life expectancy in Europe, 1870s to 2010s 74 Trends in life expectancy in Northern and Eastern Europe, 1920-2015 79 Trends in literacy in Europe, 1475-2000 89

Trends in homicide in Europe, 1800—2010 128

Plague epidemics in Europe and the Mediterranean, 1340-1890 138 Trends in smallpox mortality in selected European countries, 1751-1935 141 Trends in malaria incidence in Europe, 1900-1978 148

Trends in tuberculosis mortality in Europe, 1750-2015 157

Trends in diphtheria mortality in Europe, 1900-2015 174

Trends in respiratory disease mortality in the Netherlands, 1901-1992 176 Trends in pneumonia mortality in Europe, 1900-2015 178

Trends in maternal mortality in Europe, 1700-2015 183

Trends in infant mortality in Europe, 1745-2015 190

Trends in still-births in Europe, 1775-2015 196

Trends in appendicitis mortality in Europe, 1900-2015 206

Trends in sulphur dioxide emissions in Europe, 1850-2005 215

Trends in ischaemic heart disease mortality in Europe, 1900-2015 221 Trends in cerebrovascular disease mortality in Europe, 1900-2015 229 Trends in diabetes mellitus incidence in Europe, 1984-2015 233

Trends in cancer mortality in Europe, 1900-2015 235

Trends in breast cancer mortality in Europe, 1900-2015 241

Trends in lung cancer mortality in Europe, 1900-2015 243

Trends in liver cirrhosis mortality in Europe, 1900-2015 254

Trends in motor vehicle injury mortality in Europe, 1900-2015 262 Trends in suicide in Europe, 1750-2010 268

Trends in AIDS mortality in Europe, 1983-2017 273

Trends in life expectancy in the Western Balkans, 1920-2015 312

Supplementary Figures

Trends in life expectancy in Europe, 1730—2015, women 341

Mortality decline in Europe, by age and sex, 1870—2010 350

Life expectancy from age 85 in Europe, 1750-2015 351

Trends in height of military recruits in Europe, 1800-1985 352

Shifts in cause-of-death patterns in Europe, ca. 1900-2015 353

Trends in national income in Europe, 1700-2015 356

Trends in education levels in Europe, 1820-2010 357

Trends in typhus incidence in selected European countries, 1901-1951 360

ILLUSTRATIONS XI m.

oO oN awn f UO N

Trends in mortality from typhoid and paratyphoid fever in Europe, 1901-1975 362

Trends in syphilis mortality in Europe, 1900-2015 363

Trends in mortality from childhood infections in the Netherlands, 1875-1992 364

Trends in influenza mortality in Europe, 1900-2015 365

Trends in peptic ulcer mortality in Europe, 1900-2015 366 Trends in mesothelioma mortality in Europe, 1992-2015 367 Trends in diabetes mortality in Europe, 1900-2015 368

Trends in stomach cancer mortality in Europe, 1900-2015 369 Trends in colorectal cancer mortality in Europe, 1900-2015 370 Trends in prostate cancer mortality in Europe, 1900-2015 371 Trends in lung cancer mortality in Europe, women, 1900-2015 372 Trends in dementia mortality in Europe, 1979-2017 373

Tables

Rise and fall of diseases in Europe: an overview 46 Estimated contributions of public health and medical care to mortality decline 285

Supplementary Tables

Sources of mortality data 342

ICD-codes for causes of death 344

Correlations between determinants and life expectancy, 1870-2010 346 Differences in population health trends between European countries 354 European war deaths, 1700-2010 358

A selection of major European famines, 1700—2010 359

Deaths from cholera in selected European countries, 1831-1923 361 Contributions of specific diseases to mortality decline, ca. 1870-1950 374 Contributions of specific diseases to mortality decline, ca. 1970-2015 376

Introduction

Utopia Come True?

Are we living in Utopia? This may seem a strange question — our television news with its footage of disaster does not immediately suggest we do — but today’s world is much more similar to our ancestors’ utopian dreams than most people realize. ‘Utopia’ — a newly invented word meaning ‘nowhere’ — was the title of a book by Thomas More (1478-1535), published in 1516. It describes an imaginary and perfectly organized kingdom, located just off the coast of America. A few decades before, the ‘New World’ had been discovered, and this had sparked the idea that an ideal society did not have to await the hereafter, but could be created here and now.

