Migrants in the City of Tripoli, Libya Author(s):

Migrants in the City of Tripoli, Libya Author(s): Robert S. Harrison Source: Geographical Review, Vol. 57, No. 3 (Jul., 1967), pp. 397-423 Published by: American Geographical Society Stable URL: http://www.jstor.org/stable/212641 Accessed: 29/11/2009 14:34 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=ags. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. American Geographical Society is collaborating with JSTOR to digitize, preserve and extend access to Geographical Review. http://www.jstor.org
MIGRANTS IN THE CITY OF TRIPOLI, LIBYA* ROBERT S. HARRISON r 1HE chief feature of the pattern of internal migration in western Libya' is urbanward movement-more precisely, movement to the city of Tripoli, the largest center in the country and the only urban area in the region (Fig. 1). Rural-urban migration is not new in North Africa, but it has been accentuated in the twentieth century as a result of economic expansion in the coastal cities. Traditionally, the northern coastlands have exerted the greatest attraction on Libyan migrants. Motives behind migration have most commonly been economic, and it is in the north that employment opportu- nities have been most numerous because of its natural advantages for agricul- ture (as in the Tunisian tell and, to a smaller extent, the eastern Jebel of Tripo- litania), mineral exploitation (in the phosphate mining regions of central Tunisia and today in the Libyan oil fields south of the Gulf of Sirte), and urbanization. Although the general flow of Libyan migrants remains northerly, the areal pattern has changed greatly in the last half-century. During the Turkish period migration was associated with French agricultural and urban develop- ments in Tunisia and with long-established seasonal movements inside Libya; during the Italian regime migration to Tunisia declined as Tripoli grew in importance; and today the "oil boom" has further stimulated economic ac- tivity in the city and strengthened the urbanward flow. From 1843 to 1911 the whole of western Libya was nominally united in the Ottoman vilayet of Tripoli, but Turkish authority was weak, movement was not controlled, and little of the frontier was delimited.2 Until the establishment of the French Protectorate in Tunisia Libyans migrating there were moving within Otto- man territory, and even until the Italian occupation of Tripolitania Libyans migrated freely into Tunisia, automatically becoming subjects of the regency * This paper is based on some of the findings of a program of research carried out in Libya in 1963- 1964. The writer wishes to express his gratitude to the many organizations and individuals in Tripoli who offered their assistance. I That is, the former provinces of Tripolitania and the Fezzan. In 1963 the federal form of govern- ment was abandoned in favor of a unitary system. 2 "So ignorant were the Turks of their own African dominion that at the outbreak of the war [1911], when the Sultan asked for a map, there was not one to be found" (Charles Lapworth, in collaboration with Helen Zimmern: Tripoli and Young Italy [London, 1912], p. 161). > DR. HARRISON is assistant professor in the Department of Geology and Geography at C. W. Post College, Long Island University, Greenvale, New York.
398 THE GEOGRAPHICAL REVIEW -I u, 12: ; I 1 4' ;''''''I'- 10 2 1.4 ~ WESTERN LIBYA 50 0 100 Miles ~~ OAST 0 ~~~~~~ 50 100 150 Kilometers IWESTIJOA ZONE zzazie TUNISIA 16o. TUNISIA * ~JEFARA PLAIN Misurata1 320> *~~~I...sBirGhenem ? .3 Jefren * 'EAST COAST ZONE.- Gi /ado PRE-DESERT ZONE t , -:.,C IT Y, brOA ZaIe ,, \\ _\_ METEOR.RV UY BAB7 ....~ ........ Each dot represents one m ....... Dahman ........ OFIN M GR NT. CEMETERY ..... Sd MA BB . Bum nge .. .......A.. ZIA XA HABR X SE 1\ BAR ~~~~ BA.. iVBAB HAA Gu -a /,Y 193 4 bidonvilles \9 9* BAR .A.IN ZARA *- -- 9t *c1-;-*-*-- HOUIN PRQJqT SIDI- MESRI-tstt}oln ed ,, ............. .. : :. . .: . _EOGR REV.,JUL Y,1967 EacGdo 5-represetsane migats DISTRIBUSoresfr ae a:lnfTripoNi OF IN-M(se igurANTSlao In9te8Ol City parea ommrionly, IN T50,16;adfo eicpe htgah n rIoLIbevtinaeb inheabitedob migrnt ar1 idiatd3-1002006004Fe by G shaDing(fridetai n see Figs irat 7n 12)l.Dt o hsan olwn as(is.7 nlsv)fo sample survey, 1963-1964 (see text).~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~c.e:tam~ N '~~~~~~~~llhII*~~~~~~~~~~~~ ~~~~ ~TAG IRA~4 - ~ ~ ROYAL *. 4 4 B~~~~~~Y * CEMETER LKV PAAC .... . uraB OLD...] - e&**~ BABHN RAILWAY ARAL h k ~ *eSC* SkI We~~~~~~~~~S BABii A GARGARES AZIAABAHIR~B A ~ ~~~~~ ,RAS Garg~resc *~Acara "L-CCA HASSAN' e \e BibBen BAB AIN ZAAmZr UrgIS~~~G b~~d 4bidonill. ~~' -.- :~~~~ . ~ .%~~~S~D - MESRI::::q oln ed ' 4 4 * ~~~. * A' ~~EOGR.REV.,JULY,1967 FacG.o -ripolietsand miEsnt bionile.SoresfrRae Ia:BlnUfTrIpOli aF IN-o(seMIGuReA)lNTof 1958;e fOmd pltyaneof Triponl,1y00 92 n rmhlcpe phtorah anTRIOunLbevtnIaeb Fb G 6-ain Distributaion ofe i-irnsiTrpl.Dtfothsadolwngm s(Figs. 7-12inclusive)from sample survey, 1963-1964 (see text).~020 40 60 80 Mter
Each symbol represents DISTRIBUTION OF MIGRANTS one migrant FRO M THE .-CENTRAL AND EASTERN JEBEL BIRTHPLACE 0 1000 2000 3000 Feet o-Garian *-Tarhuna ~~~~~~~~~0 200 400 600 800 Meters .- Kusabat/ in- Marconi MEDITERRANEAN HARBOR FESCLUM..... . -BAB E t0 ...... ..TA HUN .......... ~ ~ 0 CEMETER Ha-)T~~tammukelGa m S. Sidi 0 ~~~~~~ ..BAB.... Bumnge GoDAFRRNAS Nr .........ASSN.' ~. ~E5 Ba Be Gasir .... * ColinaVere....e ********* .. . SIDI-.. FESCLUM? *@Gurgi ~ ' 3333 */e@~.3~GEOGR.RE. ...Y.... FIG ...... 7A ' BITHPAE 0 002000Fe GARG ~ ~ ~ ~ ~ ~ ARO ORAILWAY AREA e0 ~~~~~~BA AITARHUAJ AiZr BabBenrnengeCllia VrdFoRNASC BAB" BA BABBEN~~~~~~~~~~~S ESI0090 ***X *00x~~*Gurgi ~ ' bidonville SDI MER/ /0 EO0G R. R E V., JU L Y .1%96 FIG. 8
Each symbol represents DISTRIBUTION OF MIGRANTS one migrant FROM THE EAST COAST ZONE BIRTHPLACE 0 1000 2000 30p0 Feet o- Homs #-Misurata 0 200 400 600 800 Meters *- Zliten *- Tauorga MEDITERRANEAN HARBOR SEA ,t +/ t'+= = \ _ ?CASTAL zII ->9 aF / Ba\biBJerl iGlsciara Sciara ........... BAB EL CEMETER eS e ammar . . . .. . . . . . . . Each~~~ ~~ TAblrpeet DSRBTO FM GURANT one migrant FROM HEWESTOLU ZO BIRTHPLACE ~~~~~~~~~~~~~0 100 003AB Fe RAILVWAY AREA IB AK INA ~~ * 0 ~ a xFescIu Skel- S.Bumengel -~jjIG. 10 BAB VK.~ Buene 0 FORNASe BAB"- B ABB1 GARG"ARECAZGSI G9gaes * I*HASGASHIR G'I RA"~T cc 0000... 00\7=X ege,,1T 000000000000\x DOOOOOO * BAB AIN ZARA Bab Ben ~ *0 3 Collina Verde oo-*Gurg Bab Benv Gash ******c 0SD- ER Fornaci 0040 Grgi '~idonviIes ~*****.4 3 GEOGR.REV.,JULY,1967 FsG. 9 Each symbol represents DISTRIBUTION OF MIGRANTS one migrant FROM THE WEST COAST ZONE BIRTHPLACE 0 1000 2000 3000 Feet *-Zavia 0- Agelat n3-Zuara n- Sorman 0 200 400 600 800 Meters *-Other places in the region MEDITERRANEAN HARBOR CASTLE~~~~~~ I CEMETER ~~~~~cirOaLSir FES.LU BAB ELI OLD-U ~ ~ 4t ecmbr ave AMRUNA Sc. Srim .*.. iaddat ...siu 'CEMETERY ............ a A ~~~~~~~~~~BAB Bu /.\?'J2~~~~~ANAC:-:.....RFECSU - '~~~~~~~~ "ei?~~~~~~~~~~ BA NARA ~0 Gurgi ~ ' bi donvalles ZPghet-: Fe SD-MER CHn Ved S. Sidi BAB~FsG 1
DISTRIBUTION OF MIGRANTS FROM THE REGION OF ORIGIN PRE-DESERT AND DESERT ZONES *-The Desert Zone 0 1000 2000 3000 Feet o- The Pre-Desert Zone 90 200 400 600 800 Meters Each symbol represents MEDITERRANEAN one migrantSE HARBOR .IT 1 ' 4t Sciara Sciara .. ... BAB EL 24hDecember Zaviet A RS~ CEMETERY. G~~~~~~~iaddat Dahmani nB~~~~~~~~~~~~~~~T ScIG.f 117 . . ......... ROYAL _ JaalFMEOTHER R EGIOPALAC SCLUM (Libyan nationality / /~ c.~ / 7 / Ct birth) /5I,-G\ MEDITERRCEMANIma 0 SSid, i\\i '~~~~~~~~~~BAB Ghyorres ARGARESC AI ZIA BTABA BAB>'~ ~ X1 BA B3\gSL ScSara RcarS_ 4' --Z-= 0~~~~~~~~e Hmm T 0 '-Ga,r9are B aRA_b Ben __ Gashir 0 Ver Gurgi \ b idonvilles .ga o > o oSs \\nic /Ai SIDI EG.E,UYle FIG. 12 REGONOFORgIN DISRIBTIOO MIRNANSC CoB Ast EatofTipl 0A 100200300Fe GAG* SidC 0 0 6080Mtr 0 Foreign states~~~~~~~ oo (Lba Bnto ality G i olia ed REGION OF ORGINDISTRMEDITERNEANMGRNT Eac symbol represents at birt CEMTERYPALCEDIT ESCLUMA RAILWAYblAereAsents HABO SE ARUNA * Sc.Srimk~~~~~ 0* * ~~~ FesSiaramciar CEMETERY .,i.! ...... ;c ma m IA BAB GASHIR-~~~~~~~~....RAS.. B .. .... c,e ... aVere....aciAin ar \X Ba Be GahA F II ESCLU x. Gurgi bidoALWAY ........OT R .REVIN Llee S. Sidi BAB~FsG 1
MIGRANTS IN TRIPOLI 415 The bidonvilles of Tripoli (Fig. 5) are not, as has been suggested,39 a completely modem phenomenon; it might even be said that their forebears were the encampments made by seminomads who used to move seasonally to Tripoli and "pitch their camps under the walls of the city."40 In the late nineteenth century there were settlements around Tripoli where Negroes lived in "huttes de branchages ou de sparte" and "campements d'Arabes, avec leurs tentes basses et rondes." 4 The Negro camps were still in existence in 190242 outside the wall of the Old City, and it is likely that their inhabitants included a large number of former slaves from the Fezzan. The problem of a large in-migrant population seems to have faced the Turkish authorities, much as it faces the Municipality of Tripoli today; for example, a kind of poor camp (where whipping was apparently necessary to maintain order!) was established by the Turks near Bab Ben Gashir.43 Andcjust after the Italian occupation of Tripoli Lapworth attacked the Turks for having allowed the growth of encampments of "poor Bedouins, Arabs, and Fezzans-a heap of huts composed of sticks, palm-leaves, and all the dirty rags and refuse of the city" ;44 if he thought that shantytowns would disappear with the Ottoman regime, he would be sadly disillusioned today. It was in the Italian period, however, that the present pattern of bidon- ville development was begun. A striking feature of the areal distribution of the shantytowns is their arrangement in a semicircle about 11 2-21 2miles out from the city center; in fact, they have attained their most extensive de- velopment just outside the Italian wall, and, more exactly, at the points marking the old gates in the wall-Bab Gargaresc, Bab Azizia, Bab Accara, Bab Ben Gashir (Porta Benito), Bab Fornasc, and Bab Tagiura. Thus as the modern city grew, circumscribed by the line of fortifications, the old en- campments under the wall of the Old City were in effect pushed outward to new positions under the Italian wall. At first growth outside the defended wall was probably largely haphazard, and bidonville development presumably got out of hand, because in 193 5 the Italians constructed a "campo dei beduini" in the east outside Bab Tagiura, to which "were transferred all the beduin who had been living in filthy 39 Luigi Maria Bologna: Report to the Government of Libya on Settlement Planning. F.A.0. Rept. No. 732, Rome, 1957, p. 9. 40 Tully, op. cit. [see footnote S above], p. 46. 41 M. Fournel: La Tripolitaine (Paris, 1887), pp. 15 and 83. 42 F. Minutilli: La Tripolitania (Turin, 1902), pp. 167-168. 43 E. Corradini: L'ora di Tripoli (Milan, 1911), pp. 68 and 70. 44 Lapworth, op. cit. [see footnote 2 above], p. 126.
