publichealth-3 D

file: hph_lec3d.mp3

A History of Modern Public Health: The Sanitary Idea, part D

So continuing now with the role of statistics and epidemiology:

As the modern state began to emerge from the late 16th century onwards, insipient ideas of national health slowly gained ground. The relationship between the health and the wealth of nations was an essential theme of 18th century political and intellectual life. If it is assumed that the wealth of the state is intrinsically linked to its health, then it is unsurprising that a variety of methods should emerge by which the number and health of a state's citizens could be measured. So political arithmetic and social mathematics became common in a number of European states during this period.

And here are a few examples for you: In 1748 in Sweden, legislation was approved requiring parish clergy to prepare tables and records of the local population. These tables were eventually sent to central government where they were condensed into a general summary for the entire country. The constitution of the United States provided for a decennial census, and the first was carried out in 1790 by direct enumeration. Censuses had in fact been taken earlier in some colonies such as Connecticut in 1756 and Massachusetts in 1764. It was also common for the Caribbean islands to report on their trade and their populations to their French, Spanish, and British rulers.

And taken together, these innovations have been termed by historians as "numbering the people." Counting and evaluating the strength of the states became very important and was supported by a political philosophy known as "mercantilism." Mercantilism viewed the monarch's subjects as his or her property and equated the entire well-being of society as being coterminous with the well-being of the state, as embodied by the sovereign himself or herself. So the preservation of the body politic such as a monarchical system and preservation of the body natural, in other words the population and the trade at the states were linked, and the strength of the state could be anatomized statistically.

And one good example of this was a publication by William Petty on the "Political Anatomy of Island." And you can get the feeling from the title of this work, the "Political Anatomy" that what Petty is doing is dissecting the country along certain lines, and the lines that he was looking at were population, trade, manufacturing, education, revenue, and disease. So Petty was gathering together a compendium of statistics on all these fields and on all these themes, and he was in effect dissecting the state of island. And Petty believed, for example, that knowledge of population, of trade, and so on enhanced the state's chances of effective military defense, better commerce, and technological expansion, and social reform. So statistics was becoming very important as a way of monitoring and evaluating and improving the state of the nation. And it is from this desire to create and collect social and economic information that vital statistics and epidemiology grew, and these bodies of knowledge became a prerequisite for systematic disease prevention.

And what you have here is an abstract of mortality information taken from Baltimore in the early 19th century. And you have here on the top left-hand part of the table deaths arranged by males and females in different months of the year, on the right-hand side of the top you have male and female deaths arranged by different ages, from under one year to over a hundred years of age, and at the bottom half of the table, you have a statement of

deaths by disease, so ranging from apoplexy through to cholera morbis, consumption (which was an old term for tuberculosis) down to fits, flux, hives, poisoning, and suicide and teething.

So this sort of information, it is important to emphasize, in this period is new. It's newly collected, it's being organized in new ways. So for example, if you begin to classify deaths by age, you can begin to look at how mortality varies between say, for example, infants under one year, and children aged 1-4 years of age, and you can begin to think about population and epidemiological change and interventions in new sorts of ways.

And these fields of vital statistics, in other words the collection of information on births, deaths, and marriages and on epidemiology, were fields that became associated with developments in statistical techniques the calculus of probabilities, and methods of collecting data on social groups. And these sorts of techniques and, if you like, sociospacial epidemiology, the application of looking at and analyzing epidemiological information between places filled a methodological vacuum. Social scientists and early epidemiologists who were interested in analyzing and condensing and synthesizing this sort of information at the beginning of the 19th century did not possess the tools of inquiry that existed for example in other sciences such as clinical medicine, physics, and chemistry. They had no autopsy, they had no microscope, and they had no laboratory. So for early social scientists and epidemiologists, epidemiological techniques filled a methodological vacuum, and they became the tools of the trade for epidemiologists. Comparative statistics on population change, mortality rates, and rather sophisticated developments such as the life table came to be used to demonstrate the supposed links between ill-health and wealth in the condition of the population. For example, life tables were the epidemiologists' tool of the trade, and they were the methological advances that enabled these sorts of relationships and correlations between ill-health on the one hand and wealth and environmental conditions on the other to take place.

And what these methodologies and analyses did was to provide objective proof for theorizing and social reform, and it is in this way that epidemiology and statistics fits in with the rational theses of the radical thinkers of the enlightenment.

And these modes of enquiries were particularly associated with French hygienists in the early 19th century such as Louis Renee Vilherme. A distinct group of sociomedical investigators emerged in France in the early 19th century. Most had studied in the Department of Hygiene at the Royal Academy of Medicine, and Louis Vilherme was one of those who had served as an army medical surgeon during the Napoleonic wars.