The perfect organisation of Utopia guarantees its citizens complete happiness. Private property and the privileges of the nobility have been abolished, everybody works only 6 hours a day, and the head of state is chosen in free, representative elections. In More's Utopia, people live in spacious and ventilated houses, and the government inspects their food and supplies them with clean drinking water. A system of social security prevents those who fall ill from becoming poor, and those who are poor from falling ill - and people who despite all countermeasures still fall ill, have the right to be treated in excellent public hospitals. No wonder that, as More notes, “[not] anywhere are there healthier men and freer from diseases.”!

Although the term ‘utopia’ has become synonymous for unattainable ideals of perfect societies, it is remarkable how much of More’s utopian health vision has been realized in the 20th century, and mostly without the draconic reorganization of society that More thought necessary. Through the centuries, utopian visions have served as a source of inspiration for those who believed that a better world could be created, in which nobody would suffer from avoidable or remediable ill-health. This is even more clear in the case of a number of 19th

1 Thomas More, De Optimo Rei Publicae Statu Deque Nova Insula Utopia [On the Best State of a Republic and on the New Island Utopia] (Leuven, 1516). The sentence in the text was cited from the Open|Utopia edition, edited by Stephen Duncombe, p. 135 (www.theopenutopia.org, accessed 25/08/2019). For commentaries on the health aspects of More's Utopia, see Phil Withington, “Utopia, Health, and Happiness,” Lancet 387, no. 10033 (2016): 2084-085; Johan P. Mackenbach, “Thomas More, Etienne Cabet and the Paradoxes of Utopian Thinking,” European Journal of Public Health 14, no. 2 (2004): 113.

This is an open access chapter distributed under the terms of the cc BY-NC 4.0 License.

century Utopias. The novel Voyage et Aventures de Lord William Carisdall en Icarie by Etienne Cabet (1788-1856) is a good example. This book, published in 1840, describes a communist utopia in which prevention of illness had a high priority (Plate 1).

The following quote gives an idea of Cabet’s utopian dream:

Within the city there are no cemeteries, no noxious products manufactured, no hospitals: all these establishments are on the outskirts, in open places, near swift-flowing streams or in the country. [...] You would see here neither cabarets, nor roadhouses, nor cafés, nor smoking joints, nor the stock-exchange [...] just as there are no prostitutes or pickpockets, no drunkards or mendicants; but instead you would find everywhere PRIV- IES, as elegant as they are clean and convenient, some for women, others for men [...].?

Cabet’s work attracted considerable support, and in 1848 a group of 1500 followers set off from France to America to establish a colony on the model of Icarie. However, practice proved to be more difficult than theory: the group split, and Cabet himself died in St. Louis shortly thereafter. Nevertheless, many igth century readers must have felt attracted by the prospect of living in a cleaner, safer, more equitable, and healthier city. And it only required social justice and good government!®

Rising Life Expectancy Over the past three centuries, health of Europeans has improved enormously. This can most clearly be seen in the spectacular increase in the length of life (Figure 1). Around the middle of the 19th century, life expectancy at birth fluctuated around an average of less than 40 years, but in the last decades of that century life expectancy began to rise rapidly, to reach the current values of between 65 and 80 years among men, and between 75 and 85 years

2 The original publication is Etienne Cabet, Voyage et Aventures de Lord William Carisdall en Icarie (Paris: H. Souverain, 1840). The quote is cited from an extract at http://urbanplanning. library.cornell.edu/DOCS/cabet.htm (accessed 20/08/19).

3 Some philosophers have argued that striving for utopia inevitably leads to totalitarianism, because the realization of utopian societies is incompatible with human freedom (e.g., Melvin J. Lasky, Utopia and Revolution (Chicago: University of Chicago Press, 1976)). More’s Utopia is indeed far from a liberal society, and even needs slavery for its functioning. Also, seriously ill, but incurable patients are persuaded to commit suicide or have themselves euthanized. See Chapter 7 for the Soviet Union as a ‘realized utopia’, and Chapter 8 for the need to ‘re-think Utopia’.

INTRODUCTION

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PLATE 1 Cabet’s utopian principles. Title page of Voyage en Icarie, 1848 Title page of the 5th edition of Cabet’s Voyage en Icarie, published in 1848. It lists a number of principles summing up Cabet’s philosophy, such as Fraternité [Brotherhood], Tous pour chacun — Chacun pour tous [All for everyone — everyone for all], Premier droit, Vivre — Premier devoir, Travailler” [First right, to Live — First duty, to Work], and Bonheur commun [Common happiness]. After settling his utopian community in Nauvoo (Illinois), Cabet announced that the common dining room would be decorated with wall inscriptions listing the principles of the community. These ranged from the abolition of private property to the duty to work, and from the duty of mutual assistance to the prohibition of tobacco. COLLECTION KONINKLIJKE BIBLIOTHEEK, THE HAGUE. REPRODUCED WITH PERMISSION

CHAPTER 1

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FIGURE1 Trends in life expectancy in Europe, 1730-2015 Notes: For women, see Suppl. Figure 1 SOURCE OF DATA: SEE SUPPL. TABLE 1 among women. It is difficult to think of a more important change in the whole of human history — unimaginable even for the most utopian among our predecessors.