416 THE GEOGRAPHICAL REVIEW tents on the outskirts of the city."45 This camp, with its five hundred stone huts, still remains, and conditions there were described as fairly satisfactory in 1952,46 though shanties have been built within it. Despite this effort on the part of the Italians to control bidonville expansion, the Bab Tagiura camp was only a temporary palliative. Another stage in the history of the Tripoli bidonvilles was the establish- ment of "family camps" at Bab Gargaresc, Bab Azizia, Bab Accara, and Bab Ben Gashir for Libyans serving with the Italian colonial militia or employed by the Italian Army. These camps remained after World War II,47 but they were used by anybody who could not find a home, and with the heavy postwar in-migration they grew into bidonvilles. During the serious drought of 1946-1948 the British Military Administration was forced to establish a new "poor camp" at Fesclum, through which thousands of destitute mi- grants passed.48 The largest shantytowns are still around the Italian wall or its ruins, particularly at Bab Ben Gashir and Bab Accara. But the bidonvilles are not a static feature of the urban geography of Tripoli: the shacks are only temporary buildings, easily pulled down and moved to another site, and other factors have made the shantytown an ephemeral phenomenon. In the outward shifting of the old encampments made necessary by the physical ex- pansion of the city the "official" Italian camps acted as centers of develop- ment. After the war the shantytowns grew without hindrance, but in recent years there has been some slum clearance as a result of official legislation on housing. In 1952 work was started on a housing project south of Bab Accara, and in 1954 part of the bidonville at Bab Gargaresc was demolished and its inhabitants rehoused in the new settlement. Since then the Bab Azizia bidonville has disappeared, and some of those displaced by its clearance have been moved into the government low-cost housing project at Bab Ben Gashir. But these housing projects do not provide sufficient accommoda- tion, and bidonvilles have merely "migrated." This happened as recently as 1963-1964, when a new shantytown appeared between the 1952 housing project and the old Bab Accara camp. Owing to official action and the increasing numbers of in-migrants, the 45 L. V. Bertarelli: Libia (Guida d'Italia della Consociazione Turistica Italiana, Vol. 23; Milan, 1937), p. 132. 46 Benjamin Higgins: The Economic and Social Development of Libya (United Nations Technical Assistance Programme; New York, 1953), p. 78. 47 Ann. Rept. on the British Military Administration of Tripolitania, 1943, Tripoli, 1944, p. 42. 48 Sunday Ghibli, July 8, 1947, and May 23, 1948.
MIGRANTS IN TRIPOLI 417 bidonvilles are constantly expanding and changing shape, especially in the Bab Ben Gashir-Bab Accara complex. But another, natural, factor has also played a part. The shantytowns on the southern fringe of Tripoli lie in the bed of the Wadi Megenin, which rises in the Jebel and reaches the sea at Bab Gargaresc. When in exceptionally rainy winters the wadi floods, a spate of turbulent, muddy water washes away many of the flimsy shacks; sometimes lives are lost, as in 1945,49 in 1952,50 and, most recently, inJanuary, 1964. But the destruction caused by the floods is only temporary, and new huts soon spring up to replace those swept away. It is noteworthy, however, that the latest bidonville carefully avoids the bed of the wadi. Although the extramural pattern of bidonvilles is still apparent, the shantytown areas of Bab Ben Gashir and Bab Accara have extended south- ward from the defended wall to and beyond the ring road. At the same time, the bidonvilles on the western outskirts of the city have almost disappeared. But there are numerous small shanty areas within the Italian wall, mainly in an inner belt from the Dahra in the east, through Goz Azuz and the Zenghet el-Hamman-Sciara Bu Harida district, to the old railway area (the site of the former Central Station and marshaling yards of the Italian-built system) and the environs of the Jewish cemetery southwest of the Old City. There is also much sporadic bidonville development in the Sciara Srim-Sciara Bu Harida-Zenghet el-Hamman area, where shanties have been built among ordinary houses; these might be called "shantied" zones. In 1960 the munic- ipality prohibited the building of shacks inside the city, and all huts were to be removed from the Giaddat Omar el-Muktar, the Dahra, Bab Gedid (the "New Gate" on the southwest of the Old City), Bab Gargaresc, Bab Azizia, and Sciara Srim.5' Some of these sections were cleared, but hundreds of shanties remain in the inner belt. Indeed, the windows of Tripoli's newest and most luxurious hotel look down on a group of cardboard and tin-can shacks, and within a stone's throw of the expensive new villas on Sciara Ben Asciur lie the pathetic shanties of Goz Azuz. However, as modern construc- tion proceeds the inner bidonvilles are gradually being reduced, especially in the northeast area. Most of the inhabitants of the bidonvilles are believed to be in-migrants or of in-migrant origin, and a comparison of Figures 5 and 6 makes clear the relationship between the shanty areas and the abodes of migrants. The popu- 49 Ann. Rept. on the British Military Administration of Tripolitania, 1945, Tripoli, 1946, p. 7. 50 Sunnday Ghibli, Sept. 28, 1952, and Dec. 7, 1952. 5I Ibid., Aug. 28, 1960.
418 THE GEOGRAPHICAL REVIEW lation of the bidonvilles has never been accurately determined, but in 1952 an estimate of 8ooo-io,ooo was made for those outside the Italian wall.52 According to the 1954 census of Libya, 5993 families were living in shanties in Tripoli;s on the basis of the average size of household in the city in 1954 (4.275 persons) this would mean a shanty population of about 25,620. How- ever, the figure is to be regarded as minimal, since it is not known whether all the shanties of the city were included or only those of the larger bidon- villes. Moreover, the size of household was probably larger among the citizen population than among the total population (to which the average figure refers), and even larger among the bidonville population. The pre- liminary results of the 1964 census show that there was a population of 25,820 in the euphemistically named "Municipal Villages."54 The areas covered by this term are not indicated, but it is certain that the inner shanties were not included. In any case, census enumeration under bidonville con- ditions is likely to be highly inaccurate. In 1964 a private Tripoli source estimated the bidonville population to be about 40,000, but it is probably greater than this. Figure 5 is based on the 1961 G.S.G.S. plan of Tripoli and personal observations made in 1963-1964. From the plotted data it can be calculated that the area covered by bidonvilles in 1964 was about 161 acres (the Bab Ben Gashir bidonvilles amounted to about 44 acres, and the largest single shantytown was the one south of the old Bab Accara camp, with an area of about 27 acres. From a study of air photographs and helicopter photographs taken in 1964, the number of shanties in various sections of the large bidonvilles and in some of the inner- belt shanty areas was counted; then, by applying the figure of 4.275 persons per household to the number of shanties, an approximate population total was calculated. The density of settlement varied from camp to camp, being higher in the inner belt, for example, than in the outer bidonvilles. Since not enough air photographs were available for full coverage, a "high den- sity" figure and a "low density" figure were worked out for the total popula- tion of the shantytowns, 71,6oo and 32,600 respectively; the average gave a possible total of about 52,100. The problem of overcrowding is indicated by the high population density this would imply for the bidonvilles-324 persons per acre. In comparison with the other bidonvilles, conditions in the 1952 housing project and the Bab Tagiura camp are fairly satisfactory. They have water 52 Higgins, loc. cit. [see footnote 46 above]. 53 General Population Census of Libya, 1954 [see footnote 34 above], Table 3, p. 54. 54 Preliminary Results of the General Population Census, 1964 (i0c. cit. [see footnote 34 above]).
MIGRANTS IN TRIPOLI 419 tl I W FIG. 13 Bidonville adjacent to the new housing project, south of the ring road (background), showing typical haphazard development. * 4I ,*SZR;~~~~~~~~~ w~~~~~~~~~~~~~~~~~~~~~~~~~~~~.1 FIG. 1i4-Detail of a bidonville. Building materials are flattened gasoline cans, pieces of wood, scrap metal, cardboard, and anything else that comes to hand.
420 THE GEOGRAPHICAL REVIEW and some sanitation facilities, shops, schools, and mosques, but even in the housing project the inhabitants have begun to build lean-to shanties. Living conditions in all the other shantytowns are very poor. Invariably the shanties are crudely built with petrol cans, pieces of corrugated iron and scrap, card- board, and odd pieces of wood, and although in places attempts have been made to improve them with whitewash, the general appearance of the bidon- villes (Figs. 13 and 14) indicates a terrible poverty. There is no lighting. Sani- tation is inadequate, and there is no good water supply; health standards are low, and occasionally disease sweeps through the shantytowns. In 1944 typhus was found to be common in the bidonvilles,55 and since the war there have been several smallpox epidemics; more recently the incidence of tuber- culosis has been related to the overcrowding.56 In the Old City too, in the maze of narrow alleys and old Turkish or Arab houses so attractive to the tourist, there are problems of poor housing and lack of facilities. In 1964 the population of the Old City numbered 22,820,57 with a density of 217 persons per acre. However, although overcrowding would become a problem in the Old City in any case, in the bidonvilles it has occasionally reached the point at which the authorities have been forced to return migrants to their home regions."8 There are other social problems associated with in-migration. Movement to the city can be successful-economically, socially, and psychologically. There are migrants who have found good jobs and are happy living in Tripoli. But there are others who do not easily adjust to urban life and return home as soon as possible. And there are still others who cannot find good jobs yet remain in Tripoli, unemployed or only occasionally employed, a source of concern to the local authorities. The severing of family and community ties partly explains the social disorganization. Many young migrants in Tripoli retain close connections with their homes and parents, but at the same time some reaction exists among the younger generation against all forms of traditionalism. The de- cline of tribal organization is perhaps more significant than the weakening of family bonds: the migrant in Tripoli feels free of the responsibility toward the tribe that forms part of the "old-fashioned" way of life in Libya. In the bidonvilles and the new housing settlements sheikhs have been appointed in 55 Ann. Rept. on the British Military Admintistration of Tripolitania, 1943 (hoc. cit. [see footnote 47 above]). 56 "The Economic Development of Libya" [see footnote 14 above], p. 277. 57 Preliminary Results of the General Population Census, 1964 (hoc. cit. [see footnote 34 above]). 58 Snntiday Ghibli, July 17, 1960; "The Economic Development of Libya" [see footnote 14 above], p. 293.
MIGRANTS IN TRIPOLI 421 an effort to maintain some sort of social cohesion, but there is little respect for their authority. Economic considerations also have a bearing on such problems of morale. Many in-migrants underestimate the difficulties of obtaining ur- ban employment, and the frustration of finding that the streets of Tripoli are not paved with oil-company gold may be as socially disturbing a factor as the breaking of tribal bonds. Social disorganization and poverty among the migrants have given rise to crime, juvenile delinquency, and vagrancy. The British Military Administra- tion in 1947 related the increase in criminal acts to increased migration to the city,59 and conditions in the bidonvilles are particularly conducive to crime, vice, delinquency, and, perhaps, political fanaticism. "Inter-family quarrels and fights are frequent. Most of the occupants have come from outside Tripoli, and . . . camps seem to attract the most undesirable characters who drift into the city, including the potential juvenile delinquent. The almost complete absence of lighting at night aggravates the problem and adds to the difficulties of the police to whom the camps are a source of concern."'0 Other problems have been the spread of prostitution6' and the practice of sending young children to beg in the streets of the city. MIGRATION AND ECONOMIC DEVELOPMENT In the past, rural out-migration was often regarded as a useful means of supplementing low and uncertain agricultural incomes, but nowadays migra- tion is becoming longer-term or permanent and is resulting in serious labor losses in the regions of origin. Traveling through the desert oases, for in- stance, one is immediately impressed by the large proportion of their popu- lations made up of old people and young children, and by the lack of younger men. All the agricultural areas are experiencing a shortage of labor, but it is especially acute in areas that depend on irrigation, where the traditional methods of drawing water and preparing the land require a great amount of manual labor. To take an example from the Fezzan, the number of workers in the date palmeries decreased from about io,ooo in 1936 to only about 2000 in 1960.62 The loss of labor in the rural areas, and the reduced efficiency of the remaining labor force, have resulted in a reduction in the cultivated area. Ac- cording to Italian statistics, there were 2,657,000 hectares under all types of 59"Handbook on Tripolitania" [see footnote 19 above], pp. 53-54. 60 Higgins, op. cit. [see footnote 46 above], p. 78. 6I Ann. Rept. oni the British Military Administration of Tripolitania, 1943 (toc. cit. [see footnote 47 above]). 62 V. W. H. Dowson: Report to the Government of Libya on Date Production, F.A.O. Expanded Technical Assistance Program Rept. No. 1263, Rome, 1961, p. 14.
