IJE Advance Access originally published online on August 17, 2005
International Journal of Epidemiology 2005 34(5):1163-1164; doi:10.1093/ije/dyi132
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Published by Oxford University Press on behalf of the International Epidemiological Association
Letter to the Editor |
Social capital and the history of mortality in Britain
Department of History, Essex University, Wivenhoe Park, Colchester, Essex CO4 3SQ, UK
* Corresponding author. E-mail: peter.razzell{at}clara.co.uk
There are two main areas of disagreement between Simon Szreter1,2 and ourselves,3 one concerning the evidence on mortality in the 18th and 19th centuries and the other its interpretation.
Szreter dismisses the evidence quoted in our letter, yet it is relevant to a number of themes in his original article:
- The increase in infant and child mortality in the 18th century contradicts his argument that England was a country with ‘burgeoning bridging and linking social capital’ and a ‘polity’ which was ‘the most prosperous, socially cohesive, and socially secure in Europe’ at this time.
- London was by far the most important city in England in the 19th century, and one of the main centres of industrial activity until well into the 20th century.4,5 Its life expectancy improved throughout the whole period, directly contrary to Szreter's thesis of increasing mortality in urban industrial centres.
- The decline in mortality outside the main urban areas during the second half of the 19th century is relevant to the argument about social capital: it supports the thesis of Guha as well as others that the fall in mortality was not the result of public health measures but resulted from changes in personal hygiene and other individual measures.6
One central part of Szreter's thesis is that there was a deterioration in the physical environment of large towns between the 1820s and 1870s, which was reflected in an increase in mortality and declining life expectancy. The only direct evidence that Szreter cites for large towns in the precivil registration period relates to Glasgow and Bristol. The data indicate that life expectancy in Glasgow decreased from 35 years in 1821–25 to 27 years in 1837–41, supporting his argument for this period. He also cited a life expectancy figure of 29 years for Bristol in the year 1825, and although there are no other data for the period before civil registration, expectation of life in Bristol had grown to 39 years by 1851–60, indicating a long-term increase in life expectancy contrary to his main argument.7 Additionally there is the question of the validity of the pre-1837 data on Glasgow and Bristol which were derived from contemporary Bills of Mortality, and have not been independently assessed through research based on family reconstitution.
More reliable figures become available only after 1837 with the introduction of civil registration. Szreter and Mooney have published data for three cities in the post-1841 period, Manchester, Liverpool and Glasgow, and this evidence indicates that overall mortality diminished between 1841 and 1871. Expectation of life at birth increased in Manchester from 27 years in 1841 to 31 years in 1861–70, from 28 years in 1841 to 30 years in the 1860s in Liverpool, and in Glasgow from 27 years in 1837–41 to 32 years in 1861.7 In Manchester and Liverpool there was a slight dip of one year in the 1850s, but the figures in this early period are insufficiently reliable to be confident of such slight fluctuations. Overall, the evidence does not indicate that mortality increased in large towns in the period 1841–71, contradicting a major aspect of Szreter's thesis.
An equally significant problem with the mortality data however, is its interpretation. For example, it is difficult to assess Szreter's claims about improving mortality in cities, as little detailed work has been published on the history of water supply, street cleaning and other public health measures in the 19th century. Local variations in mortality were important, and although Szreter criticizes us for neglecting the role of place in explaining mortality patterns, we have ourselves documented the importance of disease environment not just for the end of the 19th century, but for the longer period 1500–1950.8
Employing a concept, such as social capital, in the analysis of mortality further complicates the problem of interpretation. The term is abstract and highly ambiguous, involving a number of possible elements. It implies a degree of social consensus and cohesion, and Szreter explicitly refers to the importance of ‘enhanced cross-class relations.’ In fact, many medical and public health measures were implemented not as a result of a humanitarian social concern, but were due to sectional and social class interests.
This can be illustrated by reference to the history of smallpox. Parish authorities began to pay for the inoculation of their poor during the 18th century, and this was extended to the free provision of vaccination in the 19th century. Many parishes, however, refused to pay for this form of medical treatment, on the grounds of increased cost to ratepayers. In some cases, free inoculation and vaccination were provided only for the servants and nominees of the rich, and this was the case with the London Smallpox Hospital. The wealthy feared infection and insisted that in order to prevent secondary infection to themselves, their servants be either inoculated or immune through a previous attack of smallpox.