In the late 1820s, Vilherme attempted to correlate differential mortality between arrondissements, or districts, within Paris and a range of independent variables. He first examined climate and environmental conditions such as elevation of the soil and movement of the prevailing winds. In terms of population overcrowding, densities within these districts were so mixed that no clear relationship with mortality emerged, but when Vilherme used accommodation rental levels as an indicator of wealth, he was able to show that districts with high levels of untaxed renters (when we talk about untaxed renters, we talk about the poorest citizens within the city, within districts), these districts had the highest rates of mortality. And as you can see from this table, those districts, those arrondissements that had high percentages of poor families tended also to have the highest levels of mortality. So for example in the arrondissement that is the last of the list there, the 12th, 38% of the families were living in poverty, and in 1817-21, one out of 62, and in 1822-26, one of 44 people died. And these were the correlations that Vilherme made when he compared the rates of mortality with the rather more wealthy arrondissements which are listed towards the top of the table. And as you can see, they have much lower proportions of mortality.

So there is a clear association established by Vilherme between wealth and poverty. But there is a question here as to why this sort of information did not translate in France in the early 19th century into state legislation. And it has been suggested that the French social hygienists believed in the progressive nature of a modern industrial free market's economy. And they adhered to what they felt were the true legacies of the French Revolution of 1789 in their beliefs of liberty, freedom of individual action, and the rights of property. The imperfections of progress, of modern life and society, and the social costs of unequal mortality and disease visited on the poor could be improved by individual behaviors and those who bore those social costs. So in other words, that translated into a lesser role for the state in terms of specific legislative intervention, because it was believed in France in this early period by the social hygienists that such interventions would fundamentally undermine individual freedoms and initiatives and would violate the rights of property. And so it was left in France to the entrepreneur and the masters of industry to see that workers lived responsibly and were educated in moral habits.

And one of the interesting questions to which we can now turn is to why similar sorts of methods in terms of epidemiological and social investigations were used to much different effect in Britain. Epidemiology became highly formalized in British society in the mid 19th century. And the geography of health, because effectively that is what we are talking about here, was examined as part of the discovery of the social conditions of the poor.

So in the 1830s, around about the same time, a little later to Vilherme's investigations in Paris, the Statistical Society of London was set up, and this society combined perspectives from political economy, demography, and mathematical calculation to debate and bring forward evidence about the social conditions of the British population. But it just wasn't a debating shop. It was also a forum by which this information, information about the social conditions, about trade, about employment, about disease and health was combined with the possibility of reform and in particular the utilitarian view of society that we referred to in an earlier section.

Around about this time as well in Britain, the General Registry Office for England and Wales was set up in 1837. This was established, this office, to marshal the massive statistics generated by the compulsory registration of births, deaths, and marriages. And the Registry Office began to produce annual reports that, if you like, evaluated the social condition of the British population as based on the evidence of the registration of births, deaths, and marriages. And this was used quite often by presenters of papers at the Epidemiological Society of London that was formed in the 1850s. And this Epidemiological Society had a mixed membership of local medical officers, ex-army and ­navy medical officers and civil servants. Important papers were presented at the society's meetings, including one by John Snow in 1853 and titled "the Comparative Mortality of Large Towns and Rural Districts and the Causes By Which It Is Influenced". And this paper by Snow - some of you may have heard of John Snow, of course - prefigured some of the methods that he used two years later to demonstrate the water-borne contagiousness of cholera in his famous study of the Broad Street Pump in London.

And in effect this coming together of statistics and societies and interested individuals produced a new agenda in terms of social reform. So doctor William Farr, who was appointed the Chief Statistician at the General Registrar Office in 1837 used the annual reports of the office to stress that the social conditions of towns and urban areas were the main determinants of high mortality. And he highlighted the unhealthiness of urban over rural districts, and he used the life table as a biometer of health and as a measure of salubrity. Farr by the way had been trained and educated in statistics in Paris, so he was very well aware of the methodologies and techniques that were used by the French social hygienists. But he developed this idea of the life table as the biometer, and it is comparable in some ways to the way in which a barometer is used for meteological measurement or the thermometer is used for recording heat. So in this sense, epidemiology was becoming increasingly scientific, and it could base itself within the enlightenment and utilitarian philosophies of rational thinking and using evidence to create human perfectibility. So epidemiology became a very important component of the analysis of British society.

And what I want to do when we come back is have a look and consider how epidemiology and statistics was used in a very important summitary report that was published in 1842 and was penned by Edwin Chadwick.