422 THE GEOGRAPHICAL REVIEW cultivation in Tripolitania in 1925 ;63 according to the 1960 agricultural cen- sus,64 there were only 1,724,246 hectares under arable and permanent crops (including fallow land). In the oases the extent of the cultivated area is pri- marily a function of the amount of water available. Where irrigation is from nonartesian wells, the cultivated area depends on the amount of water raised by the djebbad; with the migration of many of these workers many wells have been abandoned, and the irrigated area has been greatly reduced. In the Fez- zan, according to a 1953 estimate, the total productive land amounted to 125,000 hectares, of which 1 5,000 were in use,65 but in 1960 there were only 37,224 hectares under all types of land use.66 Except to the small extent that modern techniques have helped maintain efficiency, it may be assumed that the decrease in cultivated area has led to a decrease in agricultural production, though this cannot be easily substantiated from available statistics. Generally, it can be concluded that migration is resulting in a loss of productive capacity in the rural areas. The economic problems connected with migration to the city arise from the fact that more workers are trying to find employment than the nonagri- cultural sector can absorb. This has resulted in both actual and potential prob- lems of unemployment and underemployment. There is little recorded un- employment in Tripoli, but the number of nonregistered unemployed work- ers is probably much greater than the official figure. Throughout 1958 the number of registered unemployed remained fairly constant at about 15oo- 2000.67 A trade-union estimate of 1o,ooo unemployed in 1953 is most likely an exaggeration, but recorded unemployment in the city after the war oc- casionally reached more than 7000.69 If in-migration continues, the danger of serious unemployment will increase. Underemployment in Tripoli is already a handicap to economic growth, and according to the report of the International Bank Mission the belief that widespread unemployment exists "finds expression in the employment policy of the public enterprises in Tripoli where appreciably larger numbers of 63 R. L. Robb: Survey of Land Resources of Tripolitania (British Military Administration, Tripoli, 1945), p. 9. 64 1960 Census of Agriculture: Report and Tables (Ministry of Agriculture, Tripoli, 1962), Table 7-002-044, P. 59- 65 W. B. Fisher: Problems of Modern Libya, Geogr.Journ., Vol. 119, 1953, pp. 183-199; reference on p. 189. 66 1960 Census of Agriculture [see footnote 64 above], Table 7-1 52-o68, p. 83. 67 Labour Survey of North Africa (International Labour Office, Geneva, 1960), p. 103. 68 Higgins, op. cit. [see footnote 46 abovel, p. 85. 69 Ann. Rept. on the British Military Administration of Iripolitania, 1945 [see footnote 49 above], p. 35.
MIGRANTS IN TRIPOLI 423 workers are employed than required for efficient production."7o There is much disguised unemployment in the small-scale textile, tanning, and food- preparation industries of the city; simple technological improvements could release much labor from these industries and at the same time increase pro- duction.7' But in view of the already large numbers seeking employment, any such improvements will have to be made gradually if unemployment is to be avoided. Another important factor is that increasing spatial mobility of labor is not being accompanied by increasing interindustrial mobility; that is, in-migra- tion to Tripoli is only emphasizing the problem of shortage of skilled labor. And the excess of unskilled labor, since it tends to be inefficient and therefore expensive, only serves to increase mechanization, which in turn means that little opportunity in industry will be offered to the mass of unskilled migrants. As far as can be seen, it is not going to be possible to create extensive op- portunities in the nonagricultural sectors of the Libyan economy, and the land must remain the main resource for the bulk of the population. Despite the oil boom, of extreme importance for the long-term expansion of Libya's national income, the petroleum industry cannot greatly increase employment opportunities. Other mineral resources are not promising. Industrial develop- ment is likely to remain limited: raw materials are few, and mainly of agricul- tural origin. Expansion is further limited by the small size of the national mar- ket-the total population of Libya in 1964 was only 1,559,399.72 The popula- tion is unevenly distributed as well as small, which means that transportation costs are high and the problems of distribution and marketing are formidable. In the light of these circumstances, and in a situation where land is going out of cultivation at the same time that food imports are increasing, the problem of rural-urban migration in Libya would seem to be solved most logically by improving agriculture to the point at which rural incomes are more on a par with urban incomes-that is, to the point at which there would be no need to differentiate between the "modern sector" and the "traditional sector" of the Libyan economy. 70 "The Economic Development of Libya" [see footnote 14 above], p. 445. 7I A. Pappayoanou: Handicraft Occupations in Libya: Their Existing Techniques and Possibilities of Expansion (International Labour Office, Geneva, 1951), pp. 3 and 48; Higgins, op. cit. [see footnote 46 above], p. 85. 72 Preliminary Results of the General Populatioin Census, 1964 [see footnote 34 above], Table 1, p. 1.

Does the English NHS Have a 'Health Benefit Basket'?

Does the English NHS Have a 'Health Benefit Basket'? Author(s): Anne Mason Source: The European Journal of Health Economics, Vol. 6, Supplement (Dec., 2005), pp. S18- S23 Published by: Springer Stable URL: http://www.jstor.org/stable/20069423 Accessed: 29/11/2009 14:51 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=springer. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Springer is collaborating with JSTOR to digitize, preserve and extend access to The European Journal of Health Economics. http://www.jstor.org
Eur J Health Econ 2005 [Suppl 1] 6:18-23 DO110.1007/sl 0198-005-0314-1 Published online: 5 November 2005 ? Springer Medizin Verlag 2005 Original Papers_ Anne Mason Centre for Health Economics, University of York, Heslington, York, UK Does the English NHS have a 'Health Benefit Basket7? I he English National Health Service (NHS) was established in 1948 to provide healthcare for all, free at the point of use and irrespective of ability to pay. Legis lation outlines the broad categories of healthcare service that should or could be provided within the NHS. However, the legal duties and powers of provision are not absolute, but tempered by powers of discretion as to what is a 'reasonable re quirement' and by the right to take into account NHS financial capacity. Strictly speaking, this means that patients have no entitlement to specific services; this part ly explains the existence of variation in lo cal provision known as the postcode lot tery' [1]. Furthermore, the courts have es tablished that NHS organisations may not operate a 'blanket ban on the provision of particular services [2]. Consequently the re are few services that are explicitly un available to all NHS patients. Within a health service with no specif ic entitlements but few explicit exclusions, internal quality control mechanisms are important to ensure that citizens' rights to health care, established under interna tional law, are honoured [3]. National stan dards, embodied in guidance from Nation al Service Frameworks (NSFs), the Nation al Institute for Health and Clinical Excel lence (NICE) and waiting time guarantees, are regulated by the Healthcare Commis sion, which monitors NHS organisations' compliance. The regulatory framework contributes to what may be considered as 'reasonable requirements' for health ca re provision and helps to specify entitle ment. Fixed charges or payments, whilst in no way guaranteeing provision, implic S18 I Eur J Health Econom Suppl 1-2005 itly brand services with an 'NHS' label and may therefore also serve to signal the ser vice is, or should, be in the health basket. Incentive payments for clinicians may be seen in a similar light. This paper describes the statutory and regulatory frameworks and discusses how these may impact upon patient enti tlement to NHS 'services of curative care', 'HO' of the International Classification for Health Accounts (ICHA) taxonomy [4]. An overview of the legal and regula tory framework defining benefits for Eng land is given in O Table 1. England's'Health Benefit Basket7: the case of services of curative ca re Services of curative care are defined as those where the principal medical intent of care is to relieve symptoms or reduce sever ity or protect against exacerbation or com plication of illness or injury. In addition to in-patient and day care, HCi includes but-patient care, defined as basic medical and diagnostic services, out-patient dental care and other specialist health care pro vided to outpatients by physicians or pa ramedics, including services provided at home [4]. The legal framework Primary legislation addresses the establish ment and promotion of'a comprehensive health service, requiring the Secretary of State for Health 'to provide or secure the ef fective provision of services'. However, dis cretion is at the heart of these duties and politicians are entitled to take into account the resources available to them. Under the 1977 National Health Ser vice Act (chap. 49), the Secretary of Sta te has a duty to provide 'to such extent as he considers necessary to meet all reason able requirements': (a) hospital accommo dation [s. 3 (i(a))], including high securi ty psychiatric services (s. 4); (b) other ac commodation necessary for the purpose of any other services required by the Act [s. 3 (i(b))]; (c) medical, dental and nurs ing services [s. 3 (i(c))] (N.B.: 'medical' in cludes 'surgical'); and (d) such other ser vices as are required for the treatment of illness [s. 3 (i(f))] (N.B.: 'illness' includes a mental disorder and any injury or dis ability requiring medical or dental treat ment or nursing). The Secretary of State for Health also has powers to provide 'as he considers appropriate facilities for the care of persons suffering from illness [s. 3 (i(e))]. The responsibility for providing these services has passed to local health authorities, which in the current organisa tional structure are known as Primary Ca re Trusts (PCTs). The 1977 NHS Act also places a duty on PCTs to provide general medical services (s. 29), general dental ser vices (s. 35), pharmaceutical services (s. 41) and general ophthalmic services (s. 38). In the law courts "R v NW Lancashire Health authority, ex p A, D and G" exam ined the case of three applicants suffering from gender identity dysphoria [2]. The Health Authority had identified this ill ness as amongst the bottom 10% in terms of need (together with cosmetic surgery, reversal of sterilisation, correction of myo pia and most 'alternative' medicines) and
Table 1 Documents defining the English Health Basket, 2005 Catalogue: type of document, actors and contents Type of document Legally Positive/nega- Degree of Updating binding tive definition explicitness* of benefits Criteria used for defining benefits N C E CE B Other Acts of Parliament Yes Irregular, amended by further legislation Political judgement 'necessary to meet all reasonable requirements' Statutory instruments Yes (SI) PorN 1-3 Irregular, amended by further legislation + Safety Directions Yes No National Service Frameworks No 2or3 Unclear NICE technology appraisals Yesb PorN Every 4 years + + + NICE clinical guidelines No 2or3 Every 4 to 6 years + + + NICE ?nterventional procedures No PorN Unclear Safety Contracts Yes 1-3 Infrequent-although small amendments more frequent + Waiting time guarantees0 No Irregular HRG tariffs No 2or3 Still evolving Devices tariff No Monthly + + Safety, quality, appropriateness Fee schedules No Annually (at least) N need, C costs, E effectiveness, CE cost-effectiveness, B budget (from [1,2,3], DH website (http://www.dh.gov.uk/home/fs/en), HMSO website (http://www.hmso.gov.uk/), expert advice (see Acknowledgements)) a "Explicit is subdivided as 1: all necessary"; 2: areas of care; 3: items. b The statutory duty is upon PCTs to ensure funding is available to facilitate implementation, not upon doctors to adopt the approved technology. c The dominant instrument for securing these are performance ratings prepared by the Healthcare Commission. therefore transsexual surgery would be provided only in cases of overriding clin ical need'. The court acknowledged the need for priority setting in which issues of effectiveness, the seriousness of the con dition and cost were taken into account. However, the court found that the Health Authority had in practice adopted a 'blan ket ban and recommended the authorities introduced a fair and consistent policy for decision making that adequately assessed exceptional cases by considering each re quest for treatment on its individual mer its. The case therefore made it illegal for health authorities to refuse to provide spe cific services, with the possible exception of a treatment where 'the clinical evidence of its inefficacy is overwhelming [2]. The case implies that costs and benefits should be evaluated on an individual patient ba sis, rather basing entitlement on the typi cal or average case. Primary legislation and case law have therefore not prescribed which services are to be included in or excluded from the English health basket. However, secondary legislation on professional contracts goes some way towards defining entitlement to specific services. For example, the 2004 National Health Service (General Medical Services Contracts) Regulations provide details of the terms of service for general practitioners (GPs) and state that essen tial services' must be provided, covering emergency treatment and treatment for patients with chronic, terminal and self limiting disease [National Health Service, General Medical Services Contracts, regu lation SI 2004/291, reg. 15 (3:5,6:8), 2004; see Q Table 2]. For dental practitioners the Nation al NHS (General Dental Services) Regu lations 1992 make provision for the Sec retary of State for Health to determine dentists' remuneration, including a 'sca le of fees' for providing particular ser vices [reg. 19 (1)]. Updated at least annu ally, the Statement of Dental Remunera tion describes over 400 services covered by the fees, including clinical examina tions and treatment planning, diagnostic procedures, such as radiographie examina tions, preventative, periodontal, conserva tion and surgical treatments and the sup Eur J Health Econom Suppl 1-2005 I Si 9
