Public water and sewage investments and the urban mortality decline: - PDF document

Public water and sewage investments and the urban mortality decline: Sweden 1875-1930 *** Draft, please do not cite or circulate *** Jonas Helgertz Centre for Economic Demography and Department of Economic History, Lund University Martin Önnerfors Centre for Economic Demography and Department of Economic History, Lund University Financial support from the Crafoord foundation for the project “Effects of exposure to health shocks and interventions during the fetal stage and the first year of life on labor market outcomes in Sweden 1900-2012” is gratefully acknowledged. We thank Jonas Wallin and Siddartha Aradhya for helpful comments on modelling. For the digitization of data, we acknowledge the assistance of Federica Braccioli, Magda du Toit, Anita Terzic and Glen Williams.

1 Introduction and aim The mortality decline that started in the 18th century, and led to an unprecedented rise in life expectancy in Europe and other parts of the world, has been considered to be one of the most significant events in human history. In Sweden, the mortality decline began during the early 19th century, being driven by rapidly declining infant mortality towards the latter half of the century. From the end of the 19th century, infant mortality declined from about 17 percent to less than five percent in 1930, less than half a century later. Coupled with declining fertility, the (first) demographic transition, had substantial consequences at the macro as well as micro level, through reducing the dilution of capital per capita as well as enhancing labor productivity through increased human capital formation (Galor, 2012). In combination, these were fundamental processes for industrialization and rapid economic growth during the 19th and 20th centuries, resulting in substantially changing standards of living. Despite the importance of the mortality decline for the emergence of today’s developed countries, the understanding of which factors drove this decline remains poorly understood. Robert Fogel remained hesitant to call it one of the greatest human achievements, as he was unsure regarding how much of this development was due to human intervention (Fogel, 1986, p.376). The question was not, he argued, whether factors such as economic development, medicine, public health or nutrition were involved in the decline, but the contribution of each respective factor to the decline. Due to the historical importance of the mortality decline, substantial research has been conducted into its determinants. A noteworthy characteristic of the mortality decline was that it typically occurred with a distinct delay in urban areas. This is important, as cities in Sweden and elsewhere across industrializing countries came to host an ever increasing share of the population, why the analysis of urban areas allows for conclusions that are more representative for the country as a whole. This paper examines a newly created database, with annual data covering all Swedish cities between 1875 and 1930. This period was characterized by a steady expansion in public water and sewage provision, as well as being a period when the urban mortality declined to reach rural levels. The data set is unique in the sense that it covers a full range of cities, all within the same national context – this will allow for a more complete picture The aim of the paper is not only to quantify the relevance of the provision of piped water and sewage for the Swedish urban mortality decline, but also to better understand how this process was affected by the implementation of more advanced water processing methods. It is expected that the provision of (clean) water not only caused an overall reduction in mortality, but more so in terms of deaths due to waterborne disease. The ability to drink and prepare food using clean/safe water, in combination with the ability to dispose of fluid and solid waste, should diminish the spread of waterborne disease, an important cause of death at the beginning of the period examined. The relevance of understanding the role of here investigated public health interventions is not only linked to obtaining a better understanding of a process of significant importance occurring in the past. Whereas deaths due to the consumption of unsafe water represents a remarkably rare event in today’s developed countries, it 2

continues to be a problem in many other parts of the world even today. According to the WHO, 1.8 million people die every year from diarrhoeal diseases related to unsafe water supply, sanitation and hygiene (WHO, 2014). The sanitary conditions in several developing countries today are in many ways similar to the disease environment found in western cities in the end of the 19th century (Ferrie & Troesken, 2008, p.2), which makes study of the mechanisms behind historical urban mortality relevant also in a contemporary setting. There is, however, a need for more information on the effectiveness of interventions in improving water and sanitation, to distinguish them from other interventions in reducing mortality (Fewtrell et al., 2005, p.42). The paper is organized as follows. Initially, we will present a section describing the core features of the mortality decline and explanations encountered in the previous literature. Subsequently, we will present existing evidence which links water and sewage provision to mortality, followed by the history of investments into water and sewage in Sweden. Following this, we will describe the data used, as well as the key variables and methods used in the multivariate analysis. Lastly, the results, sensitivity analysis and conclusions sections close. 2 Background 2.1 The mortality decline: hypotheses and empirical evidence This paper focuses on a period which begins when Sweden has already experienced approximately 70 years of steady mortality decline. The period here examined takes place during the third phase of the demographic transition, characterized by declining fertility as well as mortality. Compared to when the mortality decline was initiated, at the beginning of the 19 th century, the crude death rate had declined from between 25-30‰ to around 20‰ in 1875. Indeed, by the end of the period analyzed – in 1930 – CDR had reached a level that is comparable with the level today. The pattern of decline for the country as a whole, however, disguises considerable heterogeneities between urban and rural areas. As elsewhere in the industrializing world, mortality tended to be higher in urban areas due to a range of different factors, including a higher degree of crowding as well as being hubs for migration flows, facilitating the spread of disease (Reher, 2001). As a consequence, the mortality decline occurring during the time period analyzed in this paper is to a significant driven by improving survival in the cities. This is illustrated by Figure 1, showing annual infant mortality rates calculated for urban and rural areas, separately. In the beginning of the analysis period infant mortality in urban areas were around 30 percent higher, having converged to the rural levels by 1930. Figure 1 here. To some extent, the mortality decline was a process that occurred simultaneously across Europe and North America. The reasons behind the mortality decline have been widely debated, and a number of potential explanations have been put forward. One important hypothesis links the declining mortality to increasing standards of living. An important proponent of this view was McKeown, Brown & Record (1972, p.382), who argued that improved nutrition and economic growth were the primary cause of mortality decline. More 3