Even where public health initiatives were introduced as a result of a general concern for public welfare, this did not always mean they generated consensus and social harmony. For example, central government became so concerned about the increasing severity of smallpox epidemics that in 1853 it introduced compulsory vaccination, overriding the objections of local ratepayers and others who resented this form of compulsion and expenditure. These measures were highly effective and gradually eliminated smallpox from most communities, although eventually the government had to introduce a conscientious objection clause because of the opposition from the antivaccination movement. Vaccination was often imposed against the wishes of local communities and created conflict rather than social and political consensus; it is questionable whether the term social capital can be applied to this form of compulsory treatment.
There was a similar situation with respect to the introduction of environmental improvements in the 18th and 19th centuries. Many towns introduced improvement acts because of concern for the health and well-being of their middle class ratepayers. In London, the first improvement acts were introduced in Westminster and the City of London, and the improvement of poorer districts took place only at a much later date. Ratepayers continued to object to payment for public health measures, and during the 19th century there were frequent clashes between central and local government over the appointment of medical officers of health and other measures which involved financial expenditure.
There is, however, a more central objection to the use of the term social capital in analysing mortality history. Szreter has correctly pointed out that most of the fall in mortality did not occur as the result of economic growth, but was probably due to a variety of medical, individual, and public health improvements. Population expanded rapidly as a result of falling mortality and in the absence of full economic development in the early phase of England's economic history, created unemployment and a surplus of labour. This resulted in a range of social and political conflicts during the 19th century.
There are some similarities between the demographic history of England and the population change which has occurred in underdeveloped countries over the past 30 years. Most developing countries have experienced falls in mortality without economic development.9 Twenty-three underdeveloped countries outside sub-Saharan Africa had negative per capita income growth between 1970–75 and 2000–04. All 23 experienced significant falls in mortality during this period. Mean expectation of life at birth increased by 9 years, and child mortality fell from an average of 142 to 55 per 1000—and this was accompanied by an average decrease in per capita income of 2.4% per annum.10
Most falls in mortality in third-world countries have been the result of medical and public health interventions,11 which have led to rapid population expansion without economic development. Additionally, demographic factors have played an independent role in initiating economic change, with multinational companies exploiting third-world labour surpluses for both manufacturing industry and the service sector. These demographic and economic changes have been associated with a polarisation of wealth, with increases in relative poverty among large sections of the population.
It is inappropriate to link these developments with social capital, given the unintended consequence of growing poverty and inequality. Although humanitarian medical interventions are universally supported, it is important that epidemiology and demography as disciplines transcend narrow concepts like social capital, and develop a full understanding of the demographic, economic, and social consequences of medical and public health programmes.
References
1 Szreter S, Woolcock M. Health by association? Social capital, social theory, and the political economy of public health. Int J Epidemiol 2004;33:650–67.
2 Szreter S. Response. Int J Epidemiol 2005;34:479–80.
3 Razzell P, Spence C. Social capital and the history of mortality in Britain. Int J Epidemiol 2005;34:477–8.
4 Barnett DC. London, Hub of the Industrial Revolution. London: Tauris, 1998.
5 Hall P. The Industries of London Since 1861. London: Hutchinson, 1962.
6 Guha S. The importance of social intervention in England's mortality decline: the evidence reviewed. Soc Hist Med 1994;7:89–113.[Abstract]
7 Szreter S, Mooney G. Urbanization, mortality, and the standard of living debate: new estimates of the expectation of life at birth in nineteenth-century British cities. Econ Hist Rev 1998;51:84–1122.[CrossRef]
8 Razzell P, Spence C. Poverty or disease environment? The history of mortality in Britain 1500–1950. In: Breschi M, Pozzi L (eds). The Determinants of Infant and Child Mortality in Past European Populations. Udine, Italy: Forum 2004.
9 Preston S. The changing relation between mortality and level of economic development. Popul Stud (Camb) 1975;29:231–48.
10 Human Development Reports, 2004. United Nations Development Programme.
11 Caldwell J. Routes to low mortality in poor countries. Popul Dev Rev 1986;12:171–220.
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  S. Szreter Author's Response Int. J. Epidemiol., October 1, 2005; 34(5): 1164 - 1165. [Full Text] [PDF]
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