Scientific explanations come in many different forms, and can be roughly classified in two types: explanations of ‘how’ certain things occur, and explanations of ‘why’ they occur. In the previous chapters, we have mainly focused on the ‘how’, but have already started to address some ‘why’-type questions, for example when we related the rise of public hygiene to the Enlightenment, and the reversal in the trends of syphilis to the sexual revolution of the 1960s. But in this chapter we will do this in a more systematic way, along two lines. We will first try to understand why, over the past three centuries, European population health has improved so much. Is it possible to identify a ‘prime mover’? After that, we will use a few special cases – countries that did remarkably well, or remarkably badly – to understand why the European experience has been so diverse. How did economic, political and sociocultural factors combine to produce this diversity? For example, is there a deeper explanation for the consistently good performance of the Swedes, and the consistently bad performance of the Russians?1
Why Did European Population Health Improve?
The Rise and Fall of Disease
The trends of most diseases reviewed in this book have followed a ‘rise-and-fall’ pattern. Most diseases which were common at one point in time were much less frequent in previous centuries. As we have noted above in Chapters 2 and 3, this clearly suggests an exogenous or environmental origin. Equally remarkable is the fact that most diseases have at some point in their history started to decline, which suggests that humans have usually succeeded in counteracting whatever caused the previous rise.2
The time-scale at which such a pattern of ‘rise-and-fall’ manifested itself varied between several millennia (as in the case of infectious diseases which became endemic after the Neolithic or first agricultural revolution, and only were pushed back during the 20th century) and two decades (as in the case of the aids epidemic in which incidence started to rise in the early 1980s and already started to decline in the 1990s and early 2000s). In the long run, delays between rise and decline have become shorter, with the case of aids being an extremely successful example, suggesting that collective human action to reduce the incidence (or case fatality) of disease has become more effective over time.
That ‘rise-and-fall’ is the usual time-pattern in which diseases afflict human populations must have a deeper explanation. Why have, in the course of human history, so many diseases emerged? Why have, on the other hand and with shorter or longer delay, most of these diseases become less common again, or at least become less lethal? And is there a causal link between the disappearance of one disease and the emergence of another?
The history of specific diseases shows that the emergence of new diseases is often linked to changes in human behaviour. These can bring existing health risks from elsewhere (as in long-distance trade that resulted in a “confluence of disease pools”), or enhance existing health risks (as in the case of increasing population density), or create entirely new health risks (as in the case of introduction of industrial modes of production). The fundamental cause here is that improving their living conditions often requires humans to undertake activities beyond earlier boundaries on their behaviour, and sometimes allows them to indulge in new forms of behaviour, which are only later shown to be health-damaging.3
Fortunately, the history of specific diseases also shows that after some time they often retreat or become less severe. This is sometimes the result of the self-limiting character of a disease (as in the case of some infectious diseases which over time have become less lethal), but more often a side-effect of human development. Human development is associated with reductions in health risks, because better living conditions on balance and unintentionally reduce health risks, and – equally importantly – create the means for intentionally reducing health risks. That human development is associated with a
That human history is littered not only with rises followed by declines, but also with declines of one set of diseases followed by rises of another set of diseases, is not a coincidence either. Disappearance of one set of diseases may be followed by the emergence of another set of diseases due to various mechanisms. There may be mutual antagonism of the micro-organisms or vectors involved. There may be increased survival to an age at which these other diseases strike. Or changes in behaviour or living conditions that help to avoid one disease give rise to another, as in the case of diseases of poverty being replaced by diseases of affluence.4
In any case, trends in ‘aggregate’ population health are the net result of rises and falls of many specific health outcomes. Over time, rises and falls of specific health risks occur continuously, and improvements in ‘aggregate’ population health can only occur when declines of health risks exceed the concurrent increases. The improvement of ‘aggregate’ population health over the past three centuries can therefore also be seen as the result of a favourable change in the balance between ‘rising’ and ‘falling’ diseases.
The Role of Human Agency
In Chapter 1, when we introduced the debate about the role of public health and medical care in the long-term decline of mortality, we proposed a five-point scale for the degree of intentionality of population health improvements. This scale goes from entirely ‘spontaneous’ to completely ‘intentional’, with several shades of grey in-between. Where on this scale should the factors involved in the more than 30 ‘falls’ of disease reviewed in the previous chapters be placed?
Entirely spontaneous improvements, resulting from changes in living conditions that happened without any human involvement, have been rare, and most of these cases are also disputed. Some of the ‘health problems of pre-industrial societies’ may have diminished spontaneously. It has been suggested that the end of the ‘Little Ice Age’ contributed to a reduction in the frequency
Similarly, declines in virulence may have contributed to the decline of some ‘health problems of industrializing societies’, particularly tuberculosis and various streptococcal infections. On the other hand, we have found no examples of (putatively) spontaneous declines in the ‘health problems of affluent societies’. Spontaneous changes are difficult to prove or disprove, but even if they have occurred their contribution to over-all mortality decline can only have been modest, in view of the small number of health conditions in which they may have played a (partial) role.
Changes in human behaviour or man-made changes in living conditions which simply occurred, and were not pursued for reasons directly or indirectly related to health – our lightest shade of grey – have also sometimes made a contribution. Some cultural changes should probably be classified in this category. It is likely that the ‘civilizing process’ led to the adoption of more hygienic habits for reasons completely unrelated to health. Similarly, the decline of cigarette smoking may partly reflect a reversal of the symbolic value of smoking for ‘social distinction’, which might also have occurred if the health risks of smoking had not been discovered.
Other examples are changes in food conservation methods, which led to a reduction of the salt content of food, and the shift from an industrial to a service economy, which reduced exposure to hazardous work. However, while some of these changes may have contributed to population health improvement, at least as many have contributed to (temporary) health deteriorations, and it would be difficult to defend the idea that the net effect of all these changes has been positive.
Changes in human behaviour or man-made changes in living conditions which were actively pursued, but for reasons only indirectly related to health, may well form a much larger category than the previous two. Famine, one of the main ‘health problems of pre-industrial societies’ and an important cause of large-scale epidemics, has disappeared as a result of the (second) agricultural revolution. Although Europeans have probably never aimed for higher harvest yields in order to reduce their risk of infectious disease, their active drive to eliminate hunger did nevertheless have that effect.
Several ‘health problems of industrializing societies’ declined as a result of fertility control. Again, Europeans did not limit their family size in order to reduce the risk of infection, but mainly for reasons that are only indirectly related to health, such as greater family welfare and increased educational
The fourth category, changes in human behaviour or living conditions which were achieved by public health interventions have also been very important in the decline of many diseases. Among the ‘health problems of pre-industrial societies’, these contributed to the decline of famine (public grain-stores and famine relief), plague (various measures of epidemic containment), smallpox (vaccination campaigns), typhus (promotion of personal hygiene and vector control) and malaria (irrigation of marshes and vector control).
Among the ‘health problems of industrializing societies’, respiratory infections declined partly as a result of improvements in housing which were pursued, not only to provide people with more comfortable lodgings, but also as part of public health policies. Sanitation measures succeeded in eliminating cholera and other diarrheal diseases. Regulation of prostitution contributed to the decline of syphilis, and pasteurization of milk to the decline of intestinal infections. Public health measures were essential in the decline of pellagra, rickets and goitre, and even more so in the decline of the pneumoconioses.
More recently, public health interventions have continued to make important contributions to the decline of ‘health problems of affluent societies’. Tobacco and alcohol control measures have contributed to the decline of ischaemic heart disease, lung cancer and liver cirrhosis, screening programs to the decline of breast cancer mortality, and road traffic safety measures to the decline of road traffic injury.
However, over time the relative importance of individual patient care has also grown strongly. Medical care already made a contribution to the decline of malaria (quinine), and its contributions became more substantial towards the decline of many ‘health problems of industrializing societies’. This included the decline of tuberculosis, syphilis, childhood infections, pneumonia, nutrient deficiencies, peptic ulcer and appendicitis (surgery, antibiotics, antisera, substitution therapy, …). Medical care even was the dominant factor in the decline of maternal and late foetal mortality (obstetric care).
Finally, as we have seen in the previous chapters, the recent declines in cardiovascular disease, cancer and several other ‘health problems of affluent societies’ would have been impossible without improvements in prevention and treatment of these conditions. As mentioned in Chapter 3, it has been estimated
It seems, then, that we can safely conclude that the improvement of population health over the past three centuries is mostly due to ‘human agency’, and even to ‘intentional human agency’ (the third, fourth and fifth positions of our scale of intentionality).
The Role of Public Health and Medical Care
Table 2 is an attempt to summarize the above, and to more specifically apportion credit for population health improvements in Europe to public health and medical care. It includes the same health conditions as Table 1, with the exclusion of those which even in North-western Europe have not (yet) gone in decline (diabetes, depression, dementia). It combines an overview of the contributions of public health and medical care to each health condition, with an estimate of the contribution of each health condition to total mortality decline.5
Before we look at the contents of this table, it is important to note some of its limitations. First of all, it is the result of what is often euphemistically called a ‘heroic’ exercise. Quantitative estimates of the effect of public health and medical care on the decline of specific diseases are scarce, and in many cases the percentage contribution of specific diseases to total mortality decline is rather uncertain. This is why the data are presented in a semi-quantitative mode, using symbols to indicate broad outcome ranges. It is all we have – better than nothing, but far from ideal.
A second limitation is that the contributions to over-all health improvement only include the contributions to mortality decline, thus ignoring effects on the health of the living population. It may well be that the contribution towards mortality decline of, for example, medical care is different from that towards morbidity decline – but we don’t know. Furthermore, the health conditions in the table (i.e., the specific health conditions reviewed in this book) only represent about two-thirds of total mortality in the 19th and 20th centuries. The rest is taken up by other specific conditions (e.g., acute bronchitis, other heart diseases, Chronic Obstructive Pulmonary Disease, other accidents, …) and by ill-defined causes of death.
The main benefit of Table 2 is that it allows us to identify the diseases that were important for mortality decline in different ‘stages’ of the epidemiologic transition, and then to again try to compare the relative importance of public health and medical care. Although contributions to mortality decline could not be calculated for the first stage, in which the ‘health problems of pre-industrialized societies’ were tackled, the table clearly shows that public health was far more important in this stage than medical care.
In the second stage, represented in the table by the 1870–1950 period, a few infectious diseases dominated European mortality decline. Intestinal infections, tuberculosis, and four childhood infections each accounted for between 10 and 25% of total mortality decline. For the decline of these diseases, public health interventions were considerably more important than improvements in medical care, although medical care also made a contribution.
In the third stage, represented by the 1960–2015 period, ischaemic heart disease dominated European mortality decline, accounting for more than 25% of total mortality decline. Cerebrovascular disease comes second in importance, and is (surprisingly) followed by three conditions that already declined in the second stage: pneumonia, infant mortality, and stomach cancer. Both public health measures and medical care were important in the decline of these conditions. There was less evidence for a contribution of ‘other changes’ in this period as compared to the previous two stages.
These results show that, over time, medical care has become much more important for mortality decline, but that over the three centuries covered by this book public health has been the most important of the two. This is all the more likely when we take into account that mortality decline in the second stage, in which public health was clearly more important than medical care, was considerably greater than in the third stage. Between 1870 and 1950, mortality declined from ca. 2500 to ca. 1100 deaths per 100,000 in Europe as a whole. Between 1960 and 2015, age-standardized mortality declined from ca. 1200 to ca. 600 per 100,000 – still a considerable decline, but less (in absolute terms) than in the earlier period.
