Proposal preview

Health inequalities and urbanization, 17th-20th centuries

Once deadly places existing only through a constant influx of (more or less) healthy migrants, cities have gradually seen their living standards improved. This phenomenon, however, was far from linear or homogenous and little is known about the way different groups within cities took advantage of improvements in health. This is all the more important as cities were places characterized by large inequalities, that the industrial revolution or the colonization process made even starker. This session will explore the various ways in which health inequalities within cities evolved over time. While focusing on health inequality and urbanization in the long run, this session intends to place it in a broader structure of changing public policies. It will consider the evolution of mortality from different angles: ways of living for urban people, the healthy import of migrants; the relationship between urban elites and lumpen proletariat; the size and scope of infrastructure change and its consequences on health; and the rivalry between groups–defined by income, wealth or occupation–for the control of public spending.

Organizer(s)

  • Joseph Ferrie Dept. of Economics, Northwestern University ferrie@northwestern.edu
  • Lionel Kesztenbaum INED and PSE lionel.kesztenbaum@ined.fr

Session members

  • Marcella Alsan, Stanford School of Medicine
  • Vincenzo Atella, University of Rome Tor Vergata
  • Brian Beach, College of William & Mary
  • Jay Bhattacharya, Stanford University
  • Louis Cain, Loyola University Chicago and Northwestern University
  • Valentina Conti, Food and Agriculture Organization (FAO) of the United Nations
  • Martin Dribe, Lund University
  • Björn Eriksson, Lund University
  • Daniel Gallardo Albarrán, University of Groningen
  • Sok Chul Hong, Seoul National University
  • Volha Lazuka, Lund University
  • Amarah Mauricio, University of California Irvine
  • Iván Mejía-Guevara, Stanford University
  • Grant Miller, Stanford University
  • Andrew Noymer, University of California Irvine
  • Kota Ogasawara, Graduate School of Social Sciences, Chiba University
  • John Parman, College of William & Mary
  • Martin Saavedra, Oberlin College
  • Dolores Sesma Carlos, Radboud University
  • Werner Troesken, University of Pittsburg
  • Nicky Tynan, Dickinson College
  • Yuanxiaoyue (Artemis) Yang, Harvard T.H. Chan School of Public Health

Discussant(s)

Papers

Panel abstract

Once deadly places existing only through a constant influx of (more or less) healthy migrants, cities have gradually seen their living standards improved. This phenomenon, however, was far from linear or homogenous and little is known about the way different groups within cities took advantage of improvements in health. This is all the more important as cities were places characterized by large inequalities, that the industrial revolution or the colonization process made even starker. This session explores the various ways in which health inequalities evolved over time. The first part analyses processes of convergence and divergence in mortality over the long run. The second part is more focused on the persistence of health effects over the life cycle, in particular for migrants. * Presenting author.

1st half

Technological Progress and Health Convergence: The Case of Penicillin in Post-War Italy

Marcella Alsan*, Vincenzo Atella, Jay Bhattacharya, Valentina Conti, Iván Mejía-Guevara, Grant Miller

Throughout history, technological progress has profoundly transformed population health, but the distributional effects of these gains are unclear. New substitutes for older, more expensive health technologies can produce convergence in population health outcomes, but may also be prone to “elite capture” (leading to divergence). This paper studies the case of penicillin using detailed mortality statistics and exploiting its sharply-timed introduction in Italy after World War II. We find that penicillin reduced mean infectious disease mortality rates substantially and produced substantial convergence across disparate regions of Italy, decreasing the standard deviation of penicillin-sensitive disease mortality by approximately 60 percent. We provide evidence that these results are not explained by competing risks or the end of World War II.

Throughout history, technological progress has profoundly transformed population health, but the distributional effects of these gains are unclear. New substitutes for older, more expensive health technologies can produce convergence in population health outcomes, but may also be prone to “elite capture” (leading to divergence). This paper studies the case of penicillin using detailed mortality statistics and exploiting its sharply-timed introduction in Italy after World War II. We find that penicillin reduced mean infectious disease mortality rates substantially and produced substantial convergence across disparate regions of Italy, decreasing the standard deviation of penicillin-sensitive disease mortality by approximately 60 percent. We provide evidence that these results are not explained by competing risks or the end of World War II.