This increase in the length of life has been accompanied by enormous changes in people's health. Many diseases have disappeared, and while other diseases have taken their place, these occur at higher ages than the diseases of the past, so that most health problems now occur among older people. And because the greatest advances have been made by preventing diseases from occurring, not only has the total number of life-years increased, but so has the number of years that Europeans can expect to live in good health.

It is only more recently that the number of years that we can expect to live in ill-health has also increased. Since the middle of the 20th century, medical treatment of chronic conditions has made an increasing contribution to improvements in life expectancy. As a result of increased survival of patients with chronic diseases, total life expectancy has increased faster than ‘healthy life expectancy’, and years of life spent with disease have increased rather strongly.

Although the improvements in population health have been spectacular everywhere, European countries have followed very different trajectories. Health improvements have occurred at different times and with different speeds, resulting in the very broad band of upward moving life expectancies that can be seen in Figure 1. The width of this band has been indicated by the highlighted curve for Sweden, which for a long time had the highest life expectancy, and the curve for Turkey, which until recently was the country with the lowest life expectancy.

The gap in life expectancy between Sweden and Turkey increased from around 10 years in the beginning of the 19th century to around 25 years in the 1930s, and then narrowed again to around 8 years in the beginning of the 21st century. More generally, for most of the time Northern and Western Europe have taken the lead, later joined by Southern Europe, and with most parts of South-eastern and Eastern Europe consistently staying behind.*

Using a unique collection of historical data and recent research findings, this book shows that these trends and variations did not arise spontaneously, but were mostly man-made. This does not only apply to health improvements — which often resulted from increases in the human capacity to address the causes or consequences of disease — but also to temporary setbacks. Throughout European history, health and longevity were therefore closely related to economic, political and sociocultural conditions.

The Rise and Fall of Disease Talking about setbacks: the rise of life expectancy has not been a smooth process, as can be clearly seen in Figure 1. Some of the dips in the life expectancy curves were very deep indeed — the deepest dip occurred during the 1933 famine in Ukraine when average life expectancy at birth briefly declined to below 10 years. Below the surface of rising life expectancy and declining total mortality the trends are even more irregular. Specific causes of death have risen and

4 For more detailed studies of convergence and divergence of life expectancy between European countries, see Johan P. Mackenbach, “Convergence and Divergence of Life Expectancy in Europe: A Centennial View,” European Journal of Epidemiology 28, no. 3 (2013): 229-40; David A. Leon, “Trends in European Life Expectancy: A Salutary View,” International Journal of Epidemiology 40, no. 2 (2011): 271-77.

fallen over time, and it is only because ‘falls’ ultimately had the upper hand that life expectancy could rise.

This is one of the main findings of this book, which reviews the history of around 40 health conditions. These range from famine and plague to motor vehicle injuries and suicide, and from maternal mortality and cholera to diabetes and cerebrovascular disease. Seen in a long-term perspective the trends for these health conditions often follow a striking pattern of ‘rise-and-fall’. Most diseases which were common at their peak, were uncommon centuries or decades before, and their rise was usually followed by an equally impressive decline.

Although each disease has its own specific causes, we will see that the general explanation for rises of disease is that human efforts to improve their living conditions often required or allowed them to undertake new activities, which later turned out to be health-damaging. Just like long-distance trade brought the plague from Central Asia into Europe, so did education and reading increase the risk of myopia, and just like urban living increased the likelihood of tuberculosis infection, so did an affluent diet increase the risk of ischaemic heart disease.

Similarly, declines of disease had many specific explanations, but when one takes a bird’s eye view it becomes crystal-clear that it is highly unlikely that most declines occurred spontaneously. The general explanation is that the drive for better living conditions not only brought new health risks, but also created the necessary conditions for reducing these risks. For example, prosperity brought better nutrition and better housing, and economic growth made it possible for countries to invest in science and technology, safe drinking water, vaccinations, cholesterol-lowering drugs, and road traffic safety measures.