The Rise of the West: Was There a ‘Prime Mover’?
Why did the increase of life expectancy, and many other improvements in population health, start in Europe (and its offshoots in North America and Oceania), and why did it, within Europe, start in the North-west? And was there a ‘prime mover’, i.e., a single factor present in North-western Europe that can be held responsible for the whole train of changes that produced these health improvements?
This is a question that – for a similar phenomenon, namely economic growth – has been discussed extensively in the historical literature. The title of this section, The Rise of the West, refers to a book by historian William McNeill, in which he tries to explain how over the past few centuries Western civilization gradually achieved global dominance. Why ‘the West’ took such an enormous economic lead over the rest of the world, has occupied historical sociologists, economic historians, as well as comparative political scientists. A brief
Most authors agree that, somewhere in the deepest layers of causality, physical geography must have played a role. North-western Europe has a moderate climate which keeps tropical parasites away, and which produces abundant rainfall throughout the year that allows agriculture without large-scale irrigation – a technical solution which has elsewhere in the world allowed extractive social hierarchies to emerge. It also lies far away from the Eurasian steppes from which nomads could come to periodically destroy whatever had been built up.
Furthermore, it has many small river valleys which fostered the emergence of small and competing political units, instead of one all-powerful centre of power, and it has a long coast-line which made it easy to transport goods and people. Under its surface also lie abundant stores of coal. Within Europe, North-western Europe gained the upper hand when trans-Atlantic trade could be developed, because they were in a better position than countries bordering on the Mediterranean.7
But the complete story is, of course, considerably more complex than a simple sum of the hard facts of physical geography. For the fact that the Industrial Revolution started in North-western Europe, to be more precise: in England, economic historians have offered several explanations, in addition to proximity of trans-Atlantic trade routes. (The latter provided higher levels of prosperity from the 16th century onwards, and therefore facilitated many other developments.)8
A first stream of analysis has emphasized the role of institutions. Political decentralization, with many smaller political units and the early rise of
After 1700 there was a strong increase in the involvement of European governments in the economy, with tax reforms, legislative changes and investments in infrastructure promoting economic growth. This again happened earlier and more forcefully in North-western Europe, where ‘mercantilism’ was popular, than in Southern, South-eastern and Eastern Europe. The question then remains, of course, why these institutional changes happened earlier in North-western Europe than elsewhere – a question that physical geography cannot completely answer.9
Another stream of analysis has emphasized technological change as an important determinant of the transition to modern economic growth. A revolution in agricultural methods, based on rational experimentation, preceded the Industrial Revolution in the 17th century in England (and in the Dutch Republic). The increase in agricultural productivity subsequently freed labour for industrial production, and led to financial profits which allowed investments in industry. Also, some of the early breakthroughs in manufacturing, such as the invention and further development of the steam engine in the 18th century, and many of the later advances in industrial production methods had never been possible without the scientific advances of the 17th and 18th centuries.
However, although technological changes were necessary to realise growth in economic productivity, many of the breakthroughs in manufacturing in the 18th and 19th centuries were not based on scientific breakthroughs, but on advances in the application of lower-grade knowledge, e.g., by better communication and collaboration. Changes in the organisation of knowledge gathering and diffusion, by creating learned societies and re-organizing universities, also played a role. All these advances in science and technology and their
A third stream of analysis has focused on ‘human capital’, in the form of literacy, numeracy, and other economically useful human abilities. There is evidence that relatively high levels of literacy preceded the transition to modern economic growth in North-western Europe (cf. Figure 8). This suggests that this factor facilitated several of the other changes mentioned above, including institutional change (because educated people are more likely to strive for democracy) and technological change (because educated people are better in inventing and applying new modes of agricultural and industrial production). The gradual rise of levels of education may also have stimulated the acquisition of more general skills, such as discipline, punctuality, respect and ‘industriousness’. But why was North-western Europe more literate to start with?11
Economic historians have not agreed on one general explanation for the start of modern economic growth and its spread across Europe. Most of them seem to agree that the explanation lies in the beneficial interaction (‘co-evolution’) of many different factors, between which important feedback loops have operated. For example, growth-promoting institutions are more likely in a literate society, but economic growth will also allow investments in education which further promote literacy. The explanation also appears to be context-dependent, with different countries following different paths to a similar end result. Such variation in explanatory pathways is to be expected when the ultimate outcome, prosperity, is partly determined by goal-oriented human agency: when one pathway to growth was impossible or did not work, European countries tried another one.12
As I am not an economic historian, I am reluctant to propose a ‘prime mover’ of economic growth. Nevertheless, reading this literature it is almost inevitable to point to developments in the realm of ‘thinking’ as the ‘nec plus ultra’ of explaining the start of modern economic growth, or – to return to the main topic of this section – improvements in population health. It seems to me that an increase in rational thinking is a common factor that underlies the institutional changes, the technological changes and the changes in literacy and levels of education.
In a long process that accelerated in the pre-modern period, during the Renaissance and Reformation, the people of North-western Europe developed a more rational outlook to life, which was less clouded by tradition and superstition. This led to the ‘Age of Reason’ in the 17th century and the ‘Age of Enlightenment’ in the 18th century, and along the way these changes in ‘thinking’ resulted in the changes mentioned above that promoted economic growth as well as improvements in population health.
That this happened in North-western Europe may have been conditioned by geographical and long-standing cultural factors, but what changed was the way of thinking, and this occurred in an autonomous process in which one step logically followed another. If it can be shown that the sun does not circle around the earth, as previously assumed, but that the earth revolves around the sun, many other received wisdoms may be false as well. If it can be shown that the reasoning on which the absolute power of monarchs rests is false, we can also start to think that all men are equal. If it can be shown that some city districts have much higher mortality rates than others, we may begin to believe that some deaths can be prevented.13
Why Did Some Countries Rush Ahead or Lag Behind?
As has been abundantly illustrated throughout this book, there have been large variations between European countries in the ‘rise-and-fall’ of diseases, but it is difficult to get a clear picture of these differences in chapters organized on a disease-by-disease basis. We will therefore now reassemble some of the information on a country-by-country basis, to discover why some countries were
These countries were identified by inspecting – again – some Preston-curves. As will be remembered from Chapter 3, it was not until the first decades of the 20th century that a positive relationship between national income and life expectancy emerged. However, Sweden, Norway and Denmark already had higher-than-average life expectancy in the last decades of the 19th century, and Sweden persisted in having a high life expectancy throughout the 20th century, also relative to its rapidly rising national income. Norway and particularly Denmark performed less well, and we will therefore focus on the ‘Swedish advantage’.
Another country that did remarkably well, but over a much shorter period, is the Netherlands. It had below average life expectancy in the 1870s (among the few European countries that already collected mortality data), but rapidly moved ahead of most other countries to achieve a much higher life expectancy than predicted by its national income from the 1920s to the 1960s. Thereafter, the Netherlands lost its championship. Why did the Dutch not manage to keep up with the Swedes?
The Mediterranean countries also followed remarkable trajectories. Over the course of the 20th century, Spain, Portugal, Italy and Greece switched from being in the rear-guard to being front-runners in life expectancy. For example, Spain had lower life expectancy than predicted by its national income in the first half of the 20th century, but this changed into higher-than-predicted from the 1960s onwards. Life expectancy among Spanish women recently even surpassed that among Swedish women. Can these trends, and those for other Mediterranean countries, be understood from their economic, political and sociocultural history?
South-eastern Europe also contains a few big surprises. Many countries in this part of the subcontinent have struggled to keep up with other European countries, both economically and health-wise. However, Albania, despite a history of underdevelopment under Turkish rule, and despite severe repression under communist rule, managed to have higher life expectancy than countries with a similar national income since the 1980s. The Albanian experience will therefore be highlighted in a separate section, together with (former) Yugoslavia.
Finally, during the second half of the 20th century (data for the first half are often lacking) countries of the former Soviet Union have performed much worse than accounted for by their lower-than-average national incomes. This
Northern Lights: the Swedish Advantage
In this book, Sweden has often been used as a bench-mark for other countries. This was partly because of the convenience of having a country with data on population health going back to the 18th century, but mostly because of Sweden’s consistently better performance in population health than almost all other European countries.