Segregation, City Size, and Public Health in the United States

Brian Beach*, John Parman, Martin Saavedra

Early 20th century investment in water and sewers remains one of the most important public health interventions, accounting for 50 percent of the decrease in U.S. mortality between 1900 and 1940. We explore how local demographics influenced these investments. Specifically, we consider how the decision to build a waterworks and expand the system of water mains depended on the share of minority residents in a city and how segregated those minority residents were. We combine city-level data on waterworks, mains and taps with estimates of the population shares and segregation of three minority groups: black households, unskilled workers, and Irish immigrants. Preliminary results demonstrate that large minority population shares were associated with delayed construction of waterworks and less extensive systems. Increasing the segregation of those minority populations, however, was associated with earlier waterworks construction and larger systems. Evidence from the 1960 federal census suggests that these differences in the initial...

Early 20th century investment in water and sewers remains one of the most important public health interventions, accounting for 50 percent of the decrease in U.S. mortality between 1900 and 1940. We explore how local demographics influenced these investments. Specifically, we consider how the decision to build a waterworks and expand the system of water mains depended on the share of minority residents in a city and how segregated those minority residents were. We combine city-level data on waterworks, mains and taps with estimates of the population shares and segregation of three minority groups: black households, unskilled workers, and Irish immigrants. Preliminary results demonstrate that large minority population shares were associated with delayed construction of waterworks and less extensive systems. Increasing the segregation of those minority populations, however, was associated with earlier waterworks construction and larger systems. Evidence from the 1960 federal census suggests that these differences in the initial construction of water systems may have had lasting impacts on racial gaps in access to water and sewer service.

Sanitary infrastructures and the decline of mortality in Germany, 1877-1913

Daniel Gallardo-Albarrán*

Clean water provision is considered crucial towards eliminating waterborne diseases such as diarrheal ailments. However, its benefits are limited in the absence of efficient systems of waste disposal due to its recontamination or the exposure of citizens to excrement. In this article, I analyze the historical experience of a number of German cities and estimate the impact of water supply and sewerage systems on mortality. The results show that sanitary infrastructures reduced mortality significantly, especially when water supply and sewerage systems operated together in the same city. I find evidence that the main channel explaining this effect is the reduced incidence of diseases transmitted via fecal-oral mechanisms. First, sanitary infrastructures account for a quarter of the decline in infant mortality, which is largely affected by water-borne ailments. Second, I find a large effect for enteric-related illnesses, while deaths from etiologies with a different pathological basis are not affected.

Clean water provision is considered crucial towards eliminating waterborne diseases such as diarrheal ailments. However, its benefits are limited in the absence of efficient systems of waste disposal due to its recontamination or the exposure of citizens to excrement. In this article, I analyze the historical experience of a number of German cities and estimate the impact of water supply and sewerage systems on mortality. The results show that sanitary infrastructures reduced mortality significantly, especially when water supply and sewerage systems operated together in the same city. I find evidence that the main channel explaining this effect is the reduced incidence of diseases transmitted via fecal-oral mechanisms. First, sanitary infrastructures account for a quarter of the decline in infant mortality, which is largely affected by water-borne ailments. Second, I find a large effect for enteric-related illnesses, while deaths from etiologies with a different pathological basis are not affected.

Intra-Urban Health Disparities: Aging and Survival in the Wards of 19th-Century American Cities

Louis Cain*, Sok Chul Hong

This study provides historical evidence supporting that urban neighborhood conditions can affect the process of aging among the elderly and their survival. We utilize the historical records on Union Army veterans who resided in the five largest American cities in 1900 including New York City, Brooklyn, Chicago, Boston and Philadelphia. Urban neighborhood conditions are measured at the ward level---the common political division of American cities---by synthetically considering the urban characteristics of death, education and income. We find that neighborhood conditions substantially varies within the cities and that veterans who lived in better-quality neighborhood lived healthier and longer than otherwise. Today, many developing countries experience fast urbanization, population aging and increasing inequalities within cities. This study provides insight into the health and economic benefit of reducing intra-urban disparities in neighborhood conditions.

This study provides historical evidence supporting that urban neighborhood conditions can affect the process of aging among the elderly and their survival. We utilize the historical records on Union Army veterans who resided in the five largest American cities in 1900 including New York City, Brooklyn, Chicago, Boston and Philadelphia. Urban neighborhood conditions are measured at the ward level---the common political division of American cities---by synthetically considering the urban characteristics of death, education and income. We find that neighborhood conditions substantially varies within the cities and that veterans who lived in better-quality neighborhood lived healthier and longer than otherwise. Today, many developing countries experience fast urbanization, population aging and increasing inequalities within cities. This study provides insight into the health and economic benefit of reducing intra-urban disparities in neighborhood conditions.

