ESCAPE FROM HUNGER AND PREMATURE DEATH

ESCAPE FROM HUNGER AND PREMATURE DEATH - The Escape from...

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Unformatted text preview: The Escape from Hunger and Premature Death, 1700—2100 EUROPE, AMERICA, AND THE THIRD WORLD Robert William Fogel The University of Chicago and National Bureau of Economic Research ' ' CAMBRIDGE UNIVERSITY PRESS XX ACKNOWLEDGMENTS Walgreen Foundation, the National Bureau of Economic Research, and the University of Chicago. I am indebted to Jesse Ausubel, Bernard Harris, and Paul Waggoner, who read the penultimate draft and made many helpful suggestions. I am grateful to a number of publishers and individuals for their permission to reproduce diagrams and to republish parts of my own or jointly authored work. I would like to thank John Kim for allow- ing me to reprint Figures 5.1 and 5.2 from his dissertation and the University of Chicago Press for permission to reprint Figures 2.3 and 2.4 from Costa and Steckel 1997. Most of pages 67-—79 origi- nally appeared in R. W Fogel, “Economic and social structure for an ageing population,” Philosophical Transactions of the Royal So- ciety of London, series B, 352 (1997): 1905-17. The section “Fore- casting health care costs in China and other Third World countries” in Chapter 4 is a revised version of pages 7—10 of Robert W. Fogel, “Forecasting the demand for health care in OECD nations and China,” Contemporary Economic Policy 21 (2003): 1—10, © West- ern Economic Association International. Chapter 5 was published previously as Robert W. Fogel and Chulhee Lee, “Who gets health care?” Daedalus 131, no. 1 (2002): 107—17, © 2002 by Robert W Fogel. I would like to thank Chulhee Lee for allowing me to use material that he coauthored in this book. Part of the Appendix orig~ inally appeared as the note to Figure 3 on p. 34 of Robert William Fogel, “New sources and new techniques for the study of secular trends in nutritional status, health, mortality, and the process of aging,” Historical Methods 26 (1993): 5—43, © 1993 Robert W. Fogel; that note was written primarily by John Kim. Tables A2 and A3 appeared in the same article and were computed by John Kim. Katherine A. Chavigny and Susan E. Jones bore the brunt of the editorial work on these lectures, which included not only numerous suggestions for improvements in style but also most of the work on the citations. Katharine J. Hamerton also assisted in the editorial process. Ruma Niyogi prepared the Glossary and the Biographical Notes. The various drafts were typed by Marilyn Coopersmith, Karen Brobst, and Pat Mackins-Morrow. _. m fl~ a,,w.~.,...-.......,..,-,~,. New“ gnaw?“ .. t... wmw~ ~'~<v~—. aw >WW, Mn»w.~r-..ww~w~ an The Persistence of Misery in Europe and America before 1900 he twentieth century saw major improvements in the human condition, not only in the rich countries of the world but also in developing nations. Nothing has been more remarkable, how— ever, than the extension of life expectancy, which has increased by about 30 years since 1900 in England, France, and the United States and in equal or larger amounts in such countries as India, China, and Japan. Among the nations of the Third World, the rate of improvement has been nearly twice as fast as among the nations in the Organization for Economic Cooperation and Development (OECD) (see Table 1.1). What is responsible for this unanticipated extension of human life? That question has occupied some of the best minds of the past century in both the social sciences and the biomedical sciences, and it is also the central question of these chapters. The drive to explain the secular decline in mortality did not begin until about World War I because it was uncertain before that time whether such a decline was in progress. There was little evidence in the first four official English life tables covering the years 1831—80 of a down- ward trend in mortality. Although the signs of improvement in life 1 2 THE ESCAPE FROM HUNGER AND PREMATURE DEATH, 1700—2100 Table 1.1 Life Expectancy at Birth in Seven Nations, 1725—2100 (both sexes combined) 1725 1750 1800 1850 1900 1950 1990 2050? 2100? England 32 37 36 40 48 69 76 or UK France 26 33 42 46 67 77 U.S. 50 51 56 43 48 68 76 (87) (98) Egypt 42 60 India 27 39 59 China 41 70 Japan 61 79 Sources: For England 1725—1850: Wrigley and Schofield 1981; 1900: average of figures for 1896 and 1905 in Case et al. 1962. For France 1750: computed from Tables 13 and 14 for 1740—49 in Blayo 1975a, p. 140; for 1800, 1850, and 1900: Bourgeois—Pichar 1965, pp. 504—5 (figures for 1805—7, 1850—52, and 1900-2). For the United States 1725—1850: Fo— gel 1986, p. 511 (males only; shifted to 30" using Coale and Demeny 1966, West life tables); for 1900: Bell, Wade, and G055 1992. For India 1900: Carr-Saunders 1964 (figure is for 1931). For all countries 1950: Keyfitz and Flieger 1990; for 1990: World Bank 1990, 1992. Figures in parentheses for 2050 and 2100 are projections for these years based on the analysis of Oeppen and Vaupel (2002). expectancy became more marked when the fifth and sixth tables were constructed, covering the 18805 and 18905, few epidemiol— ogists or demographers recognized that England was in the midst of a secular decline in mortality that had begun about the second quarter of the eighteenth century and that would more than dou— ble life expectancy at birth before the end of the twentieth century. During the last decade of the nineteenth century and the early years of the twentieth century, attention was focused not on the small de- cline in aggregate mortality, but on the continuing large differen- tials between urban and rural areas, between low— and high-income districts, and among different nations} The improvements in life expectancy between 1900 and 1920 were so large, however, that it became obvious that the changes were not just a random perturbation or cyclical phenomenon. Sim- ilar declines recorded in the Scandinavian countries, France, and other European nations made it clear that the West, including Canada and the United States, had attained levels of survival far beyond previous experience and far beyond those that prevailed, elsewhere in the world.2 THE PERSISTENCE OF MISERY IN EUROPE AND AMERICA BEFORE 1900 3 The drive to explain the secular decline in mortality pushed research in three directions. Initially, much of this effort revolved around the construction of time series of birth and death rates that extended as far back in time as possible in order to determine just when the decline in mortality began. Then, as data on mortality rates became increasingly available, they were analyzed in order to determine factors that might explain the decline as well as to establish patterns or laws that would make it possible to predict the future course of mortality. Somewhat later, efforts were undertaken to determine the re— lationship between the food supply and mortality rates. Between the two world wars, the emerging science of nutrition focused on a series of diseases related to specific nutritional deficiencies. In 1922 shortages in vitamin D were shown to cause rickets. In 1933 thi— amine deficiency was identified as the cause of beriberi, and in 1937 inadequate niacin was shown to cause pellagra.3 Although the en- ergy required for basal metabolism (the energy needed to maintain vital functions when the body is completely at test) had been es— timated at the turn of the century, it was not until after World War II that estimates of caloric requirements for specific activi- ties were worked out. During the three decades following World War 11, research in nutritional sciences conjoined with new find- ings in physiology to demonstrate a previously unknown synergy between nutrition and infection and to stimulate a series of Stud- ies, still ongoing, of numerous and complex routes through which nutrition affects virtually every vital organ system.4 The effort to develop time series of mortality rates also took an enormous leap forward after World War II. Spurred by the develop— ment of high—speed computers, historical demographers in France and England developed new time series on mortality from bap— tismal and burial records that made it possible to trace changing mortality from 1541 in the case of England and from 1740 in the case of France.5 Two other critical sources of data became available during the 19705 and 19805. One was food-supply'estimates that were de— veloped in France as a by—product of the effort to reconstruct the pattern of French economic growth from the beginning of the 4 THE ESCAPE FROM HUNGER AND PREMATURE DEATH, 1700-2100 Industrial Revolution. Once constructed, the agricultural accounts could be converted into estimates of the output of calories and other nutrients available for human consumption through a tech- nique called “National Food Balance Sheets.” Such estimates are currently available for France more or less by decade from 1785 down to the present. In Great Britain the task of reconstructing the growth of the food supply was more arduous, but estimates of the supply of food are now available by half century from 1700 to 1850 and by decade for much of the twentieth century.6 The other recent set of time series pertains to physique or body builds - height, weight, and other anthropometric (bodily) mea- sures. The systematic recording of information on height was ini- tially an aspect of the development of modern armies, which be- gan to measure the height of recruits as early as the beginning of the eighteenth century in Sweden and Norway and the middle of the eighteenth century in Great Britain and its colonies such as those in North America. The measurement of weight did not become widespread in armies until the late 18605, after the development of platform scales. However, there are scattered samples of weights that go back to the beginning of the nineteenth century. During the 19605 and 1970s, recognition that data on body builds were important indicators of health and mortality led to the system- atic recovery of this information