Nevertheless, it would be too simple to see economic development as the only, or even the main, driver of changes in population health. The history of Europe is full of examples where economic development and population health did not move in parallel. This shows that economic growth was usually not a sufficient condition for health improvement. For example, at various points in time Sweden, the Netherlands and Albania were over-performers in health as compared to their level of economic development, whereas Portugal and Russia were under-performers.

Closer inspection of these and other examples reveals that acceptance of measures to reduce health risks also often required sociocultural change, and that effective implementation required institutions able to deliver them on a large scale, such as an effective public health sector and an accessible health care system. Throughout European history, creating these conditions was a profoundly political enterprise. This is illustrated by the fact that national boundaries and political events, such as revolutions and dissolutions of empire, often coincided with sharp break-lines in population health.

These are the issues that this book is about. Using a wide range of quantitative data, from life expectancy to infectious disease notification rates, and from lung cancer mortality to average heights of recruits, we will look through the ‘telescope of history’ to discern some of the deeper causes of the rise of life expectancy since the 18th century. The results will be used to reflect on contemporary theories of determinants of population health, and the first of these is the theory of the ‘epidemiologic transition’. Because this has proven such a powerful organizing concept we briefly introduce this theory up-front in this introductory chapter.

The Epidemiologic Transition Theory

The ‘epidemiologic transition theory’ was originally proposed in a paper by Egyptian-American epidemiologist Abdel Omran (1925-1999). This paper, published in 1971, has since become a ‘citation classic’, with more than 4000 citations in later scientific publications. The epidemiologic transition describes the mortality component of the ‘demographic transition’: the long-term decline of (first) mortality and (then) fertility that accompanied socioeconomic modernization around the world.®

Omran characterized the epidemiologic transition as a “long-term shift [... | in mortality and disease patterns whereby pandemics of infection are gradually displaced by degenerative and man-made diseases as the chief form of morbidity and primary cause of death.” This shift occurs in three stages: the “age of pestilence and famine” in which life expectancy “vacillat[es] between 20 and 40 years” and “mortality [is] high and fluctuating”; the “age of receding

5 The ‘demographic transition’ theory was introduced around the middle of the 2oth century. Its intellectual history has been traced in Dudley Kirk, “Demographic Transition Theory,” Population Studies 50, no. 3 (1996): 361-87; Jean-Claude Chesnais, La Transition Démographique (Paris: Presses Universitaires de France, 1986). More critical assessments can be found in Dennis Hodgson, “Demography as Social Science and Policy Science,’ Population and Development Review 9, no. 1 (1983): 1-34; Simon Szreter, “The Idea of Demographic Transition and the Study of Fertility Change,’ Population and Development Review 19, no. 4 (1993): 659-701. Like Omran and others, and despite its ambiguity, we will sometimes use the term ‘modernization’ in this book, usually accompanied by the adjective ‘socioeconomic’. For an interesting commentary on this somewhat dubious term, see AHR Roundtable, “Historians and the Question of ‘Modernity’ American Historical Review 116, no. 3 (2011): 631-751.

pandemics’ in which life expectancy “increases steadily from about 30 to about 50 years” and “epidemic peaks become less frequent or disappear”; and the “age of degenerative and man-made diseases” in which life expectancy “rises gradually until it exceeds 50 years” and mortality “eventually approaches stability at a relatively low level.”®

In his 1971 paper Omran did not define ‘degenerative and man-made diseases, but in a later update he mentioned cardiovascular disease, cancer, stroke, diabetes, and metabolic disorders as examples of ‘degenerative diseases’. “Radiation injury, accidents, occupational hazards, carcinogens in the environment and in industry, and food additives” are examples of “diseases introduced by man.”

Omran recognized that in Western Europe and North America the shift started early and took approximately 100 years. This is the ‘western’ or ‘classical’ model of the epidemiologic transition. In a number of other countries, notably Eastern Europe and Japan, the transition started later but proceeded much more quickly (the ‘accelerated’ model). He considered rising living standards to be an important driver of population health change in the western model, and public health and medical technologies to be relatively more important in the accelerated model.”

Although the notion of an ‘epidemiologic transition’ has stuck in the demographic and epidemiologic literatures, it has since become clear that Omran’s picture of these long-term changes in population health is less than accurate, both conceptually and factually. The characterization of the shift as one from ‘pandemics’ of infectious diseases to ‘degenerative and man-made diseases’ is imprecise, as is the distinction between the three ‘stages’. Furthermore, just when Omran published his theory a renewed decline of mortality contradicted his idea that the transition had ended in new stability.