Many examples of this extraordinary performance have been shown in previous chapters. In the early 19th century, Sweden was an early adopter of large-scale and compulsory smallpox vaccination. In the latter part of the 19th and first half of the 20th century, it was early and exceptionally successful in reducing infant and maternal mortality. Throughout the 20th century, Sweden’s recruits grew in height in advance of those of many other countries. And in the second half of the 20th century, Sweden was early and successful in bringing down ischaemic heart disease and motor vehicle injury mortality. This has not gone unnoticed, and there is a relatively large English-language literature on the history of population health in Sweden, with Swedish experts trying to explain to the outside world how this has been possible.14
Sweden started to have ambitions for the health of its population in the 18th century, under the influence of the Enlightenment and mercantilism. In Sweden these ambitions may have arisen more acutely than in other countries, because it had lost its large empire in the Great Northern War, and had become aware that its small population size was a liability. Population registers were established in the 1720s, and parish priests were ordered to regularly report the number of births and deaths, as well as the size and composition of the population they served (Plate 17). In order to compile and analyse these data, Tabellverket, the predecessor of Statistics Sweden, was created in 1749.15
Sjukdomarna [Diseases] registered by a parish priest in Varnhem, Sweden, 1773
Starting in the mid-18th century, Swedish parish priests had to register the causes of death of their deceased parishioners, and to report these regularly to “Tabellverket.” For classification they could use a pre-printed list of diseases. This plate reproduces two pages from the “kirkebok” [church book] of Varnhem, a small municipality in the South of Sweden. “Rödsot” [dysentery] was the most frequent cause of death in the months covered by these pages. Collection Swedish Digital Archives (Arkivdigital, https://www.arkivdigital.net). Reproduced with permission
The data were carefully studied by statisticians and medical scientists, and results were discussed in Swedish parliament where they gave rise to enlightened health policies, such as the creation of a system of provincial doctors who not only served the poor but also acted as officers of health. The scope of
All these measures contributed to early and strong improvements in population health, but so they did elsewhere in Europe. One additional reason why Sweden gained an advantage on other countries during the 19th century is that Sweden had a somewhat deviant pattern of industrialization. Unlike Great Britain and other industrializing countries in Western Europe, Sweden remained rural during most of the 19th century, even during the first phases of its industrialization, and this protected it from some of the high urban mortality of the early industrializers.16
Sweden subsequently managed to keep its population health advantage when, during the 20th century, infectious diseases and infant mortality were replaced by ‘diseases of affluence’ and middle- and old-age mortality. It was far from obvious that this would happen: several other countries, such as the Netherlands and Denmark, lost their pre-war advantage in the 1960s and 1970s because they were less successful in coping with the smoking epidemic than they had been in coping with puerperal fever and other pre-war health problems.17
Sweden’s continued advantage cannot be simply due to an effective public health infrastructure that was already in place. In the second half of the 20th century, all countries including Sweden had to innovate their public health infrastructure to cope with cardiovascular disease, motor vehicle injuries and other ‘diseases of affluence’. They had to develop new forms of expertise, new forms of organization, and new rationales for government intervention. It also was not simply a matter of prosperity: although Sweden is among the richest European countries, it has throughout the 20th century performed better than predicted by its national income.18
To understand Sweden’s consistent advantage we therefore need to identify the conditions which helped Swedish society to cope effectively with a range of different health problems over more than two centuries. At first sight, political factors seem to be a good candidate. In the 16th and 17th centuries, Sweden had a large empire in Central-eastern and Eastern Europe, based on military might, and this left a relatively strong state apparatus with a competent bureaucracy. Somehow, in contrast to the Danes and the Dutch, the Swedes also accepted the state to be present in their lives, which must be based on the experience of a consistently benign state that can be expected to act for the benefit of all.19
During the 20th century, the remarkable success of Sweden’s Social-Democratic Party, which has governed for decades in a row, may also have played a role. Many of Sweden’s successes in the fight against (diseases of) poverty as well as ‘diseases of affluence’ have been enacted by Social-Democratic governments. Comparative analyses show that across Europe there is a positive association between left-wing government and indicators of population health, as well as with health policies in the areas of tobacco and alcohol control. But if left-wing politics would be the explanation of the Swedish success, the next question should be: why do the Swedes vote for left-wing parties?20
At second sight, therefore, it seems likely that cultural factors also play an important role in Sweden’s remarkable health achievements. One aspect to this may be Lutheranism: historically, almost all Swedes were Lutherans, and although Sweden now is one of the most secularized countries in Europe, the Lutheran church is still very present. As explained in Chapter 3, over the last centuries Protestantism in Europe has been associated with several factors
This is an explanation shared by many observers of the Swedish health advantage, but Sweden has been more successful than other Protestant or Lutheran countries, so this can – again – not be the entire explanation. And why have the Swedes become Lutherans in the first place? At a certain point in history, i.e., the foundation of the Swedish (Lutheran) Church in the last decades of the 16th century, this was a choice that could have been made differently.22
Present-day studies of cultural values, such as Inglehart’s two-value system of ‘secular-rationalism’ and ‘self-expression’, show Sweden to occupy an extremely advanced pole of the European cultural spectrum. This suggests that deeper cultural differences than those captured by religious affiliation are involved as well. My best guess is that the secret of Sweden’s health advantage lies in the combination of a specific political legacy with a very ‘enlightened’ culture.23
On a final and more pragmatic note, it is important to acknowledge that more shallow explanations also go some way in explaining Sweden’s success. On at least two occasions, Sweden has been simply lucky. The first was when Sweden could remain neutral in two World Wars, partly because of its geographical position aside from the main European conflict zones between the great continental powers. This saved it from destruction and was even highly profitable, because Sweden could export massive amounts of iron ore for use in the German weapons industry. Tactful foreign policy also played a role in
The second piece of good luck is that Sweden has ‘snus’, a form of smokeless snuff tobacco that, when inserted under the upper lip, releases nicotine but carries far fewer health risks than smoking cigarettes or using other forms of smoked tobacco. Snus was invented in the early 1800s and became very popular in Sweden, probably because it could easily be used during manual labour. It was the most popular form of tobacco use until the 1940s when it was overtaken by the cigarette, but when the harmful effects of smoking became known in the 1960s, use of snus rose again, partly as an aid to quit smoking.
As a result, lung cancer mortality in Sweden has peaked at a considerably lower level than in many other European countries, which has contributed importantly to Sweden’s continued health advantage in the latter parts of the 20th century. Although the state has not been entirely absent in this story, and has regulated the contents of snus thereby ensuring its harmlessness, this is again difficult to explain otherwise than as a piece of good luck.25
Dutch Comfort: We Were the Champions
Most Continental-European countries did less well than the Nordic countries during most of the 19th and 20th centuries, with two exceptions: the Netherlands and Switzerland. In terms of life expectancy, the Netherlands did extremely well during the first half of the 20th century, and actually was the record holding country in some single calendar-years up to the early 1960s. However, it later fell back to second rank, due to stronger stagnation of life expectancy than that observed in other European countries. (The other exception, Switzerland, also came from second rank in the 19th century, but its life expectancy rose almost uninterruptedly during the 20th century, and ultimately surpassed that of Sweden at the end of the century.) What explains the remarkable performance of the Netherlands in the first half of the 20th century, and its falling behind in the second half?26
In the 19th century, the Netherlands had unfavourable indicators of population health. The West of the Netherlands had very high mortality, which was already well-known in the 18th century. According to British demographer Thomas Malthus (1766–1834), Holland was “Germany’s grave” because so many German immigrants found their untimely death in this country. This dismal situation contrasted sharply with the country’s glorious past: in the 17th century, the Dutch Republic had been the most prosperous, enlightened and powerful country in North-western Europe. Religiously inspired schooling campaigns during and after the Dutch Revolt (1568–1648) had also raised literacy levels to record heights (Figure 8). However, in the early 18th century the Dutch Republic lost its dominant position in world trade to Britain, and the resulting decline of its economy was further aggravated by the damage done by the Napoleonic Wars in the early 19th century.27
In more specific terms, the high level of mortality in the Netherlands during the 19th century was probably due to a combination of high population density and lack of good drinking water, which both increased the risk of infection. Public health measures were also slow to develop in the Netherlands. This situation changed around 1870, when infant mortality started to decline, probably more as a result of cultural change (e.g., the spread of modern concepts of hygiene and infant care) than as a result of economic growth. High levels of literacy – a remnant of the country’s glorious past – may have facilitated these rapid improvements.28
In the first half of the 20th century, trends in life expectancy were still strongly determined by trends in infant mortality. Due to a remarkable decline of infant mortality to record-low levels in the 1930s, Dutch life expectancy jumped up. This favourable situation continued until the early 1960s, and as this did not go unnoticed in the rest of the world, public health experts from the Netherlands were asked by the US government to explain this remarkable success. They concluded that
the favourable situation in the Netherlands reflects a long tradition of basic infant care in the family, aided by district nurses and welfare centres and supported by social security measures and a rising standard of living.
Although not explicitly mentioned in this report, we have seen in Chapter 5 that the Netherlands also was an early adopter of a national system of well-trained midwives.29
Accepting these factors as at least a partial explanation, we may then want to ask how the Netherlands – still behind the more advanced European countries in the third quarter of the 19th century – managed to join the Scandinavian countries at the top of the European rank-list. Part of the explanation is that, as suggested in the quotation given above, the Dutch economy indeed grew very rapidly, both before, during and immediately after World War I. This was due to a combination of factors, including the fact that it benefited from rapid economic growth in its immediate hinterland and main trading partner, Germany.30
However, rapid economic development is certainly not the only explanation, because levels of infant mortality and life expectancy in the Netherlands during the 1920s were far more favourable than can be accounted for by its level of prosperity. Like in Sweden, cultural factors played a role as well, but the state was less central to population health improvements in the Netherlands in the first half of the 20th century. Since the 1880s, the ‘pillarization’ (verzuiling) of Dutch society, i.e., the organization of social life in separate Protestant, Roman-Catholic, Socialist and Liberal ‘pillars’, stimulated a successful ‘civilization offensive’ within each ‘pillar’, covering all aspects of life including infant care. ‘Private initiative’ also created separate public health and health care organizations within each ‘pillar’. At the same time, consensus seeking between
“Social-democratic party demands state pension.” Dutch election poster, 1929
Like social-democratic parties in other European countries, the Dutch Labour party advocated state intervention to create a system of social security for workers, including a system of state-funded old-age pensions. A state pension was finally introduced in 1947 by Willem Drees (1886–1988), the first Labour prime minister in the Netherlands. The translation of the Dutch text at the top is: “Old. Expelled,” and that at the bottom: “sdap [Social-Democratic Labour Party] demands state pension.” Poster created by Albert Hahn Jr. Collection International Institute of Social History (Amsterdam). Reproduced with permission
Unfortunately, the Netherlands lost its advantage in the 1980s and 1990s, when a complete stagnation of mortality decline occurred in some age-groups in the Netherlands, while other high-income countries continued their rapid mortality declines. This happened both among the very young (perinatal mortality) and among the very old (80+). Although the over-all performance of the Netherlands remained well above the European average, this was cool comfort to those who believed the Netherlands to be capable of something better.
The obstetric professions at first attributed the high levels of perinatal mortality to more complete registration in the Netherlands than elsewhere, but this position became untenable with the publication of carefully harmonized figures which confirmed that the Netherlands compared unfavourably with other European countries. More detailed studies then found that stagnation of perinatal mortality decline resulted from lack of progress in perinatal care. This was due to the fact that a system that relied on midwives was less capable of absorbing new high-tech diagnostics and interventions. This suggests that the competitive advantage that the Netherlands had enjoyed in an earlier phase of mortality decline, had turned into a disadvantage in a later phase. When the government was finally convinced that something needed to be done, a government commission was installed that recommended better integration of extramural and intramural obstetric care.32
Stagnation of mortality decline among the elderly resulted partly from lack of progress in reducing smoking, which had reached extremely high levels among the cohorts dying in the 1980s and 1990s, partly from budgetary restrictions in the health care system. Interestingly, a similar stagnation of mortality decline among the elderly occurred around the same time in a small number
One common factor between the Netherlands and Denmark is the high prevalence of smoking. The Netherlands and Denmark share a history of small trading nations in which a tradition of libertarianism developed in conjunction with the requirements of free trade. In the Netherlands, the idea that everyone should be free to smoke was also strongly stimulated by the national tobacco industry, which used to be one of the largest in Europe. This libertarian trait has helped the Netherlands to develop rational policies in controversial areas like heroin treatment, aids prevention and euthanasia, but clearly also has its disadvantages.34
Southern Miracles: from Rear-guard to Forefront
One of the most remarkable features of the history of population health in Europe is that Southern European countries have moved from the rear-guard, having very low life expectancies in the late 19th and early 20th centuries, to the forefront, having very high life expectancies in the last decades of the 20th century. With a life expectancy at birth of around 40 years at the beginning of the 20th century, Spain, Portugal, Italy and Greece lagged far behind countries in Northern and Western Europe, but in a spectacular catch-up movement reached similar life expectancy levels as North-western European countries in the 1960s, and then surpassed many of them in the 1980s.
A somewhat similar trend can be seen for national income and other indicators of socioeconomic development. Southern European countries were late industrializers, and had a relatively low national income at the beginning of
That rising living standards were not the only factor in the rapid rise in life expectancy in Southern Europe is also clear when we plot European countries’ life expectancies against their national incomes in a series of successive Preston-curves. Southern European countries were ‘under-performers’, as compared to what could be expected on the basis of their level of economic development, in the beginning of the 20th century. However, they became ‘over-performers’, doing substantially better than expected, at the end of the century. What explains this puzzling phenomenon?
