University of Cambridge, St John's College, Cambridge, CB2 1TP, UK. E-mail: srss{at}cam.ac.uk
The commentary by Davey Smith and Lynch is of a different kind from the others and requires a separate response, from Simon Szreter alone, since it is almost entirely devoted to a critique of Szreter's historical work on the chronology of mortality and health change in 19th century Britain. The key claim, which Davey Smith and Lynch wish to advance, is that it is wrong to place the primary emphasis on the 1870s and on the political and social events associated with that decade as comprising the most important causes of the modern mortality decline in Britain. They assert that it is the decade of the 1850s, instead, which saw the true origins of a continuous secular fall in the nation's mortality and that we should therefore examine the political and social events associated with that decade as being of primary significance in causing the modern mortality decline. Closely associated with their claims for this revized chronology, they believe that a dynamic process of cohort-improvement in health should be given much greater prominence. They claim that the historical evidence indicates that this process of cohort improvement commenced in England and Wales with the birth cohort of the 1850s.1
The thesis of cohort improvement, as deployed by Davey Smith and Lynch, is essentially the same as in its original formulation, by Kermack et al. in their paper of 1934, which Davey Smith and Lynch cite approvingly as an authority.2 Using national aggregate data for the populations of England and Wales, Scotland, and Sweden, Kermack et al. argued that in each case, once a process of continuous nationwide mortality decline was underway, successive birth cohorts exhibited a lower age-specific mortality, as they aged, than each of their predecessors (though the theory was acknowledged not to apply to ages under 5 and it was conceded that Sweden did not fit the pattern very neatly). Thus, in Scotland, the national birth cohort born in the 1880s had a lower age-specific death rate at ages 1020 during the 1890s than those born in the 1870s had had during the 1880s; and in the 1900s they experienced a lower age-specific death rate at ages 2030 than the cohort born 10 years earlier had experienced when they were aged 2030 (though this, of course, was in the previous decade of the 1890s); and so on. Kermack et al. and Davey Smith and Lynch believe that this observable pattern shows that the early conditions of health in childhood are formative of a significant proportion of the subsequent health and mortality experience of the cohort in question. They approvingly cite Kermack et al.'s conclusion that the expectation of life was determined by the conditions which existed during the child's early years.1
While I have no doubt that conditions in early life must be important, I also think that many other factors can also be of great importance in explaining the subsequent health experience of a cohort. I do not see the statistical patterns elucidated by Kermack et al. as being uniquely interpretable in their chosen way. It seems to me to be at least as plausible to argue that the cohort improvement pattern they observed may be produced by the effect of the successively improved current conditions which each birth cohort experienced as it aged, due to the net effects of the accumulating extension of public health measures and rising living standards that occurred. In other words the fact that the 1880s birth cohort in Scotland experienced lower age-specific mortality during the 1890s, when aged 1020, than did the 1870s birth cohort when they were aged 1020 during the 1880s, could just as logically be attributable to the fact that environmental conditions on average throughout Scotland were significantly superior from a health point of view in the 1890s than they were in the 1880s, and that this affected most of those alive at these age ranges in a roughly proportionate manner. In subsequent decades the continuation of accumulating investment in public health technology and services, along with rising living standards, would have successively benefited other age groups rising up the age range from the late childhood and early adulthood ages of 530, where natural vitality is typically at its maximum (i.e. age-specific death rates are at their minimum), to produce beneficial effects on higher and higher age groups, where it is harder and harder to win mortality improvements and where it requires more and more investment and better living standards, eventually even succeeding in achieving mortality reduction effects on the two extremes of the age range, infancy and old age, where viability is typically at its minimum and mortality at its maximum.