Abstract Eur J Health Econ 2005 [Suppl 1] 6:18-23 DOI 10.1007/S10198-005-0314-1 ? Springer Medizin Verlag 2005 Anne Mason Does the English NHS have a Health Benefit Basket? Abstract A'health benefit basket'is a range of pub licly entitled health-related goods and ser vices. Primary legislation ensures the provi sion of broad categories of healthcare, but this provision is subject to political discre tion. Case law has established that health care organisations may not operate a 'blan ket ban'for particular services. This means that the English health basket currently has very few specific services explicitly includ ed or excluded. Regulation may, however, be important in determining citizens'rights. With reference to'services of curative care', this paper explores whether the NHS is mov ing towards a more explicit definition of a health basket. Keywords Health Services National Health Programmes United Kingdom Health Benefit Plans Public Policy S20 I Eur J Health Econom Suppl 1-2005 ply of prostheses; patients pay 80% of the charge up to a stated maximum, although some exemptions apply (Department of Health, Statement of Dental Remunera tion, amendment no. 93, 2005). The Doc tors' and Dentists' Review Body reviews existing fee scales and makes recommen dations regarding uplift. The Department of Health then considers these recommen dations and the Chief Dental Officer for England notifies Strategic Health author ities, PCTs, NHS Trusts (groups of NHS hospitals, each operating as a single legal entity) and all general dental practitioners of the updated fee scales (ibid.). Similarly, the 1986 NHS (General Oph thalmic Services) Regulations make provi sion for opticians and ophthalmic medical practitioners to charge for sight tests and for optical appliances (National Health Service, General Ophthalmic Services, regulation SI 1986/975,1986). Charges are determined by the Secretary of State in consultation with professional bodies, updated at least annu ally and amended by secondary legislation. For certain patients vouchers are available that reduce or remove the charge incurred by patients. Eligibility for general ophthal mic services, outlined in section 13 of the Health and Medicines Act 1988, is deter mined by age, disease (or risk of disease) or income. Voucher values are updated at least annually by secondary legislation. Quasi-law In addition to legislation, NHS provision is shaped by a considerable amount of 'quasi-law'. Quasi-law is defined as 'ru les which are not usually legally binding, although they may have some legal force, but which will in practice determine the way in which people act' [3]. Amongst the regulation helping to define patient enti tlement to services are NSFs, NICE guid ance, waiting time guarantees, fee sched ules, and incentive schemes. The Health care Commission is the key regulator, as sessing the performance of NHS organisa tions against national standards in its 'an nual health check', a monitoring process that assesses both existing performance (core standards) and capacity to improve ('developmental'standards) [5]. The programme of NSFs, launched by I the Department of Health in April 1998, usually produces one new framework a year. NSFs set national standards, identify key interventions for a defined service or care group that should be available, estab lish strategies to support implementation and outline ways to ensure progress with in an agreed time scale [6]. Frameworks cover some services of curative care (O Ta ble 3). Each NSF is developed with the assistance of an external reference group (ERG), which seeks to engage a range of views from health professionals, service users and carers, health service managers, partner agencies and other advocates. However, the economic input into NSFs is sometimes weak. The Department of Health supports the ERGs and manages the overall process. It is unclear how NSFs are to be updated to reflect changes in the evidence base that underpins them. There is no statutory obligation on health care organisations to implement NSF standards. However, the Health And Social Care (Community Health And Stan dards) Act 2003 [Health and Social Care (Community Health and Standards) Act, Chap. 43, 2003) gave the Secretary of Sta te powers to publish standards for health care [s. 46 (1)] that NHS bodies are bound to take into account [s. 46 (4)]; NSFs could inform these standards. Furthermore, the Healthcare Commission reviews health care organisations' implementation of NS Fs as part of its annual health check [5], reinforcing the quasi-legislative nature of NSF guidance. NICE, the organisation responsible for assessing whether new or existing technologies should be available on the NHS, produces three types of guidance which help define the availability of NHS services of curative care. Firstly, technolo gy appraisals give guidance on the use of new and existing treatments within the NHS. Of the 91 technology appraisals pub lished to date (July 2005) some relate to in-patient care, such as Appraisal No. 11 (the use of implantable cardioverter de fibrillators for arrhythmias); to day ca re, such as Appraisal No. 48 (home com pared with hospital haemodialysis for pa tients with end-stage renal failure); and to out-patient care, such as Appraisal No. 24 (debriding agents for difficult to heal sur gical wounds). Secondly, NICE clinical guidelines offer guidance on the appropri
Table 2 Eligibility for primary care'essential services' under the 2004 General Medical Services Contract if rom II9]) Type of essential service Immediate and necessary emergency treatment Eligibility for treatment 'Any person to whom the contractor has been requested to provide treatment... at any place in its practice area' [reg.15 (6)] Management of terminal illness Registered patients and temporary residents Treatment of conditions from which recovery is generally expected Registered patients and temporary residents Treatment of chronic disease Registered patients and temporary residents Advice in connection with the patient's health, including relevant health promotion advice Registered patients and temporary residents Referral of the patient for other services under the 1977 Act Registered patients and temporary residents Home visits Where contractor considers it inappropriate, because of a patient's medical condition, for the patient to attend the practice premises Annual health checks Patients aged over 75 years Patients not seen within 3 years; newly registered patients Table 3 Services of curative care covered by selected National Service Frameworks; ICHA category HC.1 : services of curative Category Children Services Standard 7: Guidance on hospital-based services for children Standard 3: Guidance on community-based care Coronary heart disease Standard 7: NHS Trusts to provide appropriate investigations and treatments for patients with suspected or confirmed coronary heart disease Diabetes Standard 7: NHS to provide rapid and effective treatment for diabetic emergencies Mental health In-patient hospital beds for persons needing a short period of intensive intervention and observation Elderly Standard 4: Need for appropriate specialist care Standard 7: Effective diagnosis, treatment and support for those with mental health problems Renal disease Quality requirement 2: Timely, appropriate and effective investigation, treatment and follow-up for those with chronic kidney disease Standard 5: All likely to benefit from a kidney transplant to receive a high quality service which supports them in managing their transplant (from: DH website, hnp://www.dh.gov.uk/PolicyAnd6uidance/HealthAndSocialCareTopics/HealthAndSod ID=4070951&chk=W3ar/W, accessed 12 July 2005) ate treatment and care of people with spe cific diseases and conditions within the NHS. Clinical guidelines are based on the best available evidence and are intended to help health care professionals in their work but not to replace their knowledge and skills. Services of curative treatment are included amongst the 40 currently pub lished guidelines. For example, the dyspep sia guideline (Clinical Guideline, CG, 18) recommends life-style advice and appro priate medication as secondary preventa tive measures and the guideline on head in jury (CG4) specifies treatment pathways covering emergency, out-patient and in patient care. Thirdly, NICE produces guidance on whether interventional proce dures used for diagnosis or treatment are sufficiently safe and effective for routine use in the NHS. Of the 127 currently pub lished topics most relate to hospital-based care, such as radiotherapy for age-related macular degeneration (Interventional Pro cedure Guidance, IPG, 048) and auditory brainstem implants (IPG108). The three types of NICE guidance are developed and updated using distinct methodologies. Guidance on technology appraisals is formulated by the NICE Ap praisal Committee, an independent advi sory body with individuals from a range of professional backgrounds. Preliminary guidance is based on evidence from an aca demic assessment group and from compa ny submissions. Following consultation, the Final Appraisal Determination is de veloped, approved by the NICE Guidance Executive and put out again for consulta tion. An appeal process may ensue, after which the guidance is published. All guid ance is reviewed at regular intervals [7]. To develop a guideline, NICE commissions one of the National Collaborating Cen tres to establish a Guideline Development Group. The Group appraises clinical and cost-effectiveness evidence from systemat ic reviews of the research evidence. Views of clinicians, consumers and stakeholders Eur J Health Econom Suppl 1-2005 I S21
Original Papers also inform the guideline [8]. To produce guidance on interventional procedures, the Interventional Procedures Advisory Committee, an independent body of 24 members with a range of expertise, consid ers the safety and efficacy of procedures, but does not examine clinical or cost ef fectiveness [9]. The Committee produces a Consultation document and published guidance reflects comments received over the 4-week consultation period. NICE guidance generally acts as qua si-law, but one aspect of guidance on tech nology appraisals is supported by statu te. If NICE guidance is that a new technol ogy should be made available to certain NHS patients, the funding bodies (PCTs) are obliged by law to ensure there are ade quate resources to facilitate the implemen tation of NICE guidance (Secretary of Sta te for Health "National Health Service Act 1977: Directions to Health Authorities, Pri mary Care Trusts and NHS Trusts in Eng land", 2001). However, the guidance is not binding on individual clinicians, who must assess whether the technology is ap propriate for the patients they treat [10]. Another illustration of quality stan dards impacting upon patient rights is Public Service Agreements. Published an nually, these specify national goals within the public sector, including waiting time targets (or guarantees') for the NHS [11]: (a) By the end of 2005, patients will wait a maximum of 6 months for in-patient ad mission and no more than 13 weeks for an out-patient appointment, (b) By the end of 2008 the maximum wait from GP refer ral to hospital treatment will be 18 weeks. Targets that should already be achie ved, and henceforth maintained, include the 4-hour maximum wait for emergency care and the 24/48 target for accessing pri mary care. (The 24/48 target refers to pa tients being able to see a general practitio ner within 2 working days or another pri mary care professional within 1 working day, whilst the 4-hour wait target is that pa tients should spend no more than 4 hours in an accident and emergency hospital de partment from arrival to admission, trans fer or discharge.) Where fee schedules exist for NHS ca re, patient 'entitlement' to services might be inferred. For example, the new national tariff system of payments for hospital ser S22 I Eur J Health Econom Suppl 1 2005 vices, whilst in no way guaranteeing provi sion, 'suggests' services that should be ac cessible on the NHS. The national price schedule for patient services is classified by Health Care Resource Group (HRG) codes. A range of clinical procedures, treat ments and diagnoses is included in the cur rent list of 550 HRG tariffs for elective in patient care [12]. The Quality and Outcomes Frame work, part of the GP contract, is a volun tary mechanism for encouraging primary care provision of some services of curative care, such as antiplatelets for patients with coronary heart disease [13]. With total pay ments amounting to 15-20% of available total practice remuneration [14], there is a clear incentive for GPs to make these ser vices available to NHS patients. Discussion The NHS is a complex and heavily regu lated health care system in which the ro les of actors are in general clearly defined. As the primary emphasis has historically been upon local cost control rather than quality or access issues, geographical vari ations in quality and quantity of provision have emerged [1]. The lack of explicitness in the definition of the health basket has led to a great deal of uncertainty about en titlement. Even if there is a statutory duty gov erning provision, this does not necessari ly guarantee access to NHS services. For example, the 1977 NHS Act obliges PCTs to provide, or to arrange for the provi sion of, general dental services (National Health Service Act, Chap. 49,1977). How ever, a large proportion of the population is unable to access NHS dental services be cause of a shortage of dentists willing to provide these services for the NHS. The rapid growth of private practice since 1992 was apparently precipitated by a 7% cut in NHS fees, which was designed to redress perceived excessive income [15,16]. Access problems to NHS dentistry have triggered an urgent review of the regulations govern ing the dentists' terms of service with a re cent cash injection of over ?350 ( 504) million, aimed at increasing the number of dentists working for the NHS [17]. The British Dental Association in is negotia tions with the Department of Health to develop a new contract which is expect ed in April 2006. This example illustrates the general principle that private practice flourishes where there are access or quali ty problems within the NHS. The use of regulation to address quality and access issues has had mixed results. A national evaluation of compliance by NHS organisations with NICE guidance found variable implementation. Looking at ra tes of prescribing and use of procedures and medical devices, the time-series anal ysis found significantly increased prescrib ing of some taxanes for cancer and orlistat for obesity in line with guidance. However, prescribing practice frequently appeared to have little relation to detailed guidance [18]. NICE guidance specifies entitlement in terms of patient groups and PCTs are obliged to provide funding only for the se patients. Whether this practice is equiv alent to the PCT operating a 'blanket ban for patients whose condition lies outside the specified guidance is debatable and has not been tested in the courts. Over the past decade the growth in qua si-law' suggests that the English system is heading towards a more formal statement of benefits and entitlements. NICE guid ance on new and existing technologies is in effect establishing a 'positive list' of tech nologies that the NHS should fund; NS Fs describe interventions that should be implemented to achieve standards of care. The Payment by Results system will be ex panded to cover non-elective care and the Healthcare Commission will increasing ly encourage NICE and NSF implemen tation, reinforcing standards through the annual health check' [5]. These factors to gether will take the NHS forward in defin ing a more explicit health basket for Eng land. However, variations in local capacity to comply with national standards may re sult in a more explicit rationing of health care services at the local level. Corresponding author Anne Mason Centre for Health Economics, University of York, UK e-mail: arm10@york.ac.uk