by economic and social historians seeking to explain the secular decline in mortality.7 These rich new data sources supplemented older economic time series, especially those on real wages (which began to be con— structed late in the nineteenth century) and real national income (which were constructed for OECD nations mainly between 1930 and 1960). These new sources of information about human wel- fare, together with advances in nutritional science, physiology, de— mography, and economics, form the background for these chapters. Before plunging into my own analysis and interpretation of this evidence, however, I want to summarize the evolution of thought about the causes of the secular decline in mortality. Between the late 19305 and the end of the 19605 a consensus emerged on the explanation for the secular trend. A United Nations THE PERSISTENCE OF MISERY IN EUROPE AND AMERICA BEFORE 1900 study published in 1953 attributed the trend in mortality to four categories of advances: (1) public health reforms, (2) advances in medical knowledge and practices, (3) improved personal hygiene, and (4) rising income and standards of living. A United Nations study published in 1973 added “natural factors,” such as the de- cline in the virulence of pathogens, as an additional explanatory category.8 A new phase in the effort to explain the secular decline in mor- tality was ushered in by Thomas McKeown, who, in a series of papers and books published between 1955 and the mid-19805, challenged the importance of most of the factors that previously had been advanced for the first wave of the mortality decline. He was particularly skeptical of those aspects of the consensus expla- nation that focused primarily on changes in medical technology and public health reforms. In their place he substituted improved nutrition, but he neglected the synergism between infection and nutrition and so failed to distinguish between diet and nutrients available for cellular growth. McKeown did not make his case for nutrition directly but largely through a residual argument after having rejected other principal explanations. The debate over the McKeown thesis continued through the beginning of the 19808.9 However, during the 19703 and 19803, it was overtaken by the growing debate over whether the elimination of mortality crises was the principal reason for the first wave of the mortality decline, which extended from roughly 1725 to 1825. The systematic study of mortality crises and their possible link to famines was initiated by Jean Meuvret in 1946. Such work was carried forward in France and numerous other countries on the ba— sis of local studies that made extensive use of parish records. By the early 19705, scores of such studies had been published covering the period from the seventeenth through the early nineteenth centuries in England, France, Germany, Switzerland, Spain, Italy, and the Scandinavian countries. The accumulation of local studies pro- vided the foundation for the view that mortality crises accounted for a large part of total mortality during the early modern era, and that the decline in mortality rates between the mid-eighteenth and 6 THE ESCAPE FROM HUNGER AND PREMATURE DEATH, 1700—2100 mid-nineteenth centuries was explained largely by the elimina— tion of these crises, a View that won widespread if not universal support.10 Only after the publication of death rates based on large repre- sentative samples of parishes for England and France did it become possible to assess the national impact of crisis mortality on total national mortality. Figure 1.1 displays the time series that emerged from these studies. Analyses of these series confirmed one of the im- portant conclusions derived from the local studies: Mortality was far more variable before 1750 than afterward. They also revealed that the elimination of crisis mortality, whether related to famines or not, accounted for only a small fraction of the secular decline in mortality rates. About 90 percent of the drop was due to the reduction of “normal” mortality.11 In discussing the factors that had kept past mortality rates high, the authors of the 1973 United Nations study of population noted that “although chronic food shortage has probably been more deadly to man, the effects of famines, being more spectacular, have received greater attention in the literature.”12 Similar points were made by several other scholars, but it was not until the publication of the Institut national d’études démographiques data for France and the E. A. Wrigley and R. S. Schofield data for England that the limited influence of famines on mortality became apparent. In chapter 9 of the Wrigley and Schofield volume, Ronald Lee demon- strated that although there was a statistically significant lagged re- lationship between large proportionate deviations in grain prices and similar deviations in mortality, the net effect on mortality after five years was negligible.” Similar results were reported in studies of France and the Scandinavian countries.14 The current