The EconomistAugust 1st 2020 Books & arts 712 ic. Though data from the late 18th and early 19th centu-
ries are patchy and flawed, the broad picture is clear.
Across industrialising cities, mortality rates, for the
young especially, held steady at high levels or climbed
slightly in the early 19th century, as rapid urbanisation
unfolded, despite a dramatic decline in smallpox mor-
tality over this period associated with the rise of inocu-
lation. From around 1840, however, a trend toward de-
clining mortality rates began to take hold. Life
expectancy at birth rose about 6 years, on average,
across large British cities from 1838 to the end of the
century. In Paris it rose by about ten years over this per-
iod; in Stockholm by roughly 20. In America the crude
death rate per 1,000 people rose in New York City from
about 25 in the early 1800s to roughly 35 in 1850, before
falling to near 20 by the end of the century. Trends in
other large American cities were similar.
Manners maketh men, and women too
Not all of the improvement in health can be attributed
to improvements in sanitation and hygiene. Over the
course of the 20th century, economists have debated
the relative importance of other factors such as im-
proved medical techniques (in midwifery, in particu-
lar) and better nutrition associated with rising in-
comes. Indeed, nutritional gains do seem to have
played a meaningful role in reducing mortality. But the
contribution from better diets is difficult to assess, giv-
en the fact that the bodies of people who grow up in
disease-ridden environments are less able to retain
nutrients from the food they eat.
Similarly, while some research suggests that mu-
nicipal investments in public-health measures can ex-
plain most or nearly all of the decline in mortality in
the late 19th century, it is difficult to be certain. Cities
in which public support for sanitary investments was
high, for example, might have been more aware of pub-
lic-health information generally, and more inclined to
practise good personal hygiene.
The effects of declining urban-mortality rates were
profound. Healthier cities accelerated the process of
urbanisation by boosting the natural rate of increase(births less deaths) within cities. The cap on urban
population share placed by high mortality in cities was
removed; by the end of the 19th century nearly 80% of
the British population lived in towns and cities.
Perhaps more dramatic, however, was the effect of
the decline in mortality on the skill level of the work-
force. Falling mortality rates, in cities especially, began
a process known in the social sciences as the “demo-
graphic transition”. The pace of population growth and
urbanisation both accelerated. As more children sur-
vived to adulthood, families began having fewer of
them. Meanwhile industrial economies’ increasing
demand for skilled workers raised the return to educa-
tion. Families began to invest more heavily in the
schooling of each child; longer lifespans meant the
pay-off to investments in education grew.
The cycle of increasing technological sophistica-
tion and increased educational attainment lifted in-
comes across the economy. So did the effect of slower
population growth, which allowed for faster growth in
levels of capital per worker. It was the fall in urban
mortality in the 19th century that finally launched the
world into an era in which brains dominated brawn.
By the end of the 19th century, the bacteria responsi-
ble for many endemic infectious diseases had been
identified. The first half of the 20th century brought
about the discovery of antibiotics and the develop-
ment of vaccines against a host of viral scourges. Over
the course of the century, matters of public health once
again shifted in the direction of personal responsibil-
ity: toward diet, fitness and lower consumption of al-
cohol, drugs and the like. Hygiene, meanwhile, be-
came a matter first and foremost of fashion and class,
in the rich world at least. For well-heeled metropolitan
types, personal care—the juice cleanses, pilates ses-
sions, skin treatments and so forth—is a matter of van-
ity and identity as much as an effort to prolong life or
contribute to the broader public health.
Yet recent history illustrates once more that public
health is often a matter of collective action. In the 1980s
and 1990s the hiv/aidsepidemic shook a world accus-
tomed to thinking of deadly disease outbreaks as a
thing of the past. It contributed to new public-health
campaigns built on the idea that changes in personal
behaviour were an important part of keeping both in-
dividuals and society healthy.
More recently a backlash against vaccination has
put hard-fought gains against diseases like measles at
risk. This trend has reinforced the idea that maintain-
ing collective support for public health, and shifting
social norms, is an ongoing battle for policymakers to
take seriously. So, too, have the recurring pandemic
threats of the 21st century, from sarsto covid-19.
Prosperity now, as ever, relies on human connec-
tions within great cities. A world more populous and
integrated than ever before will continue to face a seri-
ous risk of pandemic disease. What is not yet clear is
how many accommodations are needed. What new
public investments must be made to prevent conta-
gion from shutting down the world economy? What
behavioural changes will persist in the years after this
pandemic? Which invisible walls of affects will be
erected to reconcile our need to be social with our de-
sire for good health? As sophisticated and modern as
we perceive ourselves to be, our clumsy efforts to man-
age the health risks of a growing global economy might
well strike the healthier, richer people of the future as
depressingly Dickensian. 7Falling mortality
rates began
a process
known as the
“demographic
transition”