As we have seen in the disease-specific chapters above, in the first decades of the 20th century Southern European countries clearly lagged behind Northern and Western European countries in the decline of infectious diseases as well as in infant mortality. Mortality rates from smallpox, typhus, malaria, tuberculosis, syphilis, diphtheria, pneumonia – to name but a few – which had already declined in the North and West, were still high in Spain, Portugal, Italy and Greece. The decline of infant mortality also started later. This suggests that these countries were late in taking countermeasures against these health conditions.36
Unfortunately, a comparative history of public health covering all European regions has never been written. However, national histories of public health in, for example, Spain and Portugal show very clearly that large-scale measures to control the infectious diseases just mentioned only started after the turn of the century, i.e., with a considerable delay as compared to Northern and Western
For example, a history of public health in Spain suggests that the birth of public health took place in the first two decades of the 20th century – indicating its late arrival. It is only in this period that the first large-scale sanitation measures were taken and that the first large campaigns against smallpox, tuberculosis and syphilis were held. In the 1930s and 1940s these campaigns were continued and broadened to include ancylostomiasis (hookworm disease) and malaria, with important assistance from the Rockefeller Foundation.37
In Portugal, public health similarly started in the first years of the 20th century, when after a small outbreak of bubonic plague in and around the harbour city of Oporto, the ‘father of Portuguese public health’, Ricardo Jorge (1858–1939), was appointed Inspector-Geral de Saúde in Lisbon. Acutely aware of the backwardness of his country in the fight against infectious diseases, he led campaigns against influenza, smallpox, typhus and diphtheria in the 1920s.38
The reasons for the delays in public health, as well as in economic development, of Southern Europe must be sought in previous centuries. Throughout the 19th century, and into the 20th century, these countries were low in human resources: levels of literacy were much lower than in Northern and Western Europe (Figure 8 and Plate 19). Even in 1975 20% of the Portuguese population
Map of illiteracy levels in Europe, 1930
This map, from a book on Europe’s population in the Interbellum produced for the League of Nations, shows the very high levels of illiteracy in Southern, South-eastern and Eastern Europe persisting into the early 1930s. For most European countries, the data on illiteracy, defined as the inability to both read and write, were taken from a population censusDudley Kirk, “Europe’s population in the interwar years” (Princeton: Office for Population research, 1946). Reproduced with permission
Southern European countries were also held back in their development by long histories of autocratic government. These had installed extractive institutions that did little to promote economic growth, and were supported by a conservative Roman-catholic church which did little to promote social change. Nevertheless, around the turn of the 20th century Spain, Portugal and other
A recently published analysis of long-term trends in mortality in Spain concludes that the “conquest of health” in this country during the first half of the 20th century was due in large part to the modernization of public and private hygiene. This involved modernization of the sanitary infrastructure (but only in the cities – rural areas had to wait till the second half of the century), dedicated campaigns to get rid of epidemic diseases (e.g., obligatory smallpox vaccination, drainage of marshes, pasteurization of milk), and campaigns to improve infant care (e.g., education to promote breast-feeding, creation of a system of health visitors).41
One of the remarkable aspects of the 20th century history of population health in Southern Europe is, that some of the most dramatic improvements were achieved under autocratic or even fascist governments. For extended periods, autocratic governments replaced democratic governments in Spain, Portugal, Italy and Greece. In Spain, a bloody Civil War (1936–1939) replaced the Second Republic by an authoritarian nationalist government under General Francisco Franco, who stayed in power until 1975. The Civil War left deep traces in the health of the Spanish population, both in the form of hundreds of thousands of direct casualties, and of a resurgence of infectious diseases and nutrient deficiencies. Together, these caused a deep dent in Spain’s rising life expectancy curve (Figure 1).42
Despite this catastrophe, however, population health improvement resumed in the 1940s, at an even more rapid speed than before the Civil War. As some observers have noted,
undoubtedly, this is one of the most shocking and most ‘remarkable’ findings [of our analysis], because it relates above all to the mortality effects of the population policy of the Franco dictatorship.
Although this and other dictatorships in Southern Europe had a stifling effect on many other developments, they did often engage in large-scale health
Miraculously, after having finally pushed back mortality from infectious diseases, Southern European countries experienced much less of a rise in ‘diseases of affluence’, particularly ischaemic heart disease, than Northern and Western European countries. This is the immediate explanation for the puzzling fact that life expectancy in Southern Europe did not only catch up with, but even surpassed life expectancy in the North and West in the last third of the 20th century.44
As we have seen in Figure 22, mortality from ischaemic heart disease peaked early and at an extremely low level in Southern Europe. This is, however, likely due to a lucky coincidence, and not to superior health policies. Late economic and social ‘modernization’ of these countries also implied a delay of the ‘modernization’ of dietary and other consumption habits. One important factor is the Mediterranean diet. Mediterranean diets are rich in components which are cardioprotective: monounsaturated fats (in olive oil, nuts), omega-3 polyunsaturated fatty acids (in fat fish, vegetables, nuts, plant oils), and a variety of antioxidants (in fruits, vegetables, wine, olive oil), etc. This nutritional pattern could still commonly be found in Spain, the South of France, Italy, Dalmatia, and Greece in the 1950s and 1960s, but has more recently been eroded by the ‘westernization’ of life-styles which has accompanied economic progress and European integration.45
The fact that these traditional diets could still be observed in the 1950s and 1960s can at least partly be explained from the economic ‘backwardness’ of these countries, as compared to most countries in Northern and Western Europe. The frugality of the Mediterranean diet probably was partly a necessity: bread, pasta and vegetables (instead of meat), fruits for dessert (instead of cakes and ice-creams), and green leaves picked in the wild were cheap solutions for the hardship that lasted into the 1950s and 1960’s in many areas in the South of Europe.46
A second factor contributing to low ischaemic heart disease mortality in Southern Europe is a delay in the rise of smoking. As we have discussed above, the smoking epidemic started a few decades later in Southern Europe, mostly after World War ii, instead of in the 1920s and 1930s as in Northern and Western Europe, with even further delays among women. This is not only reflected in a later peak in lung cancer mortality (among men – among women the rates are still rising), but also in a lower peak (Figure 27). This is probably because smoking prevalence has never had the chance to rise to the absurdly high levels in Western Europe, which were reached in a time when the health risks of smoking were still unknown to the public at large.
And while Southern European populations were still relatively protected against ischaemic heart disease by their Mediterranean diets and low smoking rates, medical interventions for the prevention and treatment of cardiovascular disease were developed in other parts of the world. These were available in Southern Europe to stop any rise caused by a change towards a ‘Western’ style diet, or by a rise in smoking.47
As these favourable conditions developed in the 1970s and later, they were facilitated by the important political and economic changes happening in this period. Spain, Portugal and Greece shook off their autocratic governments in the 1970s. They then went through a period of rapid changes, both in their external relationships (an end to international isolation, membership of the European Union) and in their internal conditions (creation of a national health service and a more generous system of social security, institutional reforms).48
Balkan Troubles: the Weight of the Past
Most of South-eastern Europe has long been part of the Ottoman Empire, and these countries therefore have rather different economic, political and sociocultural histories. The geographical position of the Balkans between the great European powers (Ottoman Empire, Habsburg Empire, expanding Russia) has also made it a contested area, frequently visited by war and ethnic conflict.49
In the early 19th century, the Ottoman Empire still nominally included current Bosnia, Serbia, North Macedonia, Montenegro, Albania, Romania, Bulgaria and Greece, as well as current Moldova and Southern Russia. Only Slovenia and Croatia belonged to the Habsburg Empire. However, during the 19th century growing feelings of nationalism led to uprisings and to forms of self-government or real independence for several of these countries: first Greece, then Serbia, then Romania, then Bulgaria. After World War i, both the Habsburg and Ottoman Empires collapsed which led to the independence of the ‘Kingdom of Serbs, Croats and Slovenes’ (later renamed Yugoslavia) and Albania.
The Ottoman Empire of the 18th and 19th centuries has often been characterized as ‘backward’, and for good reasons, if we take the industrializing countries of North-western Europe or the Habsburg Empire as our benchmark. The underdevelopment of the Ottoman Empire made itself felt in many areas of life, and some of the problems of South-eastern European countries can, long after independence, still be traced back to the economic, political and sociocultural conditions prevailing under Ottoman occupation.
The Ottoman Empire kept itself shielded from Western influences. Although it repeatedly tried to reform itself (e.g., in the modernizing ‘Tanzimat’ period of the mid-19th century), these reforms were imposed from above, and met with resistance from the Islamic clergy and the upper classes which benefited from
Slovenia and Croatia escaped these unfavourable conditions, partly because they belonged to the Habsburg Empire which followed a more ‘enlightened’ path in the 18th and 19th centuries, for example by promoting education. Both countries were also predominantly Roman-catholic which oriented them towards the West, whereas most of the other countries in South-eastern Europe were predominantly Eastern Orthodox, or Muslim as in the case of Albania. Slovenia and Croatia were even for some time occupied by Napoleon, and later by Italy, which had some extra modernizing influence.
Because of space we cannot review the population health history of the whole of South-eastern Europe, but must limit ourselves to the Western Balkans, i.e., former Yugoslavia plus Albania. Albania has for a few decades had a surprisingly good performance in life expectancy, and its neighbour Yugoslavia is interesting for comparison. Yugoslavia was also the arena for the last big war (so far) on the European subcontinent, after which the country split up and life expectancies between the former Yugoslav republics diverged.
Trends in life expectancy in Yugoslavia can be traced back to the early 1930s for the country as a whole, and to the 1950s for its constituent parts. Life expectancy in Yugoslavia was still very low in the 1930s – but comparable to that in Spain – and rose rapidly during the 1940s, 1950s and 1960s. Yet, in the 1980s life expectancy started to diverge within the country, and this divergence accelerated after the country split up, with relative stagnation in Serbia, a more favourable trend in Croatia, and rapid improvement in Slovenia (Figure 32).
Trends in life expectancy in the Western Balkans, 1920–2015
Source of data: see Suppl. Table 1
As a result of this divergence, the differences are currently striking. In 2016, Slovenia had the highest life expectancy of the former Yugoslav republics, comparable to the best of North-western and Southern European countries: 78 years among men, 84 years among women. Serbia, Montenegro and North Macedonia had the lowest life expectancy: in the low 70s among men, and in the high 70s among women. Croatia was in-between, and semi-independent Kosovo had the lowest life expectancy of all: 69 years among men, and 74 years among women.
