The Decline of Infectious Diseases

Question 1

Guha’s appraisal of the debate about the decline of infectious diseases and mortality decline?

Answer 1

• McKeown thesis weakened, but Szreter’s alternative thesis is also inadequate.

Question 2

What was McKeown’s thesis and where did he publish it?

Answer 2

• the modern rise of population can be explained by a mortality decline commencing in the eighteenth century, this decline being ex- plicable, until at least 1900, mainly in terms of the improved living conditions and the better nutrition of the population

Question 3

What was Szreter’s critique of McKeown’s work?

Answer 3

not only challenged the nutritional improvement hypothesis, but also developed an alternative explanation in- dicating that public health measures played a primary role in combating the early nineteenth-century upsurge of diseases resulting from the insanitary environment created in the course of industrialization

Question 4

Szreter’s attach on the demographic underpinnings of McKeown’s work

Answer 4

• The 18th century decline in mortality was ‘within the bounds of previous pre-industrial fluctuations in the sixteenth and seventeenth centuries.’
• McKeown’s thesis ‘that there had been a single movement of continuous and uninterrupted mortality decline across the last three centuries, can no longer be considered valid’

Question 5

Guha’s view of demgographic changes, and critique of szreter?

Answer 5

Wrigley and Schofield’s ‘The Population History of England’ charts a decline in mortality from 1740s.

If Public Health measures contributed to decline in mortality in mid 19th, what happened from 1740s to 1850s?

Question 6

How did contemporaries view the improved morality rates in London in the late 18th and early 19th centuries?

Answer 6

• Dr Heberden, 1807:
• ‘cleanliness and ventilation’
• ## ‘variety of vegetables’ (nutrition)

Question 7

Szreter’s attack on McKeown’s use of evidence, and Guha’s response

Answer 7

Szreter attacks the significance McKeown attached to airborne diseases (which, in their decline indicated the importance of nutrition). (Alternatively, a decline in water/food borne diseases would indicate the importance of public health and hygiene measures)

Guha: McKeown never juxtaposes the two groups of disease

Question 8

McKeown on the decline in mortality

Answer 8

[t]he decline of mortality was due essentially to a reduction of deaths from infectious diseases

Question 9

McKeown on the significance of public health intervention

Answer 9

The other major influence on the trend of the infections was reduction of exposure. As a primary influence, this was delayed until the second half of the nineteenth century, when men began to improve the quality of the environment. The initial advances were the purification of water, efficient disposal of sewage, and food hygiene, which together led to a rapid decline of intestinal diseases spread by water and food.

Question 10

evidence on decline in cause of death in London

Answer 10

W. Farr 1881-1835: deaths by consumption per 100 000 fall from 1121 to 567

H. T. Bullstrode 1838-1851: TB falls 39.9 to 27.3

Question 11

Guha on the fall in women’s mortality rates

Answer 11

since the exposure to TB was nearly universal in the late nineteenth century, the increased female resistance to this infection is more adequately explained by better nutrition than by any other cause.

Question 12

Guha on the evidence needed to prove Szreter right

Answer 12

So mortality statistics—the final outcome of the struggle between man and micro-organism, are more adequate to prove McKeown’s case than they are for Szreter, who has the much harder task of demonstrating that it was a fall in exposure that was filtering through to the death rates and causing them to fall.

Question 13

Guha on Szreter’s treatment of water borne diseases

Answer 13

The reduction in enteric fever mortality is almost certainly one of the triumphs of those local initiatives in water supply and sewage disposal eulogized by Szreter.

In the reports submitted to the Local Government Board, we frequently find reports of local inquiries into out- breaks of this disease accompanied by recommendations for sanitary improve- ments.

Indirect evidence of low exposure to typhoid in late-Victorian England is also supplied by the very high attack rates of this disease among British soldiers posted to India, where it was the leading cause of death in the 1890s

Question 14

Guha on consensus between McKeown and Szreter, and persistent problems with both

Answer 14

McKeown and Szreter would seem to agree in attributing it to public health activities, and particularly to the improvement in water supply and sewage disposal.