According to this thesis of accumulating current or period effects, rather than cohort effects (to use the demographers' conventional distinctions), what is of critical importance in accounting for the modern mortality decline is not the original event of triggering an improvement in a birth cohort's early conditions of life, which will then stay with them throughout their lives as a cascading sequence determining their continuing superiority over earlier birth cohorts at all subsequent ages. Rather, what is important is sustaining, decade after decade, a continual upward investment by society in an increasing range of all the complex of environmental conditions (including improved quality and quantity of food) and services, which will ensure that each decade the current, somatic environment of individuals in the population will be improved, in health terms, relative to the previous decade. I am sure that both cohort and period effects were occurring throughout Britain at the time in question. It is not, in my view, a case of one interpretation being entirely correct and the other wholly false. However, neither do I think that the two effects are necessarily approximately equal in their relative importance in all times and places. In my judgement, when taking into account all the evidence we have available, it was the accumulating period effects, which were much more important than the cohort effects in explaining the timing and the principal causes of mortality decline in the latter half of the 19th century in Britain.
This judgement is partly due to my evaluation of the wide range of available forms of historical evidence which I have presented in various previous articles, drawn from my own research and that of other scholars who have worked with the historical primary sources and which I will not rehearse in detail again here.3 However, it is also because I remain sceptical of the cohort effects model, in the strong and dominant form as argued for by Kermack et al. and by Davey Smith and Lynch. I believe that, despite the allure of Kermack et al.'s diagonal lines (which are in fact rather more wavy than they should be), there are a number of important anomalies in the historical evidence which tell against its plausibility, and also that it is a rather more chronologically slippery proposition than might at first sight appear to be the case.
Chief among my reservations is the problem that a theory which asserts that the health of the man is determined predominantly by the physical constitution which the child has built up1 lacks some credibility if the vital initial months and years of infancy and early childhood are to be excluded from the theory because of the awkwardness that the data flatly contradict the theory's requirements. While Davey Smith and Lynch may reproduce Kermack et al.'s ingenious, diversionary attempt to explain (in a purely proximate sense) this glaring anomaly in the evidence, with the argument that infant and early child health could not improve until that of the mothers' had improved, this still leaves the theory with a gaping self-contradictory hole in it. Why should health after age 4 improve when it has failed to do so under this age, when, according to the theory, health improvements at higher ages are built upon those occurring at earlier ages? It is also, of course, indisputable that a major reason for the stubbornly high infant mortality of late 19th century Scotland and England was not maternal physiology but persistently high rates of summer diarrhoea in unhygienic working class homes. There is a rich and fascinating literature which continues to explore various behavioural and environmental reasons for this and why the public health arsenal was unable to prevent mortality at this age.48 Thus, while the anomaly of persistently high infant and late-declining early childhood mortality poses no necessary logical problem for the period effects model of mortality decline, it constitutes a fundamental theoretical self-contradiction within the cohort model, requiring the improvization of invoking subsequent improvements in maternal health as the source of improvements in early childhood mortality. However, it should also be noted that Kermack et al.'s special explanation looks extremely vulnerable in light of the anomalous trends in maternal mortality itself, which, as Irvine Loudon has shown, scandalously failed to fall for several decades after the late fall in infant mortality.9
A second major reservation relates to the much vaunted patterns of cohort regularities in the national data sets used by Kermack et al. These are nothing like so exact or general as the proponents of the theory would have us believe they are. Bernard Harris's judicious survey of the literature points out that two recent studies of the Swedish data, though also favouring a version of the cohort effects model, came to almost diametrically opposite conclusions to those of Kermack et al., arguing for a close relationship between rates of infant and early childhood mortality suffered by a birth cohort and the levels of mortality of the same cohort in old age, while rejecting any strong relationship with the rates of mortality prevailing across the middle of the age range.10 Harris also points out that the kinds of cohort effects which describe the patterns of age-specific rates of mortality decline in 19th century England and Wales do not match those which the most recent work of the Cambridge Group for the History of Population has identified as characterising the generally falling mortality of the 18th century (when child mortality rose for two-thirds of that century at the same time that adult mortality rates were falling).10 And it has long been acknowledged that the cohort effects model does not appear to operate as an accurate description for Scotland or for England and Wales beyond the 1930s.