Trends in life expectancy in Albania can be traced back to 1950. At first, Albanian life expectancy was similar to, and rose in parallel with, that of
Let’s now try to understand these trends and variations. Taking it historically, so starting with the low levels of life expectancy in the 1930s which undoubtedly also applied to Albania, it is immediately clear that these mirrored the general underdevelopment of both countries. In North-western Europe, average national income in 1930 had already grown to around $4300 per head per year, whereas in Yugoslavia it was still around $1400 (much lower than in Spain!). In Albania national income was even lower, i.e., around $900 per head per year. The differences in prevalence of illiteracy were even more striking: the percentage of people who could not read and write was between 0 and 5%
We can also safely assume that the upward swing in life expectancy around World War ii has a similar explanation as the catch-up movements in Southern Europe discussed in the previous section (and the catch-up movements in Eastern Europe that will be discussed in the next section). Although these trends have been less well researched for Yugoslavia and Albania, some of the same ingredients were in place, particularly massive public health campaigns: vector control against malaria, vaccinations against childhood diseases, elimination of endemic syphilis, …. These were supported by international organizations: the Rockefeller Foundation was even more enthusiastically at work in Yugoslavia than in many other Southern European countries. In addition, both countries created a primary health care system covering the whole of the country with basic facilities, which could administer the new miracle drugs: antibiotics.52
This rapid modernization of the health infrastructure was pushed through by political regimes which were autocratic but – certainly at first – inspired by high ideals. Advances in population health were supported by rapid modernization of the economy, and by reforms of the educational system and dedicated literacy campaigns. As a result, the prevalence of illiteracy fell rapidly (see Chapter 3). Both countries adopted a specific strand of communism
After the death of long-time Yugoslav president Josip Tito (1892–1980), the cohesion within the federal republic of Yugoslavia rapidly grew less. Old ethnic and nationalistic antagonisms were stirred up, and the three Yugoslav Wars of the 1990s broke out: a war in Croatia (1991–1995), a war in Bosnia (1992–1995), and a war in Kosovo (1998–1999). Together, these three wars cost around 140,000 deaths (see Suppl. Table 5), and led to a massive reshuffling of populations due to ‘ethnic cleansing’ and emigration. As mentioned above, this was followed by a strong divergence of life expectancy between the newly independent republics, but this had already started in the 1980s.53
Albania, on the other hand, followed a rather different trajectory. In the 1980s, Albania’s life expectancy grew to unexpected heights. This was not due to very low infant or childhood mortality rates (these actually remained relatively high), but due to very low adult mortality rates. These had remained low as a result of the absence of a notable epidemic of ischaemic heart disease, and can be regarded as a paradoxical effect of the policy of relentless self-sufficiency. This kept the population poor and shielded it from the factors driving the ischaemic heart disease epidemic in other countries.
A study investigating the extraordinary health situation in Albania around 1990 concluded that “Albanians benefit from eating a rather extreme version of the classic Mediterranean diet now widely recommended by nutritionists.” They had low caloric intake, a lower intake of animal products than any other European country, and the lowest alcohol consumption of the whole of Europe. Furthermore,
the lack of private vehicles necessitated everyone taking regular exercise simply to carry out daily activities. In short, the very poverty of their circumstances was, paradoxically, a significant factor in keeping Albanians healthy. This is clearly an ironic situation.54
After the death of Enver Hoxha (1908–1985), who had been president of Albania since 1944, Albania went through a political revolution which at first left many of the old communist apparatchiks in power. After the collapse of the government-supported Ponzi pyramid scheme in 1996, in which many Albanians lost a lot of money, violent riots broke out which led to a remarkable spike in homicide mortality (Figure 9). This can also be related to the fact that in Albania, like in other remote areas, the state monopoly on violence has only been introduced (and enforced) relatively recently. A UN peace keeping force had to be brought in to restore peace and order.55
Since the late 1990s, life expectancy trends in Albania have been somewhat erratic, but the high levels have by-and-large stayed. Although ischaemic heart disease mortality started to rise during the 1990s, this seems to have stopped in the 2000s, but more recent data than 2010 were not available at the time of writing (2019).
Russian Roulette: the Value of Life
If it were not so cruel, the history of Russia’s population health would rank first in Europe in terms of its spectacle. No other European country, perhaps with the exception of Russia’s immediate neighbours Ukraine and Moldova, has experienced such wide swings in life expectancy throughout the 20th century – even during peaceful periods in which other countries’ life expectancy had already arrived in much calmer waters (Figure 1).
When we take a long-term perspective it is, however, obvious that Russia has always been special. The earliest year for which we have an estimate of life expectancy at birth is 1896/1897 – which is an important fact in itself, illustrating the late arrival of modern methods of public administration in Tsarist Russia. In that year its life expectancy was 29 years for men and 32 years for women – values that have correctly been characterized as ‘medieval’.56
It is important to understand Russia’s health trajectory, if only because Russia’s population makes up such a large part of the total European population. In 1897, Russia’s population numbered around 67 million, or around 16% of the European population as a whole. Despite the demographic disasters of the 20th century, Russia still is Europe’s largest country, with around 146 million people who make up 20% of the total.57
It is not difficult to understand why Russia’s life expectancy in the late 19th century was still so low. Lying on the periphery of Europe, in a vast space between the more densely inhabited and dynamic countries to its West, and the Asian steppes to its East from where invaders had repeatedly come to devastate the country, Russia was a relative newcomer on Europe’s political stage. It grew out of the smaller Grand Duchy of Muscovy (1283–1547), and started to take its current form only in the 17th century after conquests of large swathes of land towards the North, West, South and East.
It was governed by a Tsar whose powers were absolute – which was perhaps inevitable in such a vast empire that needed to be held together – and to whom even the Eastern Orthodox Church was subordinate. In contrast to Western Europe, where authority was often shared between the Church and the State, and where religious pluralism emerged during the Reformation, Russia thus missed the creative stimulus of competition between different centres of power. Modernization had to come from above, as in the case of Peter the Great (1672–1725) and Catherine the Great (r. 1762–1796) whose attempts at reform only reached the upper echelons of society.
Russia also missed out on many of the modernizing changes that during the 19th century occurred in Western Europe. The 19th century wave of political reforms largely bypassed Russia, so that in 1870 it was the only European country, together with the Ottoman Empire, to still have absolute government without a constitution. Serfdom – peasants living in bondage to the nobility who owned the land they were forced to work – remained common until it was abolished in 1861. At the 1897 census, the average literacy level in European Russia was a low 30%.58
Industrialization also came late to Russia, like it did to Southern and South-eastern European countries. Although industrial production rose rapidly in the last decades of the 19th century, at the start of World War i Russia was still predominantly an agrarian country. In a sense, therefore, the Bolshevik revolution (1917) was – again – an attempt at reform-from-above, but one that would turn out to have tremendous impact.59
After a few years of bloody civil war, the new communist regime settled in and started to modernize the economy, and society as a whole, at break-neck pace. Rapid industrialization, together with forced collectivization of agriculture (Plate 20), moved large numbers of people into newly built cities. Living standards gradually improved, although interrupted by the dramatic famines described in Chapter 4, and contributed to a fall in mortality in ‘normal’ years, as well as a strong rise in body height.60
“Against the kulak’s howl.” Soviet poster promoting collective farming, 1928
This Soviet propaganda poster was part of Stalin’s campaign of forced collectivization of agriculture. It shows a large group of peasants marching against a ‘kulak’. Kulaks were affluent peasants who were seen as enemies of communism. The translation of the text at the top is: “Against the kulak’s howl – to sow by a concerted, collective front!.” The translation of the text at the bottom is: “Poor and middle-class peasants, increase crop plantation, establish a technical culture, and strengthen your economy.” Unknown artist. Source: Soviet Posters (Miami, FL)
One of the priorities of the new regime was also to reform Russia’s health system. In the early 1920s, a Commissariat of Public Health was created under the directorship of Nicolai Semashko (1874–1949), a progressive physician and long-term ally of Vladimir Lenin. The Bolsheviks involved physicians in public health affairs, and had a vision of a new type of physician, to be trained in a new medical curriculum with an emphasis on social hygiene, in which social factors were considered the prime determinants of health and disease.61
This fitted well with the official commitment to social change in the 1920s, but by the end of the decade official enthusiasm diminished due to a combination of budgetary problems and distrust of technocracy. In 1930 Semashko was removed from his post, and the role of the socially conscious physician was replaced by that of the sanitary scientist – who during the 1930s and 1940s
Between 1939, the last year before World War ii, and 1964, the year in which it reached its highest level for decades to come, life expectancy in Russia
These successes were highly admired in the West, particularly during the 1930s when many left-leaning intellectuals regarded the Soviet Union as a kind of ‘Utopia come true’. There were also many admirers in the health professions, who saw their ideals of a truly ‘social medicine’, freely accessible to all and with an emphasis on prevention, put into practice. This is illustrated, for example, by Arthur Newsholme and John Kingsbury’s Red Medicine (1933) and in Henry Sigerist’s Socialized Medicine in the Soviet Union (1937). Both books were based on study tours through the Soviet Union in the 1930s, and both were written in a spirit of deep admiration for what the Soviet Union had achieved. The first book, but not the second, also contains a chapter with a critical evaluation of the autocratic character of the Soviet system. In neither of the two is there any awareness of the death toll of the man-made famines and political oppression in the Stalinist years. Sigerist even defended Stalin’s show trials as a necessary defence against attempts to undermine the Soviet system.64
How, indeed, should these achievements be valued? The enormous leap forward in population health coincided with one of the most brutal periods in Russian history. After millions of people had lost their lives in the Civil War (1917–1922) and in famines (1927–1933), another 700,000 people were executed during Stalin’s purges (1937–1938). While the ultimate gains in population health can of course not justify the brutality of the communist regime, it is important to understand that the intensive state involvement with improving population health on the one hand, and the massive state violence on the other hand, served the same purpose: a rapid social transformation to a new society in which social causes of ill-health would have been eliminated.65
After the mid-1960s life expectancy in Russia (and the Soviet Union) stalled among women and even declined among men. It increased again temporarily during Gorbachev’s anti-alcohol campaign (1985–1987), and then declined even more strongly (among men) after the collapse of the Soviet Union. Russia’s mortality experience since the mid-1960s has been extensively studied, and the main conclusion has been that stagnation and decline of life expectancy since the 1960s were due to lack of progress in the prevention and treatment of cardiovascular diseases, combined with high and fluctuating levels of alcohol consumption.
In its turn, the lack of progress in the prevention and treatment of cardiovascular diseases was partly the result of the Soviet Union’s political situation. Under Leonid Brezhnev (general secretary of the Central Committee of the Communist Party between 1964 and 1982), the Soviet Union was engaged in an arms race with the West that absorbed resources that would otherwise have been available for health care expansion and innovation. Also, the Iron Curtain was a barrier for the diffusion of new knowledge on cardiovascular risk factors and their management. Furthermore, dogmatic Marxism did not go well together
Partly because of the earlier successes in infectious disease control, the Soviet Union stuck to a public health system almost exclusively focused on sanitation, thereby turning an advantage in a previous stage of epidemiological development into a disadvantage in a later stage. After the collapse of the Soviet Union, life expectancy in Russia and other former republics of the Soviet Union fell even more dramatically, as a result of the disruptive economic and political changes of the 1990s, with large-scale unemployment, declining incomes, reduced access to health care, and high levels of psychosocial stress.66
Fortunately, Russian life expectancy has started to rise again in 2004, due to a reversal of the trend in mortality from cardiovascular diseases and injuries. In contrast to earlier mortality declines (in the mid-1980s and late-1990s) this recent mortality decline has now continued for more than 10 years. It has been attributed to a combination of factors, including decreases in alcohol consumption (partly in response to some tightening of alcohol control policies) and improvements in the prevention and treatment of cardiovascular disease (hypertension control, greater supply of advanced treatment).
Russian president Vladimir Putin, who for good reasons does not have a very good press in the West, may have contributed to this reversal by officially decreeing increases in life expectancy to be an important policy goal, and by
Over the 20th century, trends in Russia have to some extent been mirrored by trends in neighbouring countries, resp. other republics of the Soviet Union. The life expectancy trajectory of Ukraine has been similar to that of Russia, both before and after the collapse of the Soviet Union, but the decline of male life expectancy during the 1990s has been less severe, and the upturn of male life expectancy came earlier in Ukraine than in Russia. Interestingly, within Ukraine there is a clear East-West gradient, with Western regions having lower mortality than Eastern regions, suggesting that the Ukrainian health situation is partly determined by its position on a cultural fault-line between West and East.68
The Baltic countries also offer interesting trends for comparison with Russia’s. As was already briefly mentioned in Chapter 3, the Baltic republics (still independent at that time) had relatively high life expectancies during the 1920s and 1930s, moving in parallel with Finland’s and slowly converging towards Sweden’s life expectancy. However, the Baltic republics lost their independence in World War ii, when they were incorporated in the Soviet Union, and after 1960 their life expectancy trends began to follow the unfavourable trends in Russia. It was only after the breaking-up of the Soviet Union that life expectancy trends in the Baltic countries started to diverge again from Russia’s.69
What then are the deeper causes of Russia’s bad record in population health? Which factor, within the intertwined constellation of geographical, economic, political and sociocultural factors, is the ultimate driver of Russia’s low life expectancy?