But such an argument presumes that deaths were fewer because illnesses were fewer as a consequence of a reduction in exposure to infection; and this hypothesis is contradicted by the persistently high death rates below five, and especially below one

• resistance lower in young age?

Question 15

Guha: conclusions

Answer 15

improvement cannot be explained by sanitary measures having prevented the encounter of human and micro-organism, but rather by a change in the outcome of that encounter. There was a shift, as Riley puts it ‘toward re- covery’. So, even as regards the food and water-borne infections public health measures cannot take all, or perhaps even most of the credit for the reduction in mortality.

it is most unlikely that the role of changes in real income, living standards and nutritional status will be found to be a minor one.

Question 16

Linda Geddes, the return of infectious diseases

Answer 16

There were 6,520 cases of TB in England during 2014

• better general health and nutrition make it less likely that large numbers of people will succumb, even if multi-drug-resistant TB becomes commonplace
• happening ‘because the pathogens that cause them are constantly evolving; and because inadequate numbers of people are being vaccinated.’

In 1901, prior to the introduction of antibiotics and vaccines, 36% of all deaths and 52% of childhood deaths in England and Wales were the result of infectious diseases. Today, it is closer to 12%.

Question 17

Roy Porter on the prominence of infectious disease

Answer 17

Roy Porter stated in his social history of London that in
Victorian times ‘Air-, water- and bug-borne diseases multiplied, and London was
visited four times by Asiatic cholera.’ Pointing to the class-bias of infectious diseases,
he went on ‘Smallpox, measles, whooping cough and scarlet fever felled labourer’s
families more than the affluent, as did the cholera epidemics of 1832 and 1848–9.
Disease threatened social collapse.’7

Question 18

revisionist approach to infectious diseases in 19th century britain

Flurin Condrau and Michael Worboys*

Answer 18

national epidemic crises, either as natural or social events, were not that prevalent in
the Victorian era;

secondly, that infectious diseases were never the ‘normal’ cause
of death, which we take to mean the most common or prevalent, which is at least
partly due to the fact that the crucial category of ‘infectious diseases’ is itself a historical
construct.

Question 19

BONS on the mortality rate due to infectious disease

Flurin Condrau and Michael Worboys*

Answer 19

in the period 1848–72, infectious diseases accounted for only 33
per cent of deaths. In other words, two-thirds of deaths in the mid-Victorian period
were classified as due to non-infectious diseases or unknown causes.

by 1901–10, infectious diseases were only responsible for 20 per cent

Question 20

Flurin Condrau and Michael Worboys, criticisms of McKeown

Flurin Condrau and Michael Worboys*

Answer 20

However valid McKeown’s provocative
stance about the limited role of medicine for population health may be, we want
to call time on using national aggregates and unhistorical disease categories to analyse
the history of death and disease.

Prefer to use age groups, gender, social classes, region

Question 21

A summary of McKeown’s thesis

Colgrove

Answer 21

Population growth was due primarily to a decline in mortality from infectious disease. This decline was driven by improved economic conditions that attended the Industrial Revolution, which provided the basis for rising standards of living and, most important, enhanced nutritional status that bolstered resistance to disease.

Other variables that may have been operating concurrently—the development of curative medical interventions, institution of sanitary reforms and other public health measures, and a decline in the virulence of infectious organisms—played at most a marginal role in population change.

The rise in population was due less to human agency in the form of health-enhancing measures than to largely invisible economic forces that changed broad social conditions.

Question 22

McKeown’s bibliography

Colgrove

Answer 22

4 seminal articles published between 1955 and 1972 in the journal Population Studies

‘The Modern Rise of Population’ and ‘The Role of Medicine: Dream, Mirage, or Nemesis?’ published 1976

Question 23

Broadly, what were some of the ways that McKeown was criticised?