Acknowledgements The results presented here are based on the pro jecf'Health Benefits and Service Costs in Eu rope-HealthBASKET" which is funded by the Eu ropean Commission within the Sixth Framework Research Programme (grant no. SP21-CT-2004 501588). I thank the following individuals for their helpful and pertinent comments on an ear lier draft: Norman Ballantyne (Public Private Part nerships Programme), Karen Bloor (University of York); Brian Ferguson (Yorkshire and Humber Pub lic Health Observatory); Caroline Glendinning (University of York); Maria Goddard (University of York); Nicky llliott (ABPI); James Mason (University of Durham); Adam Oliver (London School of Eco nomics); Phill O'Neill (ABPI); Mark Sculpher (Uni versity of York); Andrew Street (University of York); and Jon Sussex (Office of Health Economics). Pe ter Smith supervised the work and Mike Drum mond (University of York) provided supportive advice. All remaining inaccuracies and omissions are my own. Nachschlage werk! 2006. Etwa 1180 S. 60 Abb. Brosch. 34,95; sFr 59,50 ISBN 3-540-28368-4 In seiner j?hrlichen Bilanz analysiert der Arzneiverordnungs-Report kritisch und sachlich die kassen?rztlichen Arzneiverord nungen Exklusive Detail-Informationen ?ber Arznei mittel, Verordnungsverhalten, Kosten, neue Therapie-Trends, erfolgreiche Innovationen und Spar-Optionen Brandaktuelle, zuverl?ssige Daten und Fakten Jetzt in Ihrer Buchhandlung. Die -Preise f?r B?cher sind g?ltig in Deutschland und enthalten 7% MwSl Pretsanderungen und Irrt?mer vorbehalten. springer.de 4y Sprini References 1. Department of Health (2000) The NHS plan: a plan for investment, a plan for reform. Stationery Office Limited: London 2. Newdick C (2005) Who should we treat? Rights, ra tioning and resources in the NHS. Oxford Universi ty Press: Oxford 3. Montgomery J (2002) Health care law. Oxford Uni versity Press: Oxford 4. Organisation for Economic Cooperation and Devel opment (2000) A system of health accounts. OECD: Paris 5. Healthcare Commission (2005) Assessment for im provement: the annual health check - measuring what matters. Healthcare Commission: London 6. Department of Health (1997) The new NHS: mod ern, dependable. Cm 3807. HMSO: London 7. National Institute for Clinical Excellence (2004) Guide to the methods of technology appraisal. NICE: London 8. National Institute for Clinical Excellence (2004) The guideline development process: an overview for stakeholders, the public and the NHS. NICE: Lon don 9. National Institute for Clinical Excellence (2004) The interventional procedures programme. NICE: Lon don 10. Newdick C (2005) Evaluating new health technol ogy in the English National Health Service. In: Jost T5 (ed) Health care coverage: an international com parative study. Open University Press: Maidenhead 11. Treasury HM (2004) 2004 spending review: public service agreements 2005-2008. HMSO, London 12. Department of Health (2005) Implementing pay ment by results: technical guidance 2005/06. De partment of Health: London 13. Department of Health (2004) Quality and out comes framework: guidance (updated August 2004). Department of Health: London 14. Anonymous (2005) CCA calls for closer working be tween GPs and pharmacy. Pharm J 274:667 15. Oliver A (2002) Reforming public sector dentistry in the UK. BJHCM 8:212-216 16. Department of Health (2004) NSH dentistry: deliv ering change. Report b y the Chief Dental Officer. Department of Health: London 17. Department of Health (2004) Reforms with bite: 1000 more NHS dentists by October 2005: Reid un veils ?368m funding injection for NHS dentistry. Press release, 2004/0265. Department of Health: London 18. Sheldon TA, Cullum N, Dawson D, Lankshear A, Lowson K, Watt I, West P, Wright D, Wright J (2004) What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews. BMJ 329: doi:10.1136/bmj.329.747 3.9992004;329;999 19. Department of Health (2003) Delivering Invest ment in general practice: implementing the new GMS contract. Department of Health: London

Public Health Measures and Mortality in U.S. Cities in the Late Nineteenth Century

Public Health Measures and Mortality in U.S. Cities in the Late Nineteenth Century Author(s): Gretchen A. Condran and Eileen Crimmins-Gardner Source: Human Ecology, Vol. 6, No. 1 (Mar., 1978), pp. 27-54 Published by: Springer Stable URL: http://www.jstor.org/stable/4602436 Accessed: 29/11/2009 14:48 Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you may use content in the JSTOR archive only for your personal, non-commercial use. Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at http://www.jstor.org/action/showPublisher?publisherCode=springer. Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed page of such transmission. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Springer is collaborating with JSTOR to digitize, preserve and extend access to Human Ecology. http://www.jstor.org
Human Ecology, Vol. 6, No. 1, 1978 Public Health Measures and Mortality in U.S. Cities in the Late Nineteenth Century Gretchen A. Condran2 and Eileen Crimmins-Gardner3 In this paper we examine the decline in mortality rates by cause of death in U.S. cities during the last decade of the 19th century. Causes of death are grouped according to their probable relationship to specific public health mea- sures. The reduction which occurred in the death rates from some diseases, e.g., typhoid and diarrheal diseases, can probably be attributed in part to the pro- vision of sewers and waterworks. Large declines also occurred in the death rates from tuberculosis and diphtheria, but the relationship between the declines in these diseases and public health practices designed to combat them is more am- biguous. We therefore conclude that public health measures had some impact on the decline in mortality, but that these measures do not provide a complete explanation of the mortality decline. KEY WORDS: mortality; public health measures; urban areas. INTRODUCTION In the United States, high population density, inadequate water supplies, and inadequate sewage disposal systems aided in the spread of infectious diseases and contributed to high urban mortality levels for most of the 19th century. Ur- ban mortality began to decline toward the end of the century; however, the exact date of inception of the decline is hard to determine. While certain diseases (e.g., cholera, typhus, and smallpox) declined earlier than others, urban mortality in The research on which this paper is based was supported by NICHD Grant 1-ROl-HD- 05427. A version of this article was presented at the meetings of the American Sociological Association, New York, August 30-September 3, 1976. 2Department of Human Ecology and Social Sciences, Cook College, Rutgers University, New Brunswick, New Jersey. 3Department of Sociology, University of Illinois at Chicago Circle, Chicago, Illinois. 27 0300-7839/78/0300-0027 $05.00/0 ? 1978 Plenum Publishing Corporation
28 Condran and Crimmins-Gardner general appears to have remained high and may even have been rising until late in the century. By 1890, mortality levels were probably declining in many cities (Sydenstriker, 1972; Easterlin, 1977; Meeker, n.d.; Gore, 1904; Taeuber and Taeuber, 1958). The decline in mortality - rural and urban combined - which occurred during the 19th century in England and Wales and the U.S. has been attributed largely to changes in levels of living (McKeown and Record, 1962; Meeker, 1972). However, in urban areas new public health practices are also be- lieved to have contributed to the decline in mortality. Meeker (1972), writing about the period from 1880 to 1915, argues that: The improvement in the state of health was due to a rising level of living and to novel public health measures. The former refers especially to better diets and housing, the latter mainly to the installation of sewers and filtered, or otherwise improved, central water supplies. (p. 367) Thus, Meeker suggests that the public health measures which affected mortality rates involved quite specific practices. In this paper, we examine the urban mor- tality decline in the last decade of the 19th century in relation to several of these public health measures. The public health movement in general encompassed a large number of goals and procedures, some of which probably had an impact on mortality, others of which may have had little or no effect. Our analysis con- centrates on measuring the impact of specific public health measures on those causes of death which were likely to be affected by them. THE DATA All the data reported in this paper are taken from the federal censuses. Data on the number of deaths were collected in the regular decennial enumera- tions from 1850 through 1900. However, by 1880 the census mortality statistics were a combination of the enumeration data and the returns from the registra- tion systems in several states and cities. Urban death rates in this paper are based solely on the city death registration data as published in the federal censuses. Most of the city registration systems had been in operation for several years prior to 1890, and therefore the data are considered to be fairly reliable from that date on, and certainly a better source than the census enumeration. In 1880 the number of registration cities is small and therefore our research is based on data from 1890 and 1900.4 Base population figures used in the cal- 4The research reported in this paper is part of a larger study in which the changes in morta- lity from 1850 to 1900 and the regional variation in mortality in the second half of the 19th century are being examined in conjunction with the levels and trends in fertility. We are using the 1890-1900 decade for this examination of urban mortality because it is the first time period for which reasonably reliable data are available. An extension of this examination into the 20th century is also being undertaken and should provide further evidence on many of the issues raised in this paper.
Public Health Measures and Mortality 29 culation of mortality rates were collected in the federal censuses of 1890 and 1900. Coverage in these censuses was not perfect and any inadequacy in these data affects our results. Age-specific and cause-specific death rates have been calculated from data for 28 cities in 1890. The death rates for some of these cities are very low, probably as a result of poor registration. When data for individual cities are shown, all 28 cities have been included in the tables. When data are aggregated, only 26 cities with infant mortality rates over 120 per thousand were used. Data for 1900 are available for 127 cities. All correlations, however, have been calculated using only 115 cities with infant mortality rates greater than 120 per thousand because of the possibility that low rates result from poor registration and that their inclusion would bias the results. This criterion has eliminated many Midwestern cities from the analysis. EVIDENCE OF DECLINING URBAN MORTALITY Table I contains the total mortality rates and the age-specific mortality rates for 28 cities for which registration data are available for 1890 and 1900. Most of the cities in Table I show declines in some mortality rates. The declines in mortality are not uniform across all cities and, in most cities, are limited to the younger age groups. There are, of course, dangers in inferring the trend in mortality from data at only two dates. Mortality rates may fluctuate a great deal, especially when mortality levels are high and when deaths from infectious and epidemic diseases constitute a large proportion of the total deaths. The mortality statistics have been collected on a yearly basis for many of the 28 cities in Table I as well as for a number of other cities. Yearly mortality rates were calculated using population estimates based on an assumption of a geo- metric change in the population between 1890 and 1900. Five-year moving averages of the death rates of 04-year-olds for a number of cities are plotted in Fig. 1. In most cases, these figures show a downward trend in mortality over the decade. The trend in the mortality rates shown in Table I and in Fig. 1 depends on both the adequacy of the death registration system and the reliability of the population estimates used in calculating the rates. A particular problem for our analysis is that the population is thought to have been more poorly enumerated in the 1890 census than in either the preceding or following censuses. We must therefore be cautious about inferring a decline in mortality. If the registration of deaths was fairly constant from 1880 to 1900 but the population enumeration was especially poor in 1890, artificially high mortality rates in 1890 may be sug- gesting a decline in mortality which actually did not occur. The available evidence strongly suggests that while it is hard to determine exactly when mortality began to decline, death rates were actually dropping in cities during the last decade of the 19th century. The raw figures on number of