concern with the role of chronic malnutrition in the secular decline of mortality does not represent a return to the belief that the entire secular trend in mortality can be attributed to aisingle overwhelming factor. Specialists currently working on the problem agree that a range of factors is involved, although they have different views on the relative importance of each factor. The unresolved issue, therefore, is how much each of the various factors THE PERSISTENCE OF MISERY IN EUROPE AND AMERICA BEFORE 1900 7 (a) CDR 1500 1600 1700 l 800 l900 2000 Time (b) CDR 1500 1600 I700 1800 1900 2000 Time Figure 1.1 Secular Trends in Mortality Rates in England and France. (3) England 1541—1975. (b) France 1740—1974. Note: CDR = crude death rate, which is computed as the total deaths in a given year divided by the midyear population and multiplied by 1,000. Each diagram shows the scatter of annual death rates around a 25-year moving average. On sources and procedures, see Fogel 1992, notes to Table 9.1. 8 THE ESCAPE FROM HUNGER AND PREMATURE DEATH, 1700-2100 contributed to the decline. Resolution of the issue is essentially an accounting exercise of a particularly complicated nature that in- volves measuring not only the direct effect of particular factors but also their indirect effects and their interactions with other factors. I now consider some of the new data sources and new analytical techniques that have recently been developed to help resolve this accounting problem.” The Dimensions of Misery during the Eighteenth and Nineteenth Centuries It is now clear that although the period from the middle of the eigh- teenth century to the end of the nineteenth has been hailed justly as an industrial revolution, as a great transformation in social or- ganization, and as a revolution in science, these great advances brought only modest and uneven improvements in the health, nu- tritional status, and longevity of the lower classes before 1890. Whatever contribution the technological and scientific advances of the eighteenth and nineteenth centuries may have made ultimately to this breakthrough, escape from hunger and high mortality did not become a reality for most ordinary people until the twentieth century. This point can be demonstrated by looking first at the amount of food available to the typical worker in England and France during the eighteenth and early nineteenth centuries. Because at that time food constituted between 50 and 75 percent of the expenditures of laboring families, improvement in the conditions of their lives Should have been evident in their diets. However, Table 1.2 shows that the energy value of the typical diet in France at the start of the eighteenth century was as low as that of Rwanda in 1965, the most malnourished nation for that year in the tables of the World Bank. England’s supply of food per capita exceeded that of France by several hundred calories but was still exceedingly low by current standards. Indeed, as late as 1850, the English availability of calories hardly matched the current Indian level. .. awn-w 2,... firmwmmama , T a... w ‘am‘wmwaa r , ...._/.,.w.w.iw.. v“:WWn-‘wflfi‘wnf‘vfim-KW'WWM.saw, «vrwgwaa 9 THE PERSISTENCE OF MISERY IN EUROPE AND AMERICA BEFORE 1900 Table 1.2. Secular Trends in the Daily Caloric Supply in France and Great Britain, 1700—1989 (calories per capita) ~ 7' Year France Great Britain 1700 2,095 1705 1,657 1750 2,168 1785 1,848 1800 2,237 1803-12 1,846 1845—54 2,480 1850 2,362 1909—13 2,857 1935—39 2,975 1954—55 2,783 3,231 1961 3,170 1965 3,355 3,304 1989 3,465 3,149 M— Source: Fogel, Floud, and Harris, n.d. The supply of food available to ordinary French and English families between 1700 and 1850 was not only meager in amount but also relatively poor in quality. In France between 1700 and 1850, for example, the share of calories from animal foods was less than half of the modern share, which is about one-third in rich nations. In 1750 about 20 percent of English caloric consumption was from animals. That figure rose to between 25 and 30 percent in 175 0 and 1 800, suggesting that the quality of the English diet in- creased more rapidly than that of the French during the eighteenth century. However, although the English were able to increase their diet in bulk, its quality subsequently diminished, with the share of calories from animals falling back to 20 percent in 185 0.16 One implication of these low—level diets needs to be stressed: Even prime-age males had only a meager amount of energy avail- able for work. By work I mean not only the work that gets counted in national income and product accounts (which I will call “NIPA work”), but also all activity that requires energy over and above 10 THE ESCAPE FROM HUNGER AND PREMATURE DEATH, 1700-2100 baseline maintenance. Baseline maintenance has two components. The larger component is the basal metabolic rate (or BMR), which accounts for about four—fifths of baseline maintenance. It is the amount of energy n...
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