Colgrove

Answer 23

the propositions that the growth of population was due to a decline in mortality rather than a rise in the birth rate, that active human intervention in the form of medical and public health measures had little to do with the fall in the death rate, and that increasing food supplies led to enhanced nutritional status at the population level.

The methodological shortcomings for which McKeown was condemned included vaguely and imprecisely defining and categorizing the historical phenomena he was analyzing (such as “medical measures,” “standards of living,” and “food distribution”)

Question 24

The Significance of Wrigley and Schofield’s ‘The Population History of England’

Colgrove

Answer 24

Wrigley and Schofield produced a comprehensive and authoritative volume that conclusively demonstrated the invalidity of a central feature of McKeown’s reasoning—that the growth in population was due to a decline in mortality, not a rise in fertility.

Question 25

Szreter’s criticisms of McKeown (2)

Colgrove

Answer 25

McKeown had misinterpreted the death records, confusing tuberculosis, bronchitis, and pneumonia

bronchitis and pneumonia, which Szreter asserted played a more prominent role in overall mortality than McKeown had allowed

In Szreter’s new interpretation of the data, public health measures such as clean water and milk supplies assumed greater importance, while changing social conditions, to which McKeown had attributed beneficial effects such as improvements in nutrition, were in fact a detrimental influence, resulting in, for example, overcrowded and poorly constructed housing resulting from rapid urbanization.

Question 26

What one element was McKeown certainly correct with?

Colgrove

Answer 26

is that one narrow aspect of it was correct—that curative medical measures played little role in mortality decline prior to the mid-20th century—but that most of its other claims, such as the assessment of the relative contributions of birth rates and of public health and sanitation measures to population growth, were flawed.

Question 27

Szreter’s ‘Rethinking McKeown’

Answer 27

In putting such exclusive emphasis as he did on the “invisible hand” of the rising standard of living and the presumed ability of economic growth to put more and better food in the mouths of the majority of the people as the
principal source of the modern
decline in mortality, McKeown
allowed himself the luxury of arguing for the relative unimportance of all forms of socially organized intervention in relation to the history of public health.

Question 28

Anne Hardy: Smallpox in London: decline in the death rate from smallpox

Answer 28

1771-1880, death rate per capita declines from 5 to 0.46.

Question 29

Anne Hardy: Smallpox in London

Thesis

Anne Hardy

Answer 29

• Cannot only be explained by idea that ‘virtually all’ of london was vaccinated by 1840 (Razzell)
• The variations in virulence of the disease complicate the elucidation of the problem of other factors involved; Mortality may probably have been significantly increased through the introduction of more virulent strains from abroad.
• The establishment of the port sanitary authorities was a critical factor.
• (in 1885, the Public
  Health (Shipping) Act explicitly extended the ordinary powers of the local authorities
  in respect of infectious disease, granted in the 1875 Act, to the port sanitary
  authorities. These provisions enabled port medical officers to cleanse and disinfect
  where they considered it necessary to check the spread of infectious diseases;)

Question 30

Public Health Act (1875)

Answer 30

The Act required all new residential construction to include running water and an internal drainage system.

The Act also meant that every public health authority had to have a medical officer and a sanitary inspector, to ensure the laws on food, housing, water and hygiene were carried out.

Question 31

James Simpson: A Proposal to Stamp Out Smallpox)

Anne Hardy: Smallpox in London

Answer 31

The first essential was the earliest possible
notification of cases; the second, the “seclusion” of affected individuals at home

after the disease was over, all beds, sheets, clothing, utensils, bedrooms,
etc., must be thoroughly purified with water, chlorine, carbolic acid, and sulphurous
acid.

Question 32

Public Health efforts to eradicate smallpox in London

Anne Hardy: Smallpox in London

Answer 32

The effect of Simpson’s pamphlet can clearly be seen in the changed tactics of the
London medical officers between 1863 and 1871.