Thus, there is little in the way of compelling cross-cultural evidence to support the notion that the cohort effects model might reflect some general, biological principles regarding the ways in which changes in population health must unfold. It remains no more than a suggestive set of approximate descriptive regularities, which appear to apply to the aggregate populations of England and Wales and of Scotlandbut not Swedenduring a period of the later 19th and early 20th centuries.
A third problem is that far from offering precision, there is in fact an irredeemable element of chronological slipperiness in the claims of the cohort approach as applied to 19th century England and Wales, since its thesis is that improvements are carried by a birth cohort but that the cohort does not unambiguously manifest any improvements until the age of 59. Thus, in claiming that the birth cohort of the 1850s in England and Wales carried the beginnings of modern mortality decline, it is not clear whether Davey Smith and Lynch are therefore claiming that the relevant improvements in the underlying causes happened exactly simultaneously from the beginning of the 1850s, or perhaps during the decade or so prior to the 1850sso that this cohort was the first to benefit from those changes; or is it being implied that the causal changes did not really manifest themselves until the 1860s, since the average date of birth of the 1850s birth cohort would have been 1856 and the cohort approach accepts that the effects do not occur until the cohort reaches the age of 5? This would seem to license claims for any one of three decades, from the 1840s to the 1860s, as encompassing the crucial turning point, which marks the origins of the modern mortality decline.
Finally, the chronology of emphasizing the 1850s does not make sense when we triangulate with all the range of other relevant historical evidence we have at our disposal. Davey Smith and Lynch certainly review several of the kinds of historical evidence which are relevant for this evaluation, such as real wages, nutrition and heights, child labour, women's work, family size, and housing, as well as three individual causes of death. However, their review of the historical evidence on many of these important items is less than persuasive.
There are of course many individual causes of death, which could be evaluated in relation to the cohort effects thesis and the associated chronological claims, however it is agreed that respiratory tuberculosis was the single biggest killer in the mid-nineteenth century so it is important for any general interpretation of mortality decline to show that it can offer a plausible account of this disease's changing incidence. Davey Smith and Lynch are absolutely right to emphasize the significance of the precise aetiology of this disease, namely that most of its fatalities derive from secondary reactivation, not primary infection with the tubercle bacillus. However, they draw from this fact the one-sided inference that therefore improvements in early life circumstances should be reflected in TB mortality at a later age. This fails to address the completely alternative inference, which I put forward in my original contribution to this debate, and for which there is strong confirmatory evidence in William Farr's analysis of the 19th century urbanrural comparative epidemiological record.11 This is that TB was essentially a scavenger disease, killing by a secondary breakdown attack once an individual was in a weakened state, and therefore its changing fatality rate depended on changes in the current, overall pathogenic and stress load (including disease, over-work, poor housing, and repeated pregnancy for women) on the population in question.