Excessive alcohol consumption, including the use of toxic surrogate alcohols, is certainly one of the more immediate causes, and the evidence for its role in creating the recent ‘saw-tooth’ pattern in mortality is rather overwhelming. Already in the 19th century consumption of spirits was very high in Russia, perhaps as a result of the start of industrial production of alcoholic drinks. Russian drinking culture, which permits drunkenness and stimulates intake of great amounts of alcohol on a single occasion, perhaps in response to the cold and darkness of long winters, also definitely plays a role. Furthermore, the state failed in its role as protector of the people’s health, as it was dependent on income from alcohol taxes even in the Soviet period, and reluctant to take away a narcotic that kept people quiet. After the fall of communism, the international alcohol industry rapidly took possession of the huge Russian market with aggressive marketing strategies.70
Ultimately, however, excessive alcohol consumption cannot be the final explanation, because not all health problems that are more frequent in Russia are linked to alcohol, and because Russia’s alcohol culture must itself also be explained. The specific factors involved in the Russian health disadvantage – alcohol and other forms of risk-taking behaviour, plus a suboptimal health care system – ask for a more general explanation. As alluded to in the first paragraphs of this section, this should perhaps be sought in Russia’s culture, which has been shaped by its location on the inhospitable fringes of the European subcontinent, in-between the rest of Europe and Asia. Russia’s cultural history has been characterized as one long search for a specifically Russian identity between West and East. Has this also influenced the value of human life, which – according to a recent study – has never reached the supreme levels it has in the West?71
For a lucid account of the difference between “how” and “why” questions in science, see Ernst Mayr, “Cause and Effect in Biology,” Science 134, no. 3489 (1961): 1501–506. Mayr points out that the everyday word “why” is ambiguous, because it means both “how come” and “what for.” It is the first that concerns us here, i.e., “what was the process that over time led to the phenomenon,” and not the second, “what purpose does the phenomenon have.”
This book has reviewed the histories of ‘only’ 40 diseases, but a pattern of ‘rise-and-fall’ also applies to many other diseases that were not covered, such as most other infectious diseases, most other cancers, gout, many skin diseases, psychotropic drug use disorders, dental caries, occupational injuries, etc.; see Kiple, World History, various chapters.
That, through human history, contact between previously separated civilisations led to a “confluence of disease pools” was proposed by William McNeill; see William H. McNeill, Plagues and Peoples (New York: Anchor Press/Doubleday, 1976).
Recognizing the mutual dependence of diseases on each other, directly or indirectly, Grmek has coined the term ‘pathocenosis’: “the qualitatively and quantitatively defined group of pathological states present in a given population at a given time”; see Mirko D. Grmek, “Préliminaires d’une Étude Historique des Maladies,” Annales. Histoire, sciences sociales 24, no. 6 (1969): 1473–483.
Similar analyses have previously been done for England & Wales, but only for the period up to 1970; see, e.g., McKeown, Rise of Population. See Woods, Demography, table 8.7 for a more sophisticated approach than the one used in Table 2.
William H. McNeill, The Rise of the West (Chicago etc.: University of Chicago Press, 1963). A balanced summary is given in Daniel Chirot, “The Rise of the West,” American Sociological Review 50, no. 2 (1985): 181–95. An analysis emphasizing the role of coal and colonies in ‘the Great divergence’ between Europe and East Asia is Kenneth Pomeranz, The Great Divergence (Princeton & Oxford: Princeton University Press, 2000). Recent books have tried to answer this question again (e.g., Ian Morris, Why the West Rules – for Now (London: Profile Books, 2010); Niall Ferguson, Civilization: The West and the Rest (London: Allen Lane, 2011)).
Jared Diamond has argued that geographical factors have also determined why Eurasia (not only North-western Europe) has long been ahead of Africa and the Americas. The Neolithic revolution occurred much earlier on the Eurasian continent than in Africa or the Americas, because the first happens to have more domesticable plants and animals, and because it lies along a West-East axis which makes it easier for plants and animals from one part of the continent to be used in another; see Jared M. Diamond, Guns, Germs, and Steel (New York: W.W. Norton & Company, 1997).
For a discussion of the explanations given, see Joel Mokyr and Hans-Joachim Voth, “Understanding Growth in Europe, 1700–1870: Theory and Evidence,” in Cambridge Economic History of Europe. Volume 1: 1700–1870, ed. Stephen Broadberry and Kenneth H. O’Rourke (Cambridge etc.: Cambridge University Press, 2010).
One of the main proponents of the institutional determinants of economic development is American economist Daron Acemoğlu, who has argued that variation in economic performance among Atlantic trading nations is explained by the fact that countries with non-absolutist institutions, such as England, experienced faster growth; see Daron Acemoğlu, Simon Johnson, and James Robinson, “The Rise of Europe: Atlantic Trade, Institutional Change, and Economic Growth,” American Economic Review 95, no. 3 (2005): 546–79.
On the role of technological change, see Joel Mokyr, The Gifts of Athena (Princeton: Princeton University Press, 2002).
Numeracy, i.e., the ability to count, may also have been important, and levels of numeracy were already higher too in North-western Europe before economic take-off. An important proponent of the idea that literacy and numeracy have played a decisive role in economic take-off is German economic historian Joerg Baten (see, e.g., Joerg Baten, ed., A History of the Global Economy (Cambridge etc.: Cambridge University Press, 2016)).
This idea of ‘co-evolution’ has been embraced by many historians, not only to explain economic growth but historical developments more generally. For example, Bayly writes that “historical development [in the period 1780–1914] seems to have been determined by a complex parallelogram of forces constituted by economic changes, ideological constructions, and mechanisms of the state” (see Christopher A. Bayly, “The Birth of the Modern World, 1780–1914,” (Oxford: Blackwell, 2004)., p. 7). Variation in pathways to economic growth between European countries has been documented in Broadberry and O’Rourke, Cambridge Economic History of Modern Europe. Volume 1; Broadberry and O’Rourke, Cambridge Economic History of Modern Europe: Volume 2.
I borrowed the idea that developments in ‘rational thinking’ can be seen as an independent determinant of human development from Pinker, The Better Angels of Our Nature, Chapter 4.
My summary is largely based on overviews by Sundin and Willner, Social Change and Karin Johannisson, “The People’s Health: Public Health Policies in Sweden,” in The History of Public Health and the Modern State, ed. D. Porter (Amsterdam & Atlanta: Editions Rodopi, 1994).
Identical developments occurred in Finland, which was still part of Sweden in the 18th century, and similar developments occurred in Denmark, Norway and Iceland; see Halvor Gille, “The Demographic History of the Northern European Countries in the Eighteenth Century,” Population Studies 3, no. 1 (1949): 3–65. That the 18th century was a flowering period in Swedish science, is also clear from the European renown of Carl von Linné (1707–1778), who is famous as a founder of biological nomenclature, and also developed one of the earliest systematic disease classifications; see Johan P. Mackenbach, “Carl Von Linné, Thomas Mckeown, and the Inadequacy of Disease Classifications,” European Journal of Public Health 14, no. 3 (2004): 225.
This has been analysed in Sandberg and Steckel, “Was Industrialization Hazardous.”
On the Netherlands, see section below. On Denmark, see Knud Juel, Peter Bjerregaard, and Mette Madsen, “Mortality and Life Expectancy in Denmark and in Other European Countries,” European Journal of Public Health 10, no. 2 (2000): 93–100. There were other European countries in which a strong state apparatus developed relatively early, such as England and France, but in which population health trends were not as favourable as Sweden’s, so this cannot be the only explanation.
The difference between Sweden’s observed life expectancy and its expected life expectancy, estimated from the association between gdp and life expectancy across all European countries, was in the order of 5 years in the first half of the 20th century. It continued to be positive, but smaller, after World War ii, gradually diminishing to become less than 1 year in the early 2010s.
Despite their proximity, there are important differences between Sweden and Denmark in health policy. Whereas Danish health policies focus on behaviours and individual choice, and are averse to paternalism, Swedish health policies emphasize social determinants and collective responsibility; see Signild Vallgårda, “Addressing Individual Behaviours and Living Conditions: Four Nordic Public Health Policies,” Scandinavian Journal of Public Health 39, no. 6 (Suppl) (2011): 6–10.
The association between left-party government and population health is actually not very strong. A negative correlation between social-democratic government and infant mortality was found in Vicente Navarro et al., “Politics and Health Outcomes,” Lancet 368, no. 9540 (2006): 1033–037, but it is unclear whether this is a causal effect; see Enrique Regidor et al., “The Role of Political and Welfare State Characteristics in Infant Mortality,” International Journal of Epidemiology 40, no. 5 (2011): 1187–195. For a more elaborate analysis, see Johan P. Mackenbach and Martin McKee, “Social-Democratic Government and Health Policy in Europe,” International Journal of Health Services 43, no. 3 (2013): 389–413.
The health advantage of Estonians as compared to Latvians and Lithuanians is sometimes attributed to the fact that Estonians have become Lutherans under Swedish occupation. The Swedes also instituted a school system in Estonia, which has endowed it with higher levels of literacy than its neighbours; see Mackenbach, “Cultural Values”; Andres Kasekamp, A History of the Baltic States (London: Palgrave Macmillan 2017).
That the likelihood of choosing for Protestantism was greater in Northern than in Southern Europe has been attributed to a combination of greater distance from Rome and a Germanic cultural heritage (which was averse to hierarchy, perhaps because agriculture in the North did not permit the build-up of large surpluses and the creation of a hierarchical society); see Geert Hofstede, Culture’s Consequences (Thousand Oaks etc.: Sage, 2001); Michael Minkov, Cultural Differences in a Globalizing World (Bingley: Emerald Group Publishing, 2011).
For the role of cultural values in explaining between-country differences in population health, health-related behaviour, and health policies, see Mackenbach and McKee, Successes; Mackenbach, “Cultural Values.” See also Chapter 3.
On Sweden’s role in World War ii, see Christian Leitz, Nazi Germany and Neutral Europe During the Second World War (Manchester: Manchester University Press, 2000), Chapter 3.
For the history of snus, see Lars E. Rutqvist et al., “Swedish Snus and the Gothiatek® Standard,” Harm Reduction Journal 8, no. 1 (2011): 11. For the effect of snus on smoking in Sweden, see Jonathan Foulds et al., “Effect of Smokeless Tobacco (Snus) on Smoking and Public Health in Sweden,” Tobacco Control 12, no. 4 (2003): 349–59. For a different view, see Maria R. Galanti et al., “Use of Snus and Lung Cancer Mortality: Unwarranted Claim of Causal Association,” Scandinavian Journal of Public Health 38 (2010): 332–33.