30 Condran and Crimins-Gardner o' 0- ~o 0 O O- '- 90 o a C- 00 - :t 00 "kD Wm r 00 -- C ^m 4 o W) 00 C- W) ,t r-00 s-C . 00 0- r)00 ? O C :t O en 00 _ -z n O= Ol 00 D? 0-) ) 00 LO) 0O ?-) 0e 9 0 rO1t-mC t- t, oo o6 tO ,0 c, u6 o6 kr Oj c6 ,0 tr oO. cr 4 oo 4 4 6 c^ t-- 4 w;r l 0 m en en en en en n m c O tt m "m 001 m ? ^0 m Cl o t 00 00 N C 00 a-0, - O 00 en00 C,, 00 % M m 0) 0_ O N00 00 V- - t V- CD 0 r- - al OO oo v) cI, Nt e#~ 00 ON ut) CO co-.t 00o -0 tn -D -- -4 -t m n 00 CD ON cn aN 00 C' cn cn "t - t O~~~~~~~~~~~~- -- .-I _ 4 _ - -4_ --I_ 4 ll o - _ crn c>l to~~~V) 00 o x tO en O n c Om ?o kn 0 N On O- > CO 00 r- stf u 00 v~~~~~~~~~~~~~~ 06 O- o6 oo6 oo~ 'i cr oo C6 O. r_ C) O- ,6 ?-. oo 0 t- t- W tC c O0 00 00 C- " I - 0 C O 00 00 l ^ 0 o O 0 C.) ONa t v- oo r-e en^ CE M C) -4 ct " I' O ?- o M r- - ol " ON ootO_ 0 ) ~ - o ~ 00 O~ 00 O~ 00 O 00 ~C00a- t Ol 00 O0 0 O0 O 0 O 00 O" 00 1 t 0 r- 00 0q - ---O t- - - ---n ---- - t- - - v) -n c :O C" 00 CN C) CN en n m :t cn C> M O" o- D 00 -m ID m 00 ~~~ Q Q Q - .8~~~~~~~~~~~ " M C, rl M N cn q n eq I m- c" en "o en r 00 00 rl -o C) c n - cl r- r- - c ^o - rl ON - r- 'It C) CD -o 00 ON tn co>?o n r- cn .o al 'I C) v) - o n C) m CD -4 C t C) C) CN m en v) 0 00 all o t n tn oO r- 0t cro - C) -q 0 CD cq 0 0c -4 C4 Cl -4mN m b -4 C4 C4 -4 C4 C- -- -4 -- -- CCD N 0 ON )ON C)0- C= 0- C) N C) CN C) ,- N ON ) CN ) CN CD 0~C N O 0 aY O0 CN 0 CN 00 0- 0 C -0 ON 00 ON 00 X 00 ON 0 N O0 Ol 00 C,, 0N 00O *~~~~~~~~ 0 Y 000000000000000000~~~~~~~~~~~~~~~~~~~~~~~~~~~l00000 000 ~~~~~~~~~c w t _ $4 _1 _ . E~~~~~~~~' - '. 0 3 oc d 3=>
Public Health Measures and Mortality 31 n ?O r- 1t o) " 4 m m. tn tn o- N N 11 ?O m ON C N (7- oo N m oo 'I N ~ c1 o stoo or1mNottmob ---- - - -- - , - CD ?D 00 "- ~O 00 N CD N M 1- r- "t r- 1, O N CD NNm N N I - ? O tn -t -N n t ----- - - T N N m - - --t -T 0 - O -zt oo -t - o t -o N ,-O - - -- oc ON -'>N n dD en N w _N eq N N N N H- tn o N cn 'oo oo0 W) 1% D CD It W Ioo 'I 'oo 1 ) oo u) 'I 'I CD O u)- r- oIT ON m - - -- r-_ - - - -- - -4 -4 ce H -~~~~~~~~~~~~~~~~~~~~~~~~~~~~* - a-. - CD-4 ".0af) 00/0 00 C '-4O O NK '-IO 00 0 - 0 -f)" ) 040 W4C 'af CD l O ' 0 O 00 00 a-, CD 00 0O ON C , O n o o O O > N C N 0 ^ O O W _l 66 - ;4 6 _. 4 0~6cl 00 16 -V,It' 't l el;C - v 0u)1. tn 'I -- m r- tl V- Od IT 00 0) N O ?? m m 1. 01 O N N N% ^- ~ ON 0 _C5 oo a 110 00 0c"ItGo ONo- . 000- rW) NON t~ tOl- ~Cl~af)~-~Cl000000Cl0 K'?00Cl~.0Cl00r-0 O o - -y -- t O t- O - ---N O --- - v t C ---- O ^ tNt^mb^N^>ttnv)^NN^^n^^^mmt>~~~~C CO I u) U .-I N O CO M o ,* 0 O (= cn d o C)0 t0 0 D oo~ ro xoq v- ,O m m W) m O n tn m tn o ^ , qo W) o oo m % O ri CD c - 0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~C ON Z > N Z t0 - F M t C N N ^ o o6 6 i -; D aQ N -4 d e N M :t en -- -- n 'It en " N - N N N N-I C14 ct M :c t m N 0 o oo 11. W) ur b N -f 00 N W) N %- W) 1. (7 N N 00 -t en CD 0 ? r- on _s _ ) % o W\ I N o oen o= N -4 t- t)1 -.o en 00o t~- _/ N cq N N N _ 6 N eq N N > _ N _ N CI N _ tn N t- -it N - t_ r- r_ r- 1 t_- N 00 00 00 cl O 00 N 'I N 00 [ O Q Q) * ~ -; 6 6 o6 r- 4 4 c- * - 4 * - * - * * 6 tr * ~ * t* * ~ w * 6 * . v @ 4 < o=" ON" o=" a-">X2 :
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Public Health Measures and Mortality 33 Table II. Disease-Specific Death Rates for 26 Cities: 1890-1900 (Rates per 100,000 Population) 1890 1900 Measles 18.0 17.7 Scarlet fever 17.0 15.4 Diphtheria and croup 116.9 59.2 Whooping cough 17.6 13.2 Typhoid fever 53.0 33.8 Malarial fever 19.4 6.9 Pneumonia 223.2 241.7 Consumption 272.9 218.1 Diarrheal diseases and cholera infantum 216.1 153.1 Cancer and tumor 53.5 65.8 Heart diseases and dropsy 124.0 134.1 Liver 28.0 25.8 Diseases of the nervous system 260.8 206.2 Diseases of the urinary system 84.9 120.0 Old age 32.9 45.7 Unknown 9.8 8.6 All other 637.9 567.3 Total 2185.5 1932.6 Source: 1890 - U.S. Census Office (1896), Table V, pp. 410-655. 1900 - U.S. Census Office (1902b), Table XIX, pp. 285-555. deaths used in calculating the annual death rates in Fig. 1 show that for many cities the actual number of deaths was declining. Hence, even with more moderate rates of growth of the population than indicated in the 1890 and 1900 census returns, a mortality decline would be evident. In addition, the decline in morta- lity was not uniform for all causes of death but, as expected during a period of ini- tial mortality decline, occurred largely because of a decrease in the deaths from in- fectious and parasitic diseases. Table II contains the cause-specific death rates ag- gregated over 28 cities in 1890 and 1900. Mortality rates from many infectious and parasitic diseases were declining, while the rates of death from cancer, heart disease, etc. were not. If the observed decline in mortality were a result of a shift in the quality of the statistics, there is little chance that this pattern of decline in cause-specific rates would occur. We therefore conclude that a real decline in mortality was occurring in many U.S. cities by the end of the 19th century. PUBLIC HEALTH MEASURES AND THEIR RELATIONSHIPS TO MORTALITY DECLINE By 1890 the public health movement included a broad range of activities designed to combat both endemic and epidemic diseases. The stated aims of the movement in most cities included first and foremost the provision of central
34 Condran and Crimmins-Gardner water supplies and sewage systems. In addition, the movement often included plans for general street cleaning, improvements in slum housing, inspection of food and milk, use of quarantine and disinfection practices, and the distribution of diphtheria antitoxin (Rosen, 1971; Duffy, 1974; Meeker, 1972). The actual practice was often far removed from these aims. Detailed studies of the develop- ment of public health practices in local areas point out the failure to meet goals, sometimes because of lack of technology, sometimes because of political dis- agreements, and often because of corrupt city officials and contractors (Duffy, 1974; Rosenkrantz, 1972). We can find examples of specific cities in which public health measures appear to have reduced mortality from certain diseases. Whipple (1908) compares mortality rates from typhoid and diarrheal diseases in Albany, New York, and Troy, New York. Albany began filtering its water in 1899, Troy did not. Albany's decline in both typhoid and diarrheal diseases far exceeded that in Troy (Meeker, 1972). The drop in infant death rates in the City of New York between 1885 and 1915 from 273 per thousand live births to 94 per thousand live births has been attributed to the improvement of water and milk supplies (Rosen, 1971). Indeed, in reports to the Census Bureau in 1900, local health authorities clearly indicated public health measures as the major source of declines in mortality rates. The Census Bureau requested a statement from health officials of the local causes operating to diminish the death rate. The replies varied in length and detail, but in every case the decline was attributed to some public health measure. These replies, as reported in the 1900 Census, are summarized in Table III. One is, of course, tempted to believe all these reports and to generalize from the clear cases of decline in some specific diseases in local areas to the over- all decline in mortality in cities. Clearly, the various activities included under the general heading of the public health movement could have an effect on mortality only inasmuch as the goals were translated into actual practice. It is quite clear -that different aspects of the public health programs in cities were likely to affect some diseases and not others. Some causes of death - cholera infantum, diar- rheal diseases, and typhoid - should certainly have been directly affected by such public health measures as sewers and waterworks. Other infectious dis- eases - tuberculosis, diphtheria, measles, influenza, scarlet fever, whooping cough, etc. - were less related to these specific public health measures. However, they may have been affected by general improvements in cleanliness and by quarantine and disinfection practices and, in the case of diphtheria, by the de- velopment and use of antitoxin. Finally, the etiology of other diseases like cancer and heart disease suggests little or no connection to any public health measures of the time. A breakdown of diseases into categories reflecting their relationship to public health practices provides a way of assessing the importance of these practices in explaining the urban mortality decline.
Public Health Measures and Mortality 35 DIARRHEAL DISEASES, CHOLERA INFANTUM AND TYPHOID: SEWERS AND WATERWORKS Table IV contains the mortality rates from diarrheal diseases and cholera infantum combined and from typhoid for 28 cities in 1890 and 1900. Diarrheal diseases and cholera infantum show a fairly large decline in a number of cities and at least a moderate decline in all but five cities. Typhoid declines in all but two cities. The size of the decline in typhoid is very impressive in some cities, particularly in those cities which started out with very high rates in 1890. These findings suggest that sewers and waterworks may have contributed to the decline in mortality in these cities. Data indicating the extent of sewers and waterworks in these cities are very limited. While some data for selected cities are published in the reports of public health officers, most data are unusable for comparison across cities or for observation of changes in practices for more than a few cities. The 1890 Census and 1901 Statistics of Cities published by the Department of Labor provide some information on these phenomena. In 1890, data on miles of sewers, num- ber of sewer connections, and gallons of water consumed were published for the 28 large cities for which mortality data were published. For 1900, the available data include miles of water mains, expenditures up to 1900 on construction of waterworks, and the amounts spent on yearly maintenance of sewers and water- works. Because the data for 1890 and 1900 are not comparable, changes in public health facilities cannot be calculated from these sources. Our use of these data is limited, therefore, to an analysis of the cross-sectional relationships between public health measures and mortality rates. Because 1890 mortality data are available for only a small number of cities, we have undertaken this analysis only for 1900. The expenditure variables - expenditures up to 1900 on the construc- tion of waterworks, and the expenditures on the yearly maintenance of sewers and waterworks - were calculated per capita. Only the relationships between the expenditures up to 1900 on the construction of waterworks and mortality rates are shown in Table V. The results using the other data relating to water- works are similar to those in Table V. The expenditure on maintenance of sewers gener4lly shows no significant relationship to mortality rates. Two variables were calculated using the data on miles of waterworks - the miles of waterworks per person and the miles of waterworks per acre in each city. In Table V we are pre- senting only the miles of waterworks per person. Similar results were obtained when the other variable, miles of waterworks per acre, was correlated with the death rates. All the correlations in Table V were calculated controlling for city size, percent Black, percent foreign-born, and persons per dwelling unit. Expenditures on the construction of waterworks and the miles of water- works per person show significant negative correlations with mortality rates in
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Public Health Measures and Mortality 37 O 4-4 Q~~~~ > 0 bo _ t o vz cn 45~~~~~~ X X X X Xx 00 X ~~~~~~ Cd 0~~ O~ Q ~~~~~~~~ 0 ~~~~~~~~~~ ~~ 0 -4A >44) ~~~~~~ ~~~~)0 ~0 0 ~ 4) 0 0 C 0 Z O z z 04V tsZr
38 Condran and Crimmins-Gardner Table IV. Death Rates from Diarrheal Diseases and Cholera Infantum and Typhoid Fever, U.S. Cities 1890 and 1900 (Rates per 100,000 Population) Diarrheal diseases Typhoid and cholera infantum fever Allegheny 1890 171.0 182.4 1900 172.4 103.2 Baltimore 1890 307.1 46.5 1900 185.7 34.8 Boston 1890 199.1 38.8 1900 132.1 27.3 Brooklyn 1890 234.4 24.1 1900 209.9 21.0 Buffalo 1890 233.5 31.3 1900 133.4 25.0 Chicago 1890 254.3 72.2 1900 150.4 27.7 Cincinnati 1890 140.8 50.9 1900 127.6 32.5 Cleveland 1890 204.7 62.8 1900 111.3 48.2 Denver 1890 203.4 217.4 1900 77.7 42.6 Detroit 1890 236.2 19.4 1900 151.2 18.9 Indianapolis 1890 138.5 54.1 1900 104.0 45.5 Jersey City 1890 198.8 82.2 1900 181.7 22.3 Kansas City 1890 143.9 39.9 1900 121.5 40.9 Louisville 1890 107.4 75.7 1900 98.2 73.3 Milwaukee 1890 180.0 29.8 1900 137.7 18.2 Minneapolis 1890 156.0 57.1 1900 58.7 40.2 Newark 1890 253.0 99.5 1900 149.1 10.6 New Orleans 1890 294.6 18.6 1900 268.2 66.5 New York 1890 301.3 23.0 1900 175.6 15.4 Omaha 1890 89.0 44.9 1900 85.8 40.0 Philadelphia 1890 153.0 73.6 1900 118.3 37.8 Pittsburgh 1890 192.8 127.4 1900 197.4 147.4 Providence 1890 166.5 40.1 1900 163.4 29.6
Public Health Measures and Mortality 39 Table IV. Continued Diarrheal diseases Typhoid and cholera infantum fever Rochester 1890 182.2 39.6 1900 90.4 23.4 St. Louis 1890 118.4 32.1 1900 108.5 33.0 St. Paul 1890 227.6 69.1 1900 52.1 22.1 San Francisco 1890 87.6 55.5 1900 89.0 39.4 Washington, D.C. 1890 257.0 86.8 1900 175.4 80.7 Source: 1890 - U.S. Census Office (1896), Table V, pp. 410-655. 1900 - U.S. Census Office (1902b), TableX MX, pp. 285-555. Table V. Partial Correlations Between Mortality Rates and Two Measures of the Public Health Activities Cost of waterworks to 1900 per person Miles of water mains per person North- North North- North Total east Central South Total east Central South Age N=91 N=46 N=16 N=11 N=96 N=48 N=16 N=11 Total -.16 -.18 .44 -.12 -.24 -.32a .27 -.23 Under 1 .04 -.01 .28 .11 .05 -.09 .45 *49a 1-4 .00 -.14 .19 .11 -.12 -.22 .19 -.45 5-9 .00 -.09 .43 .18 -.02 -.13 .50 -.39 10-14 -.06 -.01 .33 _.34 -.17a -.23a .36 -.06 15-19 -.10 -.22 -.03 .15 -.22a _.36a -.12 -.18 20-24 -.16 -.14 .49a -.39 -.19Ga -.27a .22 -.40 25-29 _.40a -.34a -.20 -.65a _.40a -.31a -.41a -.74a 30-34 -.17a -.13 .48a -.18 -.18a -.24a .34 -.35 35-44 -.29a -.30a .09 -.29 _ 33a -.42a .18 -.22 45-54 -.25a -.36a .53a -.08 _.33a -.45 .41a -.41 55-64 -.14 -.23 .37 -.16 -.20a -.32a .31 -.11 65+ .05 .01 .09 .16 -.04 -.07 .10 -.09 Diarrheal diseases -.05 -.02 .07 -.45 -.08 -.07 .28 -.54a Typhoid -.17a -.15 -.01 -.41 -.14 -.19 .11 -.07 aCorrelations are run controlling for city size, percent foreign born, percent Black, and persons per dwelling unit. Similar results occurred when persons per acre was substituted for persons per dwelling unit. Sources: Miles of water mains - U.S. Department of Labor (1901), Table 15. Cost of waterworks - U.S. Department of Labor (1900), Table 12. Death rates by cause - U.S. Census Office (1902b), Table xix, pp. 285- 555. Deaths by age - U.S. Census Office (1902c), Table xix, 285-555. Population - U.S. Census Office (1902a), pp. 122-149.