These and other problems have shown that Omran’s theory is in need of repair, but a satisfactory replacement has not yet been agreed on. Can the

6 Abdel R. Omran, “The Epidemiologic Transition: A Theory of the Epidemiology of Population Change,” Milbank Memorial Fund Quarterly 49 (1971): 509-38; the citations are from pages 518-20. The original paper was republished twice: in 2001 in the Bulletin of the World Health Organization, and in 2005 in the Milbank Quarterly. For the history of this ‘citation classic’, see George Weisz and Jesse Olszynko-Gryn, “The Theory of Epidemiologic Transition: The Origins of a Citation Classic,’ Journal of the History of Medicine and Allied Sciences 65, no. 3 (2009): 287-326.

7 Omran revisited his original ideas several times, without making substantial changes. See Abdel R. Omran, “The Epidemiologic Transition Theory. A Preliminary Update,” Journal of Tropical Pediatrics 29 (1983): 305-16; Abdel R. Omran, “The Epidemiologic Transition Theory Revisited Thirty Years Later,’ World Health Statistics Quarterly 51, no. 2-4 (1998): 99-119.

stages simply be relabelled or is a more fundamental revision in order? Can more recent changes simply be accommodated by adding a fourth stage, as some authors have proposed, or should these be seen as the start of an entirely new transition?

The McKeown Debate and the Preston-Curve There can be little doubt that the modern rise of life expectancy is related to improved living standards. It cannot be a coincidence that both life expectancy and national income showed steep rises over the 19th and 20th centuries — but how exactly are the two related? Two scientific studies, both published in the 1970s, still form the anchor-points of present-day discussions of this question.

The first is a series of publications by British professor of social medicine Thomas McKeown (1912-1988). McKeown made a detailed analysis of the history of cause-specific mortality in England and Wales since the 1840s, and summarized his conclusions in The Role of Medicine - Dream, Mirage or Nemesis (1976). His analyses showed that the decline in mortality was the result mainly of a decline of infectious diseases, and that infectious disease mortality decline for the most part antedated the introduction of specific medical interventions, such as vaccinations and antibiotics. In other words: the role of medicine can only have been marginal.

McKeown also showed that most of the decline of mortality from infectious diseases in England and Wales was due to a decline of air-borne diseases, particularly respiratory tuberculosis, and not to the water-borne diseases to which most public health interventions were targeted. He therefore concluded that neither medical care nor public health interventions could account for the decline in mortality. This must therefore have had another explanation — which he thought was improved nutrition, due to improvements in agricultural productivity and food transportation.®

8 McKeown published his findings first in a series of papers: Thomas McKeown and Robert G. Brown, “Medical Evidence Related to English Population Changes in the Eighteenth Century,” Population Studies 9, no. 2 (1955): 119-41; Thomas McKeown and Robert G. Record, “Reasons for the Decline of Mortality in England and Wales During the Nineteenth Century,’ Population Studies 16, no. 2 (1962): 94-122; Thomas McKeown, Robert G. Record, and R.D. Turner, “An Interpretation of the Decline of Mortality in England and Wales During the Twentieth Century,’ Population Studies 29, no. 3 (1975): 391-422. These were followed by two books, both published in 1976: Thomas McKeown, The Role of Medicine: Dream, Mirage, or Nemesis? (London: Nuffield Provincial Hopsitals Trust, 1976); Thomas McKeown, The Modern Rise of Population (London: Edward Arnold, 1976). The title of the first book reminds us of Ivan Illich (1926-2002), who argued that iatrogenic side-effects posed “limits to medicine” (Ivan Illich, Medical Nemesis: The Expropriation of Health (London: Calder & Boyars, 1975)).

Although his viewpoint that the rise of life expectancy is just a by-product of socioeconomic progress, and not of human intervention, is still commonly held, McKeown’s conclusions must be considered at least partly obsolete in the light of more recent findings. We will have a look at the results of more recent studies in various chapters of this book, and argue that public health and medical care have had a more important role than McKeown thought.?

Another influential paper, published in 1975 by American demographer Samuel Preston, also dealt with the explanation of the rise of life expectancy, but came to rather different conclusions on the role of rising living standards. This paper is mainly famous for the introduction of the so-called ‘Preston-curve’, which relates national income to average life expectancy at birth. It shows that people living in richer countries on average live longer than people in poorer countries, and that although the relation is steeper at lower levels of income, it holds at higher levels as well.1°