Oeppen and Vaupel, “Broken Limits” analysed the evolution of world record life expectancy.
The history of the rise, greatness and fall of the Dutch Republic has been analysed in Jonathan I. Israel, The Dutch Republic: Its Rise, Greatness, and Fall, 1477–1806 (Oxford etc.: Clarendon Press Oxford, 1995). ‘Dutch Republic’ is the name usually given to what was officially named ‘United Provinces of the Netherlands’ (1581–1795). After the Napoleonic Wars, the Kingdom of the Netherlands was formed. This originally included Belgium, but the latter separated itself in 1830.
The demographic history of the Netherlands has been analysed in Hofstee, Demografische Ontwikkeling; Evert W. Hofstee, Korte Demografische Geschiedenis van Nederland van 1800 tot Heden (Haarlem: Fibula-Van Dishoeck, 1981). For the 19th century history of public health in the Netherlands, see Houwaart, Hygiënisten.
Quoted from Haas-Posthuma and Haas, Infant Loss, p. 27. This report identified as main contributors to the Dutch success the quality of midwifery, the high proportion of pregnant women receiving antenatal care, the availability of maternity home help, and the performance of infant welfare centres. On the role of well-trained midwives in achieving low levels of maternal mortality in the Netherlands, see Loudon, Death in Childbirth, Chapter 24–26.
The Netherlands also remained neutral in World War i, so that it not only escaped the war’s damages, but actually benefitted through increased exports of agricultural and industrial products; see Jan Luiten van Zanden, The Economic History of the Netherlands 1914–1995 (London and New York: Routledge, 1998). There is a parallel with the remarkable performance of Sweden and Switzerland which remained neutral not only in World War i, but also in World War ii.
The affinity between the Netherlands and Scandinavia in social policy is illustrated by the fact that Danish sociologist Gøsta Esping-Andersen classified the Netherlands with the Scandinavian countries in a group of ‘social-democratic’ welfare systems. In reality, the Netherlands has always mixed a ‘social-democratic’ and a ‘Christian-democratic’ welfare system, but achieved a degree of poverty reduction similar to that in the Nordic countries; see Gøsta Esping-Andersen, The Three Worlds of Welfare Capitalism (Cambridge: Polity Press, 1990).
Mika Gissler et al., “Perinatal Health Monitoring in Europe: Results from the Euro-Peristat Project,” Informatics for Health and Social Care 35, no. 2 (2010): 64–79; Judith H. Wolleswinkel-van Den Bosch et al., “Substandard Factors in Perinatal Care in the Netherlands,” Acta Obstetricia et Gynecologica Scandinavica 81, no. 1 (2002): 17–24. Recent comparative studies suggest that perinatal mortality has declined somewhat more in the Netherlands than in other countries, but levels are still higher than in the Nordic countries; see EURO-Peristat Project, European Perinatal Health Report.
For a comparative analysis, see Meslé and Vallin, “Diverging Trends.” For a more in-depth analysis of the Netherlands, see Johan P. Mackenbach et al., “Sharp Upturn of Life Expectancy in the Netherlands,” European Journal of Epidemiology 26, no. 12 (2011): 903–14; Fanny Janssen, Johan P. Mackenbach, and Anton E. Kunst, “Trends in Old-Age Mortality in Seven European Countries, 1950–1999,” Journal of Clinical Epidemiology 57, no. 2 (2004): 203–16. For an analysis of Denmark, see Juel et al., “Mortality.”
Should this be regarded as a form of ‘antagonistic pleiotropy’ which, like certain genetic traits, reduces some health risks at the expense of increasing others (see Chapter 3, note 19)? On Dutch tobacco control policies, and the cultural, political and commercial background to the reluctance of the Dutch government to implement stricter tobacco control measures, see Marc C. Willemsen, Tobacco Control Policy in the Netherlands, Palgrave Studies in Public Health Policy Research, (n.p.: Palgrave Macmillan, 2018).
This was shown in a recently published analysis of long-term trends in mortality in Spain; see Moreda et al., Conquista. In addition to pointing at the discrepancy in timing between the rise in national income and the rise in life expectancy, the authors also show that in the first half of the 20th century improvements in nutrition in Spain were quite modest, and left large sections of the Spanish population in a state of malnutrition (pp. 302–25).
National data-series for Southern European countries start in the last decades of the 19th century. However, regional data stretch back further in time. Infant and childhood mortality in Central-Spain can be followed since the late 18th century, suggesting that Spain’s mortality rates were already comparatively high at this early point in time; see Diego Ramiro Fariñas and Alberto G. Sanz, “Childhood Mortality in Central Spain, 1790–1960,” Continuity and Change 15, no. 2 (2000): 235–67.
For histories of public health in Spain, see Esteban Rodríguez Ocaña and Ferran Martinez Navarro, La Salud Pública en España. De la Edad Media al Siglo xx, vol. 68 (Granada: Escuela Andaluza de Salud Publica, n.d.); Esteban Rodríguez Ocaña, Salud Pública en España: Ciencia, Profesión y Política, Siglos xviii–xx (Granada: Unversidad de Granada, 2005). An envoy to Spain from the Rockefeller Foundation described the situation in the 1920s as “catastrophic”; see Esteban Rodriguez Ocaña, “El Informe sobre la Sanidad Española (1926) de Charles A. Bailey,” Cronos 4, no. 1–2 (2001): 63–79. The role of the Rockefeller Foundation, and the sanitary policies of the Republican and Franco governments in the interbellum period are detailed in Josep Lluís Barona and Josep Bernabeu-Mestre, La Salud y el Estado (Valencia: Universitat de València, 2011), Chapter vi. For the Spanish anti-malaria campaign of the 1920s and 1930s, see Esteban Rodriguez Ocaña, “International Health Goals and Social Reform,” in Facing Illness in Troubled Times, ed. Iris Borowy and Wolf Gruner (Frankfurt am Main: Peter Lang, 2005).
A history of public health in Portugal can be found in F.A. Gonçalves Ferreira, História da Saúde e dos Serviços de Saúde em Portugal (Lisbon: Edição da Fundação Calouste Gulbenkian, 1990). Specific periods or aspects are detailed in Jorge Fernandes Alves and Marinha Carneiro, “Saude Publica e Politica do «Codigo Sanitario» ao Regulamento Geral de 1901,” Cultura, Espaço & Memória 5 (2018): 27–43; Rita Garnel, “Disease and Public Health (Portugal),” in International Encyclopedia of the First World War, ed. Ute Daniel et al. (Berlin: Freie Universitat Berlin, 2014). The life and works of Ricardo Jorge have been described in Jorge Fernandes Alves, “Ricardo Jorge e a Saúde Pública em Portugal,” Arquivos de Medicina 22, no. 2–3 (2008): 85–90; Luis Graça, “História e Memória da Saúde Pública,” Revista Portuguesa de Saúde Pública 33, no. 2 (2015): 125–27.
Houston, Literacy. See also Chapter 3.
For the role of extractive institutions, not only on the Iberian peninsula but also as exported to Latin America, see Daron Acemoğlu and James A. Robinson, Why Nations Fail (London: Profile Books, 2012). See also Chapter 3.
Moreda et al., Conquista, Chapter 4 and 7, presents a detailed cause-by-cause analysis of declines in infant, childhood, and adult mortality, relating the timing of decline to the introduction of various health-related policies in Spain.
For the effects of the Spanish Civil War on population health in Spain, see Barona and Bernabeu-Mestre, Salud, Chapter ix.
For the health policies of the Franco government, see Barona and Bernabeu-Mestre, Salud. The contribution of these policies to population health improvement have been analysed in Moreda et al., Conquista, from which the quote comes (p. 392). For infant mortality decline under European dictatorships, see Regidor et al., “Role of Political.” For Mussolini’s ‘Bonifica’ program, a large-scale anti-malaria campaign carried out with the help of the Rockefeller Foundation, see Bruce-Chwatt and De Zulueta, Malaria; Darwin H. Stapleton, “Lessons of History?,” Public Health Reports 119, no. 2 (2004): 206–15. For the remarkable performance of autocratically governed countries, see also Chapter 3.
This is not the only explanation: Spain (and other Southern European countries) also continued to have rapid declines in other causes of death, including causes amenable to medical intervention and liver cirrhosis, suggesting adoption of effective health policies in a range of areas. For the rapid introduction of haart therapy in Spain, see Enrique Regidor et al., “Major Reduction in AIDS-Mortality Inequalities after Haart,” Social Science & Medicine 68, no. 3 (2009): 419–26.
For the traditional Mediterranean diet and its cardioprotective effects, see Daan Kromhout, Alessandro Menotti, and Henry Blackburn, Prevention of Coronary Heart Disease (Dordrecht: Kluwer Academic Publishers, 2002); Ancel Keys, “Coronary Heart Disease in Seven Countries,” Circulation 41, no. 1 (1970): 186–95; Kromhout et al., Prevention of Coronary Heart Disease. For a discussion of “why” a diet composed of products grown in the Mediterranean area is more cardioprotective than a diet composed from products grown in other parts of Europe, see Johan P. Mackenbach, “The Mediterranean Diet Story Illustrates That “Why” Questions Are as Important as “How” Questions,” Journal of Clinical Epidemiology 60, no. 2 (2007): 105–09. For recent changes, see Walter C. Willett et al., “Mediterranean Diet Pyramid: A Cultural Model for Healthy Eating,” American Journal of Clinical Nutrition 61, no. 6 (1995): 1402S-06S, Laurenzi Martino et al., “Is Italy Losing the ‘Mediterranean Advantage’?,” Preventive Medicine 18, no. 1 (1989): 35–44.
Fernand Braudel, Les Structures du Quotidien: Le Possible et l’Impossible (Paris: Armand Colin, 1979); Angus Maddison, The World Economy (Paris: Organization for Economic Cooperation and Development (oecd), 2001).
This argument has been further elaborated in Ivana Kulhanova et al., “Why Does Spain Have Smaller Inequalities in Mortality?,” European Journal of Public Health 24, no. 3 (2014): 370–77, which also discusses another remarkable feature of population health in Southern Europe: socioeconomic inequalities in mortality are smaller than elsewhere in Europe.
See Mackenbach et al., “Democratization” and Chapter 3.
See Misha Glenny, The Balkans, 1804–1999 (New York etc.: Viking Penguin, 2000) for a comprehensive political history of the Balkans, and an analysis of how this history still shapes the present. A compact but insightful history is Mark Mazower, The Balkans: From the End of Byzantium to the Present Day (London: Weidenfeld & Nicolson, 2000).
Şevket Pamuk, Uneven Centuries: Economic Development of Turkey since 1820 (Princeton: Princeton University Press, 2018).
Estimates of Gross Domestic Product (in 1990 I$) are from Maddison, World Economy. Estimates of illiteracy (calculated from census data and counted among the population 10 years and older) are from Dudley Kirk, Europe’s Population in the Interwar Years (Geneva: League of Nations, 1946), App. ii. Within Yugoslavia, illiteracy varied between 7% in the Drav region (part of current Slovenia) and 71% and 73%, respectively, in the Vardar region (current North Macedonia) and the Vrba region (current Bosnia & Herzegovina).