40 Condran and Crmmins-Gardner the middle to old age groups. There is variation in the pattern of these relation- ships from region to region. In the Northeast the relationships are negative; the more a city spends on sewers and waterworks, the lower the mortality rates. The South shows generally similar relationships to those in the Northeast, al- though the correlations are somewhat weaker. Finally, the North Central shows a significant positive relationship between public health measures and some age-specific mortality rates. We have no conclusive explanation for this ususual pattern of relationships by region. The positive relationship in the North Central region may be the result of poor public health administrations in some cities leading to both the underreporting of mortality and little or no expenditure on waterworks and sewers. Tentatively, however, we hypothesize that in the North Central region only cities with very high mortality had installed water and sewer systems. High mortality is therefore related to having begun the construction of sewers and waterworks. In the Northeast sewers and waterworks have a longer history and are much more widespread. In this region, therefore, public health facilities are negatively related to mortality rates in a number of age groups. As these findings indicate, there are difficulties in predicting even the sign of cor- relation between sewers and waterworks and mortality rates. On the one hand, if sewers and waterworks reduce the number of deaths from certain disease cate- gories, the mortality rates should have a negative relationship with these public health measures. On the other hand, if high mortality leads cities to make major expenditures on sewers and waterworks, the relationship with mortality may well be positive. Other problems in using these measures exist. The introduction of central water systems and sewage systems does not always have an immediate impact on disease. Provision of a central water supply, for example, is not synonymous with the provision of uncontaminated water. In some cases, early systems pro- bably continued to supply contaminated water and, in other cases, they may even have replaced uncontaminated water with contaminated water. Filtration of water supplies had a much more clear-cut effect on mortality reduction. Data on the initiation of filtration in individual cities are not available for the cities used in our analysis. While water supply systems were first built in some cities just after the beginning of the 19th century, it appears that it was much later be- fore filtered water was provided. According to Winslow (1923), in 1880 only about 30,000 people in U.S. cities over 2,500 in population were supplied with filtered water. Sewage systems should have operated to reduce mortality by inhibiting the spread of a number of diseases. Sewage systems were fairly widespread by 1890. "Of the 96 cities of 10,000 and over reporting whether they had sewers, only 26 had no sewers at all" (Meeker, 1972). The building of a sewer system was, however, a long-term project for a town. Portions of the town were gradually added to the system. In 1890 the cities reporting a sewer system had, on the average, less than
Public Health Measures and Mortality 41 one-half of their dwellings connected to the system (Meeker, 1972). Consequently, data reporting the existence of sewers or a year's expenditures on sewers are somewhat inadequate to deal with the questions we are asking. Table V also contains the correlations between diarrheal diseases and ty- phoid and the two public health measures. The correlations are largely insigni- ficant. A regional pattern similar to that observed using age-specific death rates occurs. The relationships between these two diseases and the costs and miles of waterworks are very weak. Indeed, the significant relationships between age- specific mortality rates and these public health measures are largely explained by disease categories other than the two in Table V. These unexpected results may be due to many of the problems with these measures outlined above. Deaths from diarrheal diseases and typhoid, two disease categories which should have been directly affected by the construction of sewers and waterworks, did contribute significantly to the overall decline in mortality in these cities. This result may indicate that sewers and waterworks are important in explaining the mortality decline. The lack of correlation between these particular disease categories and the expenditures on the construction of waterworks and the miles of waterworks per person casts some doubt on this conclusion. The decline in diarrheal diseases and typhoid may well have been due to other factors which affect other disease categories as well. However, because of the limitations of the data and the problems inherent in making longitudinal inferences from cross- sectional data, we hesitate to place too much emphasis on this result. PUBLIC HEALTH COMPAIGNS AGAINST TUBERCULOSIS AND DIPHTHERIA Table VI contains the mortality rates from tuberculosis and diphtheria and croup5 from 1890 to 1900 in 28 cities. Diphtheria and croup declined in all but one city. Deaths from these diseases were moderately high, but were often only half as high as the deaths from tuberculosis, which was the leading killer in many cities. Tuberculosis declined dramatically in many cities and hence was a major contributor to the overall mortality decline. The relationship of the incidence of tuberculosis to public health practices, or for that matter to any factor influencing mortality, is very hard to establish. Since we have no general data on public health programs designed to reduce tuberculosis in all of these cities, we must make inferences from examples of campaigns against tuberculosis in a few places. 'The available data made it impossible to separate this disease category and to look at the changes in diphtheria alone.
42 Condran and Crimmins-Gardner Table VI. Death Rate from Tuberculosis and from Diphtheria and Croup, U.S. Cities, 1890 and 1900 (Rates per 100,000 Population) Tuberculosis Diphtheria and croup Allegheny 1890 147.2 121.6 1900 160.9 28.5 Baltimore 1890 293.0 55.9 1900 220.3 73.5 Boston 1890 375.7 142.3 1900 245.0 75.6 Brooklyn 1890 288.3 169.4 1900 224.0 72.2 Buffalo 1890 186.2 86.1 1900 131.7 26.4 Chicago 1890 175.9 140.5 1900 178.6 64.8 Cincinnati 1890 280.2 164.7 1900 235.3 33.1 Cleveland 1890 158.8 147.3 1900 131.8 51.6 Denver 1890 240.8 178.1 1900 325.7 33.6 Detroit 1890 162.2 174.9 1900 125.0 46.9 Indianapolis 1890 283.6 138.5 1900 202.2 104.0 Jersey City 1890 271.8 198.8 1900 237.4 181.7 Kansas City 1890 179.3 143.9 1900 204.0 121.5 Louisville 1890 281.1 107.4 1900 233.5 98.2 Milwaukee 1890 183.9 180.0 1900 149.3 1 37.7 Minneapolis 1890 153.0 156.0 1900 130.2 5.8.7 Newark 1890 326.7 253.0 1900 234.1 149.1 New Orleans 1890 343.8 294.6 1900 357.7 268.2 New York 1890 387.5 301.3 1900 252.6 175.6 Omaha 1890 67.6 89.0 1900 107.3 85.0 Philadelphia 1890 279.6 80.6 1900 231.1 97.0 Pittsburgh 1890 149.2 189.4 1900 135.6 38.9 Providence 1890 303.5 93.8 1900 226.7 29.0
Public Health Measures and Mortality 43 Table VI. Continued Tuberculosis Diphtheria and croup Rochester 1890 213.6 45.6 1900 153.7 28.3 St. Louis 1890 184.6 61.8 1900 203.0 52.7 St. Paul 1890 125.4 104.4 1900 126.3 31.3 San Francisco 1890 378.3 58.9 1900 308.9 26.5 Washington, D.C. 1890 359.0 83.3 1900 305.3 75.3 Source: 1890 - U.S. Census Office (1896), Table V, pp. 410-655. 1900 - U.S. Census Office (1 902b), Table XIX, pp. 285- 555. In the detailed history of the public health movement in New York City, Duffy (1974) describes the antituberculosis program there. In 1889, several con- sulting pathologists for the Board of Health published a "Report on the Preven- tion of Pulmonary Tuberculosis." The authors urged the dissemination of the knowledge of the contagious characteristic of tuberculosis and the concomitant danger of human contact. They also urged the disinfection of the premises which had been occupied by tuberculous individuals, and recommended the inspection of cattle, inasmuch as diseased cattle were a source of the disease. The informa- tion contained in this pamphlet was printed in a circular for distribution in several languages. Its distribution was fairly limited, and a program of general education was deferred until 1893, when a circular, "Information for Consump- tives and Those Living with Them," was printed in English, German, Italian, and Hebrew, and sent to tenements in the city. The Health Department started a campaign for the laboratory diagnosis of suspected tuberculosis cases, and for the reporting of tuberculosis cases diagnosed by private physicians. The latter was met with opposition from physicians, who had also been directly hostile to the education campaign. Physicians were influenced by their patients not to report deaths from tuberculosis because many insurance companies were syste- matically negating policies in the event of death from tuberculosis. Opposition from the medical profession, ostensibly on the grounds that the Health Depart- ment was interfering in the doctor-patient relationship and that tuberculosis was not a communicable disease, continued until the turn of the century. Ef- forts to make tuberculosis a reportable disease were blocked by the medical profession until 1900, when the New York medical profession finally recognized the value of the Health Department recommendation. During the decade 1890 to 1900, a period in which we have seen substantial reduction in the disease, the campaign against tuberculosis was very limited. Certainly there was little in the
44 Condran and Crimmins-Gardner description of the campaign to suggest that it was the sole or even the most im- portant factor in the decline in the deaths from tuberculosis. Similar evidence on the campaign against tuberculosis in Massachusetts (Rosenkrantz, 1972) is even more ambiguous as to its likely effect on mortality rates. Indeed, in Mas- sachusetts no substantial activity against the disease began before the turn of the century. Diphtheria, a disease which shows the most consistent decline over our set of cities, has a somewhat ambiguous relationship to the public health move- ment. According to Duffy, the major innovation affecting diphtheria was the introduction of an antitoxin. The value of the antitoxin was established in January and February of 1895, when it was used to end an outbreak of diph- theria in the New York Infant Asylum. The following years saw the Division of Laboratories steadily expanding. In 1896, six additional bacteriologists and two more laboratory attendants were added to the staff. Through constant experimentation and by refining existing processes, the quantity and quality of diphtheria antitoxin was improved and production cost reduced.... The introduction of more effective antitoxin and better methods of administration reduced the mortality rate by 50 per cent within the space of six months, and by the end of 1897, the Health Department was well on its way to controlling diphtheria. (Duffy, 1974) The decline in diphtheria, at least in New York, appears to be closely related to public health activities. With so little evidence, we have difficulty generalizing about the impact of the campaigns against tuberculosis and diphtheria on the decline in death rates from these diseases. Because we can be fairly sure that these public health cam- paigns were restricted to urban areas, we have compared the declines in mortality from these causes of death in rural and urban parts of registration states. The re- sults are shown in Table VII, which contains the death rates from tuberculosis and diphtheria for 1890 and 1900, as well as the percent decline in these rates. Declines in both disease categories occurred in the rural as well as in the urban parts, and the urban declines are not consistently higher than those in rural areas. These results differ from those for diarrheal diseases, also shown in Table VII for comparison. This disease category, for which the relationship to specific public health measures seems more likely, does show very small declines in rural areas and larger declines in cities. Rural declines in diphtheria and tuberculosis pre- sumably occurred independently of public health activities. From this compari- son, we conclude that tuberculosis and diphtheria may well have been declining independently of public health campaigns in cities as well. THE DECLINE IN OTHER DISEASES The other causes of death categories for which data are available seem un- likely to have any direct relationship to any public health measures. Death rates
Public Health Measures and Mortality 45 Table VII. Selected Cause-Specific Death Rates, Rural and Urban Parts of Registration States, and Percent Decline, 1890 and 1900 (Rates per 100,000 Population) Diphtheria Diarrheal and croup Consumption diseases Cities Rural Cities Rural Cities Rural Connecticut 1890 132.7 72.3 270.5 209.6 172.8 141.4 1900 41.6 30.9 192.4 147.7 144.9 136.0 % decline 68.6 57.3 28.9 29.5 16.1 3.8 Massachusetts 1890 112.9 61.4 282.0 227.9 192.5 98.7 1900 51.9 24.8 193.7 162.5 154.3 90.1 % decline 54.0 59.6 31.3 28.7 19.8 8.7 New Hampshire 1890 143.0 63.2 191.9 194.3 211.8 125.2 1900 41.1 18.7 173.0 142.4 161.8 103.9 % decline 71.3 70.4 9.8 26.7 23.6 17.0 New Jersey 1890 147.0 55.4 269.4 193.4 222.9 117.6 1900 58.4 36.4 202.3 151.6 147.4 114.8 % decline 60.3 34.3 24.9 21.6 33.9 2.4 New York 1890 126.7 41.7 308.8 148.8 246.8 95.9 1900 56.4 21.7 220.3 138.0 164.3 82.6 % decline 55.5 48.0 28.7 7.3 33.4 13.9 Rhode Island 1890 86.0 76.3 294.9 227.6 212.4 198.7 1900 29.4 29.9 213.9 165.1 189.0 178.6 % decline 65.8 60.8 27.5 27.5 11.0 10.1 Vermont 1890 44.0 86.2 241.9 195.7 206.6 91.7 1900 16.5 18.5 155.9 152.1 142.7 66.7 % decline 62.5 78.5 35.5 22.3 30.9 27.2 Source: 1890 - U.S. Census Office (1896), Table V, pp. 410-655. 1900 - U.S. Census Office (1902b), TableXIX, pp. 285-555. from these causes are given in Table VIII. No disease category shows a decline in every city; for every disease there are at least one or two cities which show a rise in the rate between 1890 and 1900. Small changes in disease categories may be due to annual fluctuations or to changes in the diagnosis and classification of some diseases and therefore should not be regarded as evidence of a significant change. A number of diseases - measles, whooping cough, and scarlet fever - do not constitute a large proportion of the deaths in any city. Consequently, even though they show large proportionate declines in a number of cities, their contri- bution to the decline in total mortality in these cities is small. These diseases also have rising rates in a number of cities. They remain a fairly small proportion of the overall mortality rate in the cities showing an increase. The remainder of the diseases in Table VIII, with the exception of nervous system diseases, generally show little or no decline. Pneumonia, a major killer in these 28 cities, showed very small declines in some cities and slight rises in others.
