Michael R. Haines

Samuel H. Preston

English

Research Papers in Economics

This PDF is a selection from an out-of-print volume from the National
Bureau of Economic Research
Volume Title: Fatal Years: Child Mortality in Late Nineteenth-Century
America
Volume Author/Editor: Samuel H. Preston and Michael R. Haines
Volume Publisher: Princeton University Press
Volume ISBN: 0-691-04268-3
Volume URL: http://www.nber.org/books/pres91-1
Conference Date: n/a
Publication Date: January 1991
Chapter Title: Yesterday and Today: Restatement of a Main Theme
Chapter Author: Samuel H. Preston, Michael R. Haines
Chapter URL: http://www.nber.org/chapters/c11546
Chapter pages in book: (p. 208 - 210)SIX
YESTERDAY AND TODAY: RESTATEMENT OF A
MAIN THEME
I
N 1900, the United States was the richest country in the world
(Cole and Deane 1965: Table IV). Its population was also highly
literate and exceptionally well-fed. On the scale of per capita in-
come, literacy, and food consumption, it would rank in the top quar-
ter of countries were it somehow transplanted to the present. Yet 18
percent of its children were dying before age 5, a figure that would
rank in the bottom quarter of contemporary countries.
Why couldn't the United States translate its economic and social
advantages into better levels of child survival? Our explanation is
that infectious disease processes, those principally responsible for
the foreshortening of life, were still poorly understood by public of-
ficials, by most physicians, and by individual parents; that few effec-
tive technologies based upon the new understandings had been de-
veloped; that those technologies which were developed had been
slow to diffuse; and that the assumption of public responsibility for
such private matters as child death was still incomplete and often
ineffective.
The high level of mortality that existed amidst the relatively afflu-
ent American population casts further doubt on explanations of
twentieth-century mortality decline that emphasize improvements in
material resources. Thomas McKeown (e.g., 1976) has been the most
influential spokesman for such a position. By process-of-elimination
reasoning and without any direct evidence for his well-known
claims, McKeown argues that improvements in diet were responsible
for most of the British mortality improvements between 1848 and
1972. Such an explanation appears highly implausible in the United
States, where food was abundant and relatively inexpensive by the
turn of the century. Since American mortality has closely paralleled
British mortality from the late nineteenth century to the present, our
results also cast doubt on the British explanation, which in addition
suffers from internal inconsistencies and evidentiary shortcomings
(e.g., Szreter 1988).
We believe that McKeown is correct that the mortality decline sinceYESTERDAY AND TODAY 209
the middle of the nineteenth century owes little to specific drugs and
medicines. In fact, McKinlay and McKinlay (1977) have replicated
McKeown's demonstrations in the United States during the twenti-
eth century. But the new understanding of infectious disease pro-
cesses led to many other forms of innovation besides medicines. Pub-
lic-health officials had new and vastly improved criteria to use in
cleaning up water and milk supplies, and a much stronger rationale
for their work. And individual parents had access to many new, or
newly justified, methods for reducing death risks in the home: boil-
ing milk and sterilizing bottles, methods first introduced in the 1890s;
washing hands before preparing meals; protecting food from flies
and other sources of contamination; isolating sick family members;
and so on. They also had access to physicians who were better
equipped to deal with the hazards of the birth process and to render
sensible advice on health maintenance. Parenthood became more ar-
duous than when the principal sources of disease were seen to lay
outside the home; but the new procedures undoubtedly contributed
to twentieth-century advances in survival.
Further evidence that lack of know-how rather than lack of re-
sources was principally responsible for foreshortening life in the
United States in the 1890s is the pattern of social-class differences in
child mortality. Those classes which we expect to have had superior
mortality because of better awareness of good hygienic practices and
closer connection to networks of professional expertise simply did
not enjoy a substantial mortality advantage in the late nineteenth
century. Professionals did not have child mortality levels that were
very different from those of other groups, and literate classes enjoyed
less of an advantage than they do today. Particularly telling is the
mortality of offspring of doctors, which was only 6 percent below the
national average. Undoubtedly, the relative affluence of the Ameri-
can population and the relatively small inequalities in income helped
to protect the poorest groups from some of the most damaging in-
cursions of poverty, which were much more evident in England. But
the upper classes appear to have added little in the way of behavioral
advantages to their intrinsic material advantages. It is noteworthy
that, by 1925, teachers and physicians had relative levels of child
mortality that were 64 percent and 66 percent of the national average,
respectively compared to their values of 100 percent and 94 percent
in 1895 (Ewbank and Preston 1989).
In place of a sharp differentiation now commonly associated with
behavioral differences among classes were important variations in
mortality according to factors over which individuals had little or no
control. The single most important variable in predicting child mo-210 CHAPTER 6
rality levels, whether in the presence or in the absence of other vari-
ables, was race. Race was a caste-like status in 1900, and the de-
graded social and economic circumstances of blacks, who had
virtually no chance of entering the mainstream of American life, is
undoubtedly reflected in their exceptionally high mortality. The im-
portance of economic circumstances is also reflected in the role
played by husband's unemployment and level of state income in ex-
plaining variation in child mortality levels, as shown in Chapter 4.
To clarify: we are not arguing that economic factors are unimpor-
tant in establishing levels of mortality in 1900 or today. We presented
evidence of their importance in Chapter 4, and Woodbury's (1925)
study of urban infant mortality two decades later makes even clearer
the critical role of father's income. But we are arguing that the growth
of income during the twentieth century could not have been the prin-
cipal factor causing mortality to decline. Developing countries, and
social classes within countries, that have today achieved income lev-
els no better than those in the United States in 1900 have child mor-
tality levels only a quarter of that in the United States at that time.
Even if the special economic and social afflictions of the black popu-
lation in 1900 could be eliminated so that blacks achieved the same
mortality level as whites, the black child mortality level would still
have been higher than India's in the 1980s, and more than twice that
of China.
After race, the variable whose absence would be most costly to our
ability to explain variation in child mortality levels is size of place.
Larger cities had higher child mortality in the late nineteenth cen-
tury, despite having administrative structures that facilitated the in-
troduction of public-health measures. People furthest from the reach
of the modern state—and furthest from one another—enjoyed the
best health conditions. The excess child mortality of city residents,
now averted in poor and rich countries alike, is simply another indi-
cation of the extent to which people remained in the grip of natural
forces. Our evidence on mortality trends in Chapter 3 suggests that
this grip was beginning to weaken in cities. But a satisfactory escape
would await the technical and social triumphs of the twentieth cen-
tury.

Fatal Years: Child Mortality in Late Nineteenth-Century America

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