In the years 1859-64, their efforts were chiefly directed towards publicising vaccination.83 They published and issued thousands of handbills and posters advertising the advantages of vaccination and revaccination,
and where these might be obtained;

they went from house to house
through their districts, inquiring as to the vaccination state of the inhabitants, and urging the operation where required.

Question 33

Infectious Diseases and Epidemiologic Transition
in Victorian Britain? Definitely

Graham Mooney*

Main thesis

Answer 33

Disputing Condrau and Worboys’s narrow definition of infection, evidence presented here indicates that infectious diseases probably represented about 40 per cent of all deaths in England and Wales in the
1850s. This proportion easily exceeded 50 per cent in towns and cities, places where the majority of the population lived

Question 34

Why and how does Mooney dispute Condrau and Worboys assessment of Omran’s epidemiological transition framework

that ‘‘infectious diseases were never the “normal” cause of
death’ in the Victorian period;

Answer 34

First is the existence of a voluminous body of work on disaggregated national trends
and patterns in mortality.

Omran’s step-wise characterisation of epidemiological ‘ages’ was
but the second of five main propositions. The third proposition was that ‘during the epidemiological
transition the most profound changes in health and disease patterns obtain
among children and young women’

Omran also ‘sketched’ three alternative models to
his basic theory…neither Omran
himself, nor the theory he pieced together, should be held responsible for the clumsy graphical depictions of a master-narrative

Question 35

Abdel Omran’s 1971 theory of epidemiological transition

Answer 35

three successive ‘ages’ of mortality—

pestilence and famine, receding pandemics, and degenerative and man-made conditions

Question 36

Why and how does Mooney dispute Condrau and Worboys claim that ‘‘infectious diseases were never the “normal” cause of
death’ in the Victorian period;

underreporting

Answer 36

Condrau and Worboys define ‘normal’ as ‘the most
common or prevalent’

Second, it would seem that the general public frequently chose not to call in
medical attendance for ailments popularly recognised as infectious. Parents, it was
said, routinely ignored their offspring’s measles or chickenpox rashes.

on the eve of the
twentieth century, influential members of the medical profession testified that the
content of medical education was failing students in that it did not prepare them for
the reality of the epidemiologic landscape that confronted them upon graduation. In
1891, the House of Lords Select Committee on Metropolitan Hospitals admitted ‘the
ignorance of infectious fevers which hitherto has prevailed among young practitioners’

Question 37

Why and how does Mooney dispute Condrau and Worboys claim that ‘‘infectious diseases were never the “normal” cause of
death’ in the Victorian period;

exclusionary definitions of ‘infectious disease’

Answer 37

In their most bizarre exclusionary manoeuvre, Condrau and Worboys fail to consider
the significance of respiratory diseases other than phthisis

Throughout the second
half of the nineteenth century, pneumonia and bronchitis together rivalled the numerical
contribution made by respiratory tuberculosis to the annual totals of mortality

Question 38

Mooney’s assessment of the rate of infectious diseases in England

Answer 38

almost half of all deaths in England and Wales were infectious (48
per cent, Table 1). In London they represented 55 per cent, and in provincial cities
they were even more ubiquitous (58 per cent in Salford and 60 per cent in central Liverpool.

Question 39

Abdel Omran’s reasons for transition from Infectious to degenerative diseases

Answer 39

1) Ecobiologic determinants of mortality…The reasons for this recession are not fully understood, although the mysterious disappearance of the black rat may have been a contributing factor. Nonetheless, it is relatively certain that with the possible exception of smallpox, the recession of plague and many other pandemics in Europe was in no way related to the progress of medical science
2) Socioeconomic, political and cultural determinants include standards of living, health habits and hygiene and nutrition.
3) Medical and public health determinants are specific preventive and curative measures used to combat disease; they include improved public sanitation, immunization and the development of decisive therapies.