46 Condran and Crimmins-Gardner cO 0o oo o - 00 oo- D o oO C10 cl- m - 000 z CD (-- C) on "t m co t N 00 t m 0000 0 S o00 ClO -0 00> 0 ' WC ') o C Coo o z > 0C 0e6 Ni 00 000 0 aO 00'r) -''0- C-C * C00 _N 00 0 m- 00 0 ~~~ '1-~~~~r- ~ 00- C'- t 'r)'- 0-C' 00ZrW ') 0- 0'~ C)~ _o c C) o C' _ - _ 1.4CA C) (o O C't - Clef Cl0 00 000 OCf)0 OC' 'tor 0 COC) e " --4 - ~ ~ Cf)~~f C''-00 0r- (C) '0 00 '~ ~ C)r f0 0) CA 'a + 0 C>-00 00 -- O m 0-0-m 0fC) '-C c7N O 0 -C co C-I-') 0- C- C W-I 0? C;O C,;I I ct &:> o ^ m rl \D m vo o0 o-. 0_ CD oom x a- 00 ~ ~ ~~~0 :t 0%0 Cf)n 0~0 '0 0''C) 0 Cf) cf) c0~ Or-0 0'Cf CZ W s v ? O ?~~~~~~~~~~0 t- 00 r- Ol 0 0 00 DO Up 14 06 06 ooi r- O e,; 0 00 CO ~~ 0)5 00'C)0 CD0 CD -,- CIr-2 oOO C C DCl'--0- lc CD'C)0 O- X . '(cf) E a- 5 o C-C- a _ ' 0N _0C O CD c7N ' 0rN O O\ oo(- oo a-, oo o- 0 oo oo (ON U o a- oo > 00 C1 > 0 CJ ) 9 = ~0oo -C- '0-0 C) 00- t-0 r---- Cr)0 jC C:-I - ef ?? ? - - - ? dw - C5 _ CO U > s- 0) U m' m v v
Public Health Measures and Mortality 47 4 l - 00 m - -- I C It t- -4 co -e N orl 0oo N oo T I N ON t 00 h-n Clt WC Cl - tl'- q rl --q '- c--' e Ic 00 e I Ciir om c or eO r-0 d0 N 00N 00 m e . - ov 0oON ri . .; .6 . . . .4 . * .; . .; .,6 .- . . . . c oot N m 00 C O~ Ct I n o ; -- C,; 00C ~ 4,QC Q 0l O 00 C N 0OD -CI CICI (~CI '-4- CIIN c-4 4-4 ( Cl n oo ( OR I-o r-O 00CCC) W 0I C cl.- 000 0 0 co 0000 10 On 00 "C0 C - 0 0-t N It r O N r- 00 O N q cq cq c N cq cq c N I" N cn N- ~~40 C~~~40 ~r C1 f) r- a 'IO ON C --D 4040 C1C1 lf e '00 0 0 C0 n O0 O Cr-tf~ 0 -0 O 0 r -4 t- C1 - -D CI - m - ? ? ? I ? ' m o Q 0 o ^ocEo . o ?o ~oo O>40 N o oo Wo oo m ' > oo ? o c C cn tn t- It It N Wco cq cq C - N N W) m w- -4 '0- - { -4 - - -4 1- - - 4-4 -4 - -2- - ? o Cl C, Ol 0o Ot 00 I00 cl C^ Co C1 rl) It C tt 00 00 m <7> - cn ?O r- 'I 'I %DF? N cn co N tl ? - c7 _- 1-4 N -4 'I U C)t W It lo m 't 0 0) -s o o # o o U o o z 4 o s o o S o C C o z z 0) *,00 <> ss 00 cy 00 mo< oo o cr oo o 30 C, 00 ON 0 cr 3o 00 m Ce 00 csN n 3 * 2 z S S ~~~~~~~~~~~~~~~~~~~~z z z o
48 Condran and Crimmins-Gardner CO o a'Os o (t I:t m t' 00Io- 00 0) ~ -4~1 CTh ~-4C' l ll - - ~ C 06 ( C') - 0i Oa 00 tC c m 00 rN-4 oo . 00 oo 00 c1' eNr er' e _1 - _-L rN' ;4 ON I" N ?>?uot 'IC CO C06( 000 4 -t - -~ - ri - ri It -0 -' C 0 ^ 00 0 OD O cr n C me > CmN tr t6M6 0> .,.4 -W0V -0 cr' 1) 00 c lt , ) C.) c C.) ._ un > tn 00 ? o t u O N 01 ? C 9 ca O 0 o t0 t0 00 0 ' 0 00 00 00 - 0- 0 0 c ' o - C- - - - C - 4.4 cli 06 C O 0 4f X; v ~~~~~~~~~o o o CD CD 0 C) 0 o c oo ON oo ON oo or 9L0 os co cr- m0C ^~~~~~~~~~~~~~~~~~~~~~~- --- Cl -- mN m o o io
Public Health Measures and Mortality 49 c ' 06 0 000 ~-0 0 00 6 c-~ C5 ON0 '-4 00 0'Lr W; C i o o co C, t -.. co a,- m o N o oN on o ' ur 4 ? O co 00 00OC -- C 0O e4r ?0 C0 cr c o oo- O 0000 ( O=>O 0 C e 0D 00 0 C= t ON cn cli C7N craxo oom m o o "C O \D ci 00 o o- 'N u)0 o06 ic-i mo> -: (^c 0? b O0 cN N O 0 xD0 O r > c t-00 cicW N c - N - a)~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~- W N FF ~~~to O F C, cn C,, rl- 00 C - m tn co 1 tc m e - ci*' j- m (I) 0 0 r nu t00~~~C co 00 NO rq el Itt Ct C), bO c-ic-- 00~~~ 000 00~~0 Oci ~-0 cf- 0i'9 0~ ~ II -0~ 0 c C,; c i o o 00 00 ci o - t'o N o- ON C 'IO 00 0 t '-400 elO r- -- 0 e o - ;0 C, \- , C,;r ~ r_ -- k 0 \ 6 - --4ci i -4 -4 -;0 C)~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~ )C 000N - N LON 0 CF C) -4- _ -0a ci L >o ' ci ci o o LO t '- -4 ci co oo ON oo ?, oo coo a- > co 0 ooN c0 O 0 000~ ^ -0 0 - -0 0 00-4 -0 Oy x ooQ o ?o Q Q X
50 Condran and Crimmins-Gardner olc C en O t o-n - ,o eo 0m ot 00 Mt _ w; o o 6o 00 0&4 4? 6 o 6 - o o0 o ^ do 0ci r0- ef I'* r-O e 000 t ?o tn C) c bb 00 W) en o) r- CY- ?o oo C:: O ) 00 00 It aN 00 C1 db- _% Rt t dON 00' 0 o6 O o ; o6 00 o 60 o' en en c Rt O WN I O -4 C ^- ti , O N 'C O n 0 0 N Ot (4 ') tn W) t- W) t n It cn - W) co cc r- v co o r Q 0 en O Fo 0000 r- o Wo me -I> em ro0 ~ o o-m- oo 0 6 oR e-i 6r- oC6 6C el; > m CD to Q tmo - Th e e e e - n 0- , oo . FOt tn cl C14 cn cn co ? t aEn cli C) '0 0) - 0 to 0) te -- *)00 o0 -. 64 e-~~~r ~o'o- ~ r-=- o4 a; c oRoR el -id oR cd C1 N _0 W) _ l 'I It as 00 _) o 0) ~~ 64 ~~C-i 6 c el; a' ' ; 64 CL Q 0) - - - 0) 0) 0)c0 ' N - O _ m ON d 0 o o o *oo 3o o i 0o o '0 o o 3 CO ' 0' ' '' O ' 0) ' 0) a 0) _z - -) ~~~~~~~~~~~~~~ ~~ Z Z Z
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52 Condran and Crimmins-Gardner Deaths from cancer and tumors, heart disease and dropsy, and diseases of the urinary system, as well as from old age, actually showed a substantial rise in many cities. This finding is not unexpected at the onset of mortality decline; people who live into old age are subject to just these diseases. Diseases of the liver show little change. Influenza shows a marked rise. While it is possible that an epidemic disease like influenza might show this pattern of change over time, the classification of this disease also changed over the period, and the rise may be a result of the change in classification. Diseases of the nervous system show a marked decline. This category of diseases is hard to interpret. In 1890 when data by age and cause are available, the data show a high rate of infant and early childhood mortality from this cause. The particular disease within this category which affects infants and young children is convulsions. Exactly what set of symptoms was classified as convulsions is hard to determine, and therefore de- clines in this category, while they may be important in accounting for declines in infant and childhood mortality, are particularly hard to interpret. CONCLUSIONS Previous literature had suggested that mortality declines in urban areas in the 19th century were affected by public health measures as well as by other fac- tors, such as changes in levels of living, which affected both rural and urban mortality declines. We have argued that the concept of the public health move- ment in general has little analytic value, and that analysis of the causes of the mortality decline must be done in terms of specific public health practices and their impact on specific causes of death. We have therefore looked at the con- struction of sewers and waterworks in relation to the decline in diarrheal dis- eases, cholera infantum, and typhoid, which were often transmitted through impure water. We have also considered the limited available information on anti- tuberculosis and antidiphtheria campaigns in some cities. Diarrheal diseases, typhoid, tuberculosis, and diphtheria constitute a large proportion of the mortality decline in these cities. Almost 80% of the total change in mortality in these cities is accounted for by these four disease cate- gories. If most of the decline in these diseases could be attributed to public health practices, then the role of the public health movement in the decline in urban mortality would be very large indeed. However, our analysis suggests that the impact of specific aspects of the public health measures on these dis- ease categories is by no means clear. The relationship between mortality rates and the expenditures on and the extent of sewers and waterworks is negative, but these public health measures are only weakly related to mortality rates from diarrheal diseases and typhoid, the disease categories which were most likely to be affected by them. If these measures are related to diseases whose
Public Health Measures and Mortality 53 transmission is unlikely to be affected by sewers and waterworks, then alter- native hypotheses are needed. The possibility that both mortality rates and the construction of sewers and waterworks were affected by some other variable, such as per capita income, cannot be overlooked. There are, however, severe limitations in the existing data on public health practices. Further analysis, care- fully tracing developments in the construction of sewers and waterworks and changes in the death rates in individual cities, is needed. The decline in tuber- culosis appears to be unrelated to public health activities during the 19th cen- tury. Similarly, the decline in diphtheria cannot be unambiguously related to public health campaigns. Again, additional research on programs against these diseases in individual cities is necessary. Our research has shown that the decline in urban mortality was probably somewhat affected by specific public health measures. However, the examina- tion of the declines in specific causes of death has increased our understanding of the limited role of public health measures in the decline in urban mortality. ACKNOWLEDGMENTS Valuable assistance in this research was provided by George Clark, Fran Ryan, and Richard Oliver. We are especially grateful to Richard A. Easterlin for his valuable comments. REFERENCES Crimmins-Gardner, E., and Condran, G. A. (1976). Nineteenth Century American Mortality. Paper presented at the meetings of the Population Association of America, April 1976. Dublin, L. I., Lotka, A. J., and Siegelman, M. (1949). Length of Life. Ronald Press, New York. Duffy, J. (1974). A History of Public Health in New York City, 1866-1966. Russell Sage Foundation, New York. Easterlin, R. A. (1977). Population issues in American economic history: A survey and critique. In Gallman, R. E. (ed.), Recent Developments in the Study of Business and Economic History: Essays in Honor of Herman E. Krooss, Johnson Associates, Greenwich, Connecticut. Gore, J. K. (1904). On the improvement in longevity in the United States during the nine- teenth century. In Proceedings of the Fourth International Congress of Actuaries, Vol. I, The Actuarial Society of America, New York. Meeker, E. (1972). The improving health of the United States, 1850-1915. Explorations in Economic History 9: 353-374. Meeker, E. (n.d.). Public health and medicine. In Dictionary of American History, Charles Scribner's and Sons, forthcoming. McKeown, T., and Record, R. G. (1962). Reasons for the decline of mortality in England and Wales during the nineteenth century. Population Studies 16: 94-122.
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