Water on Tap: Constant Water Supply and London’s Mortality Decline, 1876-1910

Werner Troeksen, Nicola Tynan*, Yuanxiaoyue Yang

Until recently, development metrics for improved water supplies have focused on access, water source and treatment. New metrics have added frequency of delivery as a measure of the quality of water supply, noting that regularity and frequency vary substantially across locations. London made the transition from intermittent to constant water supply between 1876 and 1910. We show that having a constant supply significantly reduced gastrointestinal disease mortality, contributing to a decline in the crude death rate during this period. Idiosyncratic delays in the negotiation process between companies and property owners generated substantial variation in the timing of the transition across London. Exploiting this variation, we find that a 1 percent increase in a local population with access to constant service decreased deaths from waterborne diseases by more than 0.5 percent. Results are robust to the inclusion of controls for district wealth and population density. This suggest that increased frequency of...

Until recently, development metrics for improved water supplies have focused on access, water source and treatment. New metrics have added frequency of delivery as a measure of the quality of water supply, noting that regularity and frequency vary substantially across locations. London made the transition from intermittent to constant water supply between 1876 and 1910. We show that having a constant supply significantly reduced gastrointestinal disease mortality, contributing to a decline in the crude death rate during this period. Idiosyncratic delays in the negotiation process between companies and property owners generated substantial variation in the timing of the transition across London. Exploiting this variation, we find that a 1 percent increase in a local population with access to constant service decreased deaths from waterborne diseases by more than 0.5 percent. Results are robust to the inclusion of controls for district wealth and population density. This suggest that increased frequency of water supply has the potential to deliver further reductions in mortality in developing countries.

2nd half

Social Inequality in Adult Mortality in Swedish Cities during Urbanization: Evidence from Full-Count Micro Census Data

Martin Dribe, Björn Eriksson*

With the onset of industrialization, Sweden experienced rapid urbanization. This development resulted in stagnating life expectancy before improvement in urban living conditions were addressed through public investments. In the present study we focus on how the urban mortality penalty evolved during the late nineteenth and early twentieth century. Our analysis is based on full count censuses (1880-1950) which we link at the individual level to death records (1860-2016). This new and novel data enables us to assess whether the urban penalty differed by sex, age and socioeconomic status, and how the penalty evolved over time as cities grew larger, but also became less unhealthy places to inhabit. The paper provides new and important insights into the interaction between urbanization and social inequality with special reference to health and mortality.

With the onset of industrialization, Sweden experienced rapid urbanization. This development resulted in stagnating life expectancy before improvement in urban living conditions were addressed through public investments. In the present study we focus on how the urban mortality penalty evolved during the late nineteenth and early twentieth century. Our analysis is based on full count censuses (1880-1950) which we link at the individual level to death records (1860-2016). This new and novel data enables us to assess whether the urban penalty differed by sex, age and socioeconomic status, and how the penalty evolved over time as cities grew larger, but also became less unhealthy places to inhabit. The paper provides new and important insights into the interaction between urbanization and social inequality with special reference to health and mortality.

It’s a long walk: Lasting effects of the openings of maternity wards on labour market performance

Volha Lazuka*

Among the first welfare policies addressed particularly towards mothers and young children in Sweden was the institutionalization of childbirth in hospitals together with subsidies to their attendance in the 1930s–1940s. By providing improved conditions at birth and few weeks after birth, including better hygiene, access to medications and nursing, this health intervention through developmental mechanisms could strongly affect later-life outcomes. Using register-based longitudinal micro-level data for the whole of Sweden (1968–2014) and archival data on the reform implementation, this paper aims to explore the effects of being born in a high-quality maternity hospital, compared to delivery at home or in a low-quality nursing home on health, education and labour market performance in adulthood. An important angle is whether this early-life health intervention narrowed socioeconomic disparities in health and income in long run.

Among the first welfare policies addressed particularly towards mothers and young children in Sweden was the institutionalization of childbirth in hospitals together with subsidies to their attendance in the 1930s–1940s. By providing improved conditions at birth and few weeks after birth, including better hygiene, access to medications and nursing, this health intervention through developmental mechanisms could strongly affect later-life outcomes. Using register-based longitudinal micro-level data for the whole of Sweden (1968–2014) and archival data on the reform implementation, this paper aims to explore the effects of being born in a high-quality maternity hospital, compared to delivery at home or in a low-quality nursing home on health, education and labour market performance in adulthood. An important angle is whether this early-life health intervention narrowed socioeconomic disparities in health and income in long run.