Turning to Davey Smith and Lynch's review of our knowledge of the wider range of contextual factors, I also find their summaries of the evidence partial and misleading in important respects. For instance, the principal point about the real wage evidence is that it does not correlate at all well with any chronology of mortality decline, either nationally, or when disaggregated. Whereas national mortality levels improved during the second half of the 18th century, aggregate real wages failed to show any trend rise. At just the point when all economic historians are agreed that the national wage trend began a sustained gradual upward trend, c.1815, national mortality ceased to improve for half a century. If we disaggregate, the discrepancy becomes even more acute, since Feinstein's figures, showing only a moderate rise in national average real wages, 18151845, include the sluggish agricultural sector of the workforce. The trend rise after c.1815 would be more pronounced if only the higher-paid, urban industrial workers' wages were consideredyet this is just the section of the population who experienced an actual deterioration in mortality at this time, not simply the absence of further improvement.12
The decline of child labour is certainly a plausible candidate for an important development associated with improved child health. However, the state of knowledge is less certain than Davey Smith and Lynch suggest. Due to its very variable recording in census and other sources, trends in the changing incidence of child employment are very difficult to be certain of before 1870, when the state finally legislated for universal and compulsory elementary education (and even then it took several further acts and decades to make this a reality).13 Davey Smith and Lynch, citing the research of Horrell and Humphries, would like to enter a special plea that we look upon the 1850s as a decisive moment in child labour trends. This is as good a suggestion as any other, but the truth is that we simply do not know if there was such a decisive shift in any particular decade; if there was, the current state of evidence only allows us to say that it is unlikely to have been prior to the 1830s and the last plausible date would be the 1870s. Similarly with working mothers, it is extremely difficult to achieve any certainty on the trends because of varying perceptions and definitions of what constituted female work. For instance, as late as 18741908 it is known that there was a marked rise in the numbers of exploited female home-workers in a wide range of industries, as an unintended consequence of the Factory and Workshops Acts of the 1870s, which brought small workshops under the same protective obligations and inspection system as factories.14 This resulted in small employers out-sourcing their work to women in their own homes, rather than employing them in the small workshops which fell within the law's restrictions, creating the notorious sweated labour problem, only finally resolved by the creation of the first minimum wage legislation with the Wages Boards of 1908.15 Overall, Jane Humphries' tentative conclusion in this area is that:
... perhaps ... women's activity rates moved down in two stages from the peaks experienced during industrialisation, first towards the middle of the nineteenth century; and then again from 1871. As it stands, the data cannot rule this out.16Turning to fertility, Davey Smith and Lynch state that a decline in fertility began in the 1830s. However, the chronology is more complex. We have robust estimates of trends in the Gross Reproduction Rate (GRR) showing that while it fell from a historic peak rate in the 1810s down to 1846, it then rose again from 1846 until 1876, before decisively falling from 1876 until the 1940s, when GRR reached the relatively low levels that have since persisted through the remainder of the 20th century. A national trend towards smaller family size did not commence until the 1870s, although two distinct social groups, the predominantly southern professional middle class and some workers in branches of the midland and northern textiles industry, started to restrict fertility earlier than this.17
As to housing, while it is true that there was some early legislation in the 1840s, the authority whom Davey Smith and Lynch cite was distinctly unimpressed with the effectiveness of these measures. His overall judgement in his major textbook on the subject is as follows:
Some control over the spatial aspects of housing was, therefore, beginning in some towns in the middle decades of the century, though it was partial, irregular and often evaded. Important extensions of building control came in the last quarter of the century.18Surprisingly, Davey Smith and Lynch do not mention urban water supply. There is certainly a good case to be made for a substantial improvement in the quantity of water supplied to Britain's industrial towns in the decade of the 1850s, following the passing of the nation's first Public Health Act in 1848, which enabled towns to apply for subsidized loans to build sanitary and water facilities. The gross deficiency in urban water supply of the previous two decades was undoubtedly a major contributor to the appalling levels of mortality which had prevailed. However, as John Hassan has carefully shown, this increased supply, though benefiting the population incidentally by virtue of its partial alleviation of a truly desperate prior situation, was in fact mainly driven by commercial motives and industrial needs.19 There was no attempt by town councillors to extend domiciliary connection of water services to the working classes and certainly no effort to construct the arterial sewers systems that such dispersed connection would require. As with the question of enforcement of building regulations, we do not find towns undertaking the expense of sewering and domiciliary connection until the last three decades of the 19th century.
Thus, although sheer urban over-crowding was never worse than in the 1830s and 1840s, as was the egregious deficiency of the urban water supplies in those two decadesnevertheless, the extremely half-hearted, and under-funded remedial measures, which this desperate situation elicited in the late 1840s, only alleviated the plight of the manufacturing populations during the ensuing two decades. The activities of the 1850s and 1860s did not amount to a serious and effective strategy for producing absolute improvements and enhancement in the urban populaces' health, but only the cheapest means possible to try to avoid the worst inconveniences of absolute water shortages and the scares of cholera.