The set-up of public health institutions in newly independent Yugoslavia, with the help of the Rockefeller Foundation, has been documented in Zeljko Dugac, “New Public Health for a New State,” in Facing Illness in Troubled Times, ed. Iris Borowy and Wolf Gruner (Frankfurt am Main: Peter Lang, 2005). Croatian public health pioneer Andrija Stampar (1888–1958), who played an important role in the League of Nations Health Organization (lnho), was instrumental in forging good links between the Rockefeller Foundation and the Yugoslav health authorities; see Zeljko Dugac, “Andrija Stampar (1888–1958): Resolute Fighter for Health and Social Justice,” in Of Medicine and Men, ed. Iris Borowy and Anne Hardy (Frankfurt am Main etc.: Peter Lang, 2008). Stampar also led the movement for strengthening primary care, particularly in rural areas, both in Yugoslavia and internationally. For anti-malaria campaigns in Macedonia, a region contested between Yugoslavia and Bulgaria, and its role in strengthening the borders of the newly formed Yugoslavian Kingdom, see Patrick Zylberman, “Mosquitoes and the Komitadjis,” in Facing Illness in Troubled Times, ed. Iris Borowy and Wolf Gruner (Frankfurt am Main: Peter Lang, 2005).
See Kunitz, “Making and Breaking” for some further reflections on the consequences of the ‘breaking up’ of Yugoslavia for population health.
The “paradoxes of Albania’s health transition” have been analysed in Arjan Gjonca, “Mortality Transition in Albania” (University of London, 1999). The quotes are from Arjan Gjonca, Chris Wilson, and Jane Falkingham, “Paradoxes of Health Transition in Europe’s Poorest Country: Albania 1950–90,” Population and Development Review 23, no. 3 (1997): 585–609, pp. 603 and 605.
On the delayed fall of homicide mortality in remote European regions, see Chesnais, Histoire, Chapter 2. In the Albanian ‘pyramid crisis’ protests against the government derailed into looting of weapon depots and violence between individuals and competing gangs in which between 2000 and 4000 Albanians were killed (https://en.wikipedia.org/wiki/Albanian_Civil_War, accessed 28/08/2019).
Shkolnikov et al., “Recent Trends.” On mortality patterns in Tsarist Russia, see K. David Patterson, “Mortality in Late Tsarist Russia: A Reconnaissance,” Social History of Medicine 8, no. 2 (1995): 179–210.
The population estimate for 1897 is for Russia within its present borders. The Russian empire, which also included Poland, Finland, the Baltic states etc., then had around 100 million inhabitants.
For a general history of Russia, see Roberts, The Penguin History of Europe, especially pp. 301–07. Long-term trends in literacy in Russia and the Soviet Union have been analysed by Boris N. Mironov, “The Development of Literacy in Russia and the USSR from the Tenth to the Twentieth Centuries,” History of Education Quarterly 31, no. 2 (1991): 229–52. Please note, that the figure of 30% is based on a definition of literacy different from that used in Figure 8.
Earlier revolutions occurred in 1905 and in February 1917. The Russian revolution of October 1917 succeeded because the Bolshevik leaders remembered the failure of the 1848 revolution, and were determined to succeed at all costs.
Average body height of military recruits in the Soviet Union grew by more than 4 centimetres between those born in the early 1920s and early 1950s; see Stephen G. Wheatcroft, “The Great Leap Upwards: Anthropometric Data and Indicators of Crises and Secular Change in Soviet Welfare Levels, 1880–1960,” Slavic Review 58, no. 1 (1999): 27–60. Whether this was an extraordinary achievement of the communist regime has been disputed, however; see Millward and Baten, “Population and Living Standards.”
Early Soviet health policies were inspired by communist ideology, but also stood in a long tradition in which medical police, public hygiene and social hygiene had merged with the social orientation of 19th century Russian medicine; see David L. Hoffmann, Cultivating the Masses (New York: Cornell University Press, 2011). Illustrative is an article by Semashko in which he shows, how Karl Marx’s analysis of the negative effects of capitalism on labourers’ well-being foreshadowed social-hygienic insights; see Nikolai A. Semashko, “Karl Marx Und Die Sozialhygiene,” in Der Rote Oktober und der Sowjetische Gesundheits-schutz, ed. Kurt Winter et al. (Jena: veb Gustav Fischer Verlag, 1977 [1933]).
As far as I am aware, there is no biography of Semashko, although recent papers by Russian scholars have shed more light on his life and works (e.g., O.A. Trefilova and I.M. Sechenov, “Nikolai Semashko: Social Activist and Health Care Organizer,” History of Medicine 1, no. 3 (2014): 65–72 and other papers in the same journal issue). See for the history of Russian and Soviet public health Susan Gross Solomon, “The Expert and the State in Russian Public Health,” in The History of Public Health and the Modern State, ed. D. Porter (Amsterdam – Atlanta: Rodopi, 1994); Susan Gross Solomon and John F. Hutchinson, eds., Health and Society in Revolutionary Russia (Bloomington: Indiana University Press, 1990).
These improvements of life expectancy at birth should be balanced against the fact that of all men alive during the 1939 census, only 53% were still alive during the 1960 census; see Anatoly Vishnevsky, “Demographic Consequences of the Great Patriotic War,” Demographic Review (English Selection) 3, no. 2 (2016): 6–42. Vaccines and antibiotics, which did not have to be imported but were produced in the Soviet Union, also helped to rapidly reduce mortality from infectious diseases. See Donald Filtzer, The Hazards of Urban Life in Late Stalinist Russia (Cambridge etc.: Cambridge University Press, 2010) for an analysis of public health in the Soviet Union during the late 1940s and early 1950s.
The first book arose from a study tour commissioned by the Milbank Memorial Fund (Arthur Newsholme and John Adams Kingsbury, Red Medicine (London: Heinemann, 1934)). Its patron Albert Milbank considered it left-wing “propaganda”; see Susan Gross Solomon, “A Matter of ‘Reach’. Fact Finding in the Wake of World War i,” in Shifting Boundaries of Public Health, ed. S. Gross Salomon, L. Murard, and P. Zylberman (Rochester: University of Rochester Press, 2008). Sir Arthur Newsholme (1857–1943) was one of England’s greatest authorities in public health in the first decades of the 20th century; see John M. Eyler, Sir Arthur Newsholme and State Medicine, 1885–1935 (Cambridge etc.: Cambridge University Press, 2002). The second book first appeared in 1933 and was republished in a slightly modified form shortly after World War ii (Henry E. Sigerist, Medicine and Health in the Soviet Union (Binghamton: Citadel Press, 1947)). In the preface to this second edition, Sigerist writes “My book was given a very favorable reception when it appeared in Great Britain. At that time, the Left Book Clubs were flourishing […]. In the United States, the reception was decidedly cool. The country was under a heavy barrage of anti-Soviet propaganda. Girding to meet attack, and knowing by what methods the Nazis were striving to build up fifth columns in other countries, the Soviet Union got rid of its traitors in time. In the United States, however, few persons attempted to understand the meaning and significance of the Moscow trials.” In these sentences, Sigerist, a Swiss-German medical historian who emigrated to the United States in the early 1930s and who has been highly admired, defends Stalin’s show trials. For a short introduction to Sigerist’s life and work, see Elizabeth Fee, “Henry E. Sigerist,” Milbank Quarterly 67, no. Suppl. 1 (1989): 127–50.
Hoffmann, Cultivating the Masses.
The literature on recent trends in life expectancy in Russia is very extensive. A good description up to the early 2000s is Vladimir M. Shkolnikov et al., “Mortality Reversal in Russia: The Story So Far,” Hygiea Internationalis 4, no. 1 (2004): 29–80. An interpretation in terms of a “second epidemiological [transition] that never was” is offered in Anatoly Vishnevsky, “Mortality in Russia: The Second Epidemiological Revolution That Never Was,” Demographic Review (English Selection) 1 (2014): 5–40. Medical scientists in the Soviet Union missed out on the developments in cardiovascular disease epidemiology in the West, partly because the uncertainty inherent in the idea of risk factors and multiple causes was incompatible with Marxism-Leninism (Vasiliy V. Vlassov, “Russian Medicine: Trying to Catch up on Scientific Evidence and Human Values,” Lancet 390, no. 10102 (2017): 1619–620), and because Randomized Controlled Trials were similarly unpalatable (McKee, “Cochrane on Communism”). An early paper showing the role of fluctuations in excessive alcohol consumption is by David A. Leon et al., “Huge Variation in Russian Mortality Rates 1984–94: Artefact, Alcohol, or What?,” Lancet 350, no. 9075 (1997): 383–88. The role of economic disruption during the transition from a communist to a capitalist economy was analysed in David Stuckler, Lawrence King, and Martin McKee, “Mass Privatisation and the Post-Communist Mortality Crisis,” Lancet 373, no. 9661 (2009): 399–407. When Russia’s life expectancy is plotted in a Preston-curve, it is clear that it is far below the expected value, showing that low living standards are not the main factor; see Vladimir M. Shkolnikov et al., “Patterns in the Relationship between Life Expectancy and Gross Domestic Product in Russia in 2005–15,” Lancet Public Health 4, no. 4 (2019): e181–e88.
For an analysis of these recent trends, see Vladimir M. Shkolnikov et al., “Components and Possible Determinants of the Decrease in Russian Mortality in 2004–2010,” Demographic Research 28 (2013): 917–50 Pavel Grigoriev et al., “The Recent Mortality Decline in Russia: Beginning of the Cardiovascular Revolution?,” Population and Development Review 40, no. 1 (2014): 107–29. The recent expansion of myocardial infarction facilities has been analysed in Sergey Timonin et al., “Reducing Geographic Inequalities in Access Times for Acute Treatment of Myocardial Infarction,” International Journal of Epidemiology 47, no. 5 (2018): 1594–602.
Johan P. Mackenbach, Adrianna Murphy, and Martin McKee, “Ukraine: Not Only a Matter of Geopolitics,” Lancet 383, no. 9920 (2014): 848–50.
Within the Baltic countries, Russians now have lower life expectancies than ethnic Lithuanians, Latvians and Estonians. For life expectancy trends in the Baltic countries, see Mackenbach, “Political Conditions and Life Expectancy”; Jacques Vallin, Domantas Jasilionis, and France Meslé, “Does a Turbulent History Lead to Turbulent Life Expectancy Trends?,” Historical Methods 50, no. 4 (2017): 191–209.
Andrew Stickley, Yury Razvodovsky, and Michael McKee, “Alcohol Mortality in Russia: A Historical Perspective,” Public Health 123, no. 1 (2009): 20–6; Martin McKee, “Alcohol in Russia,” Alcohol and Alcoholism 34, no. 6 (1999): 824–29. See Chapter 6, Ischaemic heart disease, for the “saw-tooth” pattern in Russian mortality.
For a characterization of Russia’s cultural history as an eternal hesitation between West and East, see Orlando Figes, Natasha’s Dance (London: Allen Lane, 2002). Economists have compared the monetary value of human life (as estimated from decisions on health investments, or from life insurance and other compensation schemes) between Russia and other countries, concluding that in Russia the value of human life is lower than in other European countries with a similar level of income, and more similar to that of Asian countries with a lower level of income; see T. Karabchuk et al., “Как Оценить Стоимость Человеческой Жизни? [How to Evaluate the Value of Human Life?],” Economic Sociology 15, no. 1 (2014): 89–106.