Unraveling the Social Ecology of Polio

Amarah C. Mauricio, Andrew Noymer*

We explore poliomyelitis and typhoid fever mortality in the United States, 1914–69, by age, sex, and race. We show that some of the seemingly-paradoxical facets of the data — principally, that whites had higher polio death rates than nonwhites but lower typhoid death rates — are consistent with epidemiological theory, specifically, the polio hygiene hypothesis. This runs against some recent mathematical modeling work which suggested that the hygiene hypothesis is unnecessary to recapitulate observed patterns of poliomyelitis epidemiology. Data on racial differences shows that the hygiene hypothesis is necessary and probably sufficient to explain patterns of polio mortality in the United States. The present work emphasizes the view that epidemiological phenomena are best understood in their social context.

We explore poliomyelitis and typhoid fever mortality in the United States, 1914–69, by age, sex, and race. We show that some of the seemingly-paradoxical facets of the data — principally, that whites had higher polio death rates than nonwhites but lower typhoid death rates — are consistent with epidemiological theory, specifically, the polio hygiene hypothesis. This runs against some recent mathematical modeling work which suggested that the hygiene hypothesis is unnecessary to recapitulate observed patterns of poliomyelitis epidemiology. Data on racial differences shows that the hygiene hypothesis is necessary and probably sufficient to explain patterns of polio mortality in the United States. The present work emphasizes the view that epidemiological phenomena are best understood in their social context.

Persistence of Natural Disasters on Child Health: Evidence from the Great Kanto Earthquake of 1923

Kota Ogasawara*

In 1923, the Great Kanto Earthquake hit the Japanese archipelago with a moment magnitude scale of 7.9. To study its long-run effects on the development of children, we established a unique school-level panel dataset on the height of children and compiled the regional variation of the damage from official reports. We found that fetal earthquake exposure had negative effects on the development of children and that the magnitude increased with the degree of devastation. However, the results from the prefecture-level data imply that the impacts of earthquakes on child height are limited at the local level as the physical disruption due to the earthquake was concentrated on a set of municipalities in a certain prefecture.

In 1923, the Great Kanto Earthquake hit the Japanese archipelago with a moment magnitude scale of 7.9. To study its long-run effects on the development of children, we established a unique school-level panel dataset on the height of children and compiled the regional variation of the damage from official reports. We found that fetal earthquake exposure had negative effects on the development of children and that the magnitude increased with the degree of devastation. However, the results from the prefecture-level data imply that the impacts of earthquakes on child height are limited at the local level as the physical disruption due to the earthquake was concentrated on a set of municipalities in a certain prefecture.

Internal migrations in urban settings and later-life mortality. The Netherlands, 19th-20th centuries

Dolores Sesma Carlos*

This paper focuses on the role of rural-urban migrant groups by studying the effect of migration status on later-life mortality in the Netherlands, for the birth cohorts 1850-1922. The impact of rural-urban migration on mortality during the industrialization period is still considered an open debate. Studies about mortality differentials in historical societies have shown a migrant mortality advantage in certain rural-urban migrant groups but also a loss of mortality advantage in urban settings. Adopting a life course approach to residential mobility and adding more heterogeneity to the sample of study, this paper aims to contribute towards improving our understanding about historical social inequalities in health. Using micro level longitudinal data derived from The Historical Sample of The Netherlands (1850-1940), survival analysis is applied to analyse the impact of migrant status in later-life mortality, controlling by socio-demographic (civil and occupational status) as well as family characteristics over the life span of...

This paper focuses on the role of rural-urban migrant groups by studying the effect of migration status on later-life mortality in the Netherlands, for the birth cohorts 1850-1922. The impact of rural-urban migration on mortality during the industrialization period is still considered an open debate. Studies about mortality differentials in historical societies have shown a migrant mortality advantage in certain rural-urban migrant groups but also a loss of mortality advantage in urban settings. Adopting a life course approach to residential mobility and adding more heterogeneity to the sample of study, this paper aims to contribute towards improving our understanding about historical social inequalities in health. Using micro level longitudinal data derived from The Historical Sample of The Netherlands (1850-1940), survival analysis is applied to analyse the impact of migrant status in later-life mortality, controlling by socio-demographic (civil and occupational status) as well as family characteristics over the life span of permanent residents, migrants and return migrants in different birth cohorts and by gender.