This, then, is why I am not persuaded by Davey Smith and Lynch that, on the basis of the historical evidence currently available, we should reconceptualize the 1850s as the key turning point in the mortality history of modern England and Wales, rather than the 1870s. It is certainly true, as they state, that the important civil unrest and campaigns of the second quarter of the 19th century, notably the movement for parliamentary reform and for the Charter, were significant in wringing concessions from the incumbent governing elite. In his influential revisionist article on Chartism, Gareth Stedman Jones argued that the movement was killed off by parliament's timely symbolic gestures towards radical interests, notably including the Repeal of the Corn Laws in 1846 and the passing of the Public Health Act in the face of cholera in 1848.20 However, the key point is that neither the working class nor the bourgeoisie possessed at this time a coherent dynamic vision and an effective programme for the material and cultural improvement of urban society as a whole. Such notions were deemed to be the province of utopian dreamers, such as Robert Owen, at this time. The primary class aims in the political contests of the 1840s were the assertion of claims to adult male independence as grounds for political enfranchisement, on one side, and the denial of admission to this privileged status on the other, while offering enough concessions to maintain peace and order.21,22
However, a generation later, after the ideological watershed of the 1860s,23,24 such dreams of progress for the urban multitude, dressed up in the rhetoric of the civic gospel, or gas and water socialism as its detractors came to call it, could become the articulated, practical political programme of a leading section of the provincial liberal bourgeoisie themselves, requiring extremely serious and escalating levels of self-taxation on their whole class to achieve it.25 It is hard to overstate how unimaginable or ludicrous this would have seemed to the hard-nosed, rate paying shopocracy of England's towns in the 1850sthose who firmly rejected the central government's attempt in 1848 to dragoon them into paying to implement Chadwick's sanitary Idea.26 There is no doubt that ongoing working class pressure for social change was both a crucial condition for the subsequent transformation in the bourgeois social imagination and that working class involvement in the birth of municipal socialism was a direct one. It was the patient working class strategy of self-organization and trade union discipline which won them the vote from an impressed governing class in 1867 and it was this mass of new, non-property-owning working class voters to whom Chamberlain's revolutionary ward-level of local Liberal party organization was designed to appeal, with its novel programme of municipal spending (of ratepayers' money)as I emphasized in the original publication, where I presented this account of the Birmingham story.27
While I can agree with Davey Smith and Lynch on the importance of working class self-organization and advocacy as an irreplaceable part of the complex story, I could not agree that working class political expression, alone, provides a satisfactory account. Elites also matter; their changing ideals and their precise structure and their internal divisions, as well as the nature of their relationships with other classes in society, need to be examined carefully in our accounts of large-scale social, economic, and epidemiological change. The concept of social capitalbut only if including recognition of the importance of linking as well as bonding and bridging forms of social capitaloffers the promise of an inter-disciplinary communication tool with which to address, with various methodologies, the problematic nature of these intra and inter-class relationships and the quite profound influence which they can have both on the process of political formulation of public health policy and on the effectiveness of the delivery of practical measures in different times and places. And, as Davey Smith and Lynch acknowledge in a back-handed way, it may also assist with studying the complexnot infrequently inverserelationship between domestic and colonial policies towards population health.28 But that is anotherand importantstory.29
The focus here has been on the health of the population residing in Britain in the 19th century. Thinking in terms of social capital helps explain what went so wrong in the 1830s and why the 1850s represented only an alleviation of those problems, not a solution, whereas the 1870s constitutes the birth of something very newa practical programme engendered by a new configuration and imagination of the social and political relationships between the classes composing a citynew forms of social capital.
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