Ensuring universal access to clean water and basic sanitation by 2030 is a key part of the United Nations Sustainable Development Goals. Considerable progress is required to meet this target: in 2020, more than 2 billion people lacked access to clean water, and 1.7 billion required improved sanitation. Achieving the target will require substantial increases in financing in infrastructure projects, with countries potentially needing a fourfold increase in their investment in the water and sanitation sector (see here). Similar issues plagued the roll out of sanitation infrastructure in modern-day developed economies during the nineteenth century. This post summarizes a recent paper where I investigate the role of cheap borrowing in encouraging investment in sanitation infrastructure in nineteenth-century England—and the importance of that investment in reducing infant mortality. 

Cheap loans and investment in sanitation in nineteenth-century Britain

Rapid urbanization following the industrial revolution overwhelmed sanitary systems in British cities, and deteriorating health environments were followed by high mortality (see other posts on this topic published in this blog here or here). In Liverpool and Manchester life expectancy was under 35 in 1850. A growing sanitary movement pushed for government to tackle this problem through new investments in sanitation infrastructure, with some success—Chapman (2019; see here) finds that investment in sanitation infrastructure made a major contribution to decline from both waterborne and airborne disease. Yet even at the end of the nineteenth century there was considerable variation in the quality and quantity of health investments across the country, reflecting a combination of technical, political, and financial issues. 

My paper shows that the cost of borrowing was a significant determinant of towns’ willingness to invest in sanitation infrastructure, using a dataset of the annual financial accounts of more than 800 town councils. To build infrastructure town councils had to borrow considerable sums—the value of loans borrowed has thus frequently been used as a measure of infrastructure development during this period. The ability to raise cheap funds thus became an important factor in the development of clean water and sewer systems.

In the last quarter of the century interest rates plunged, and town investment—and hence borrowing—rapidly increased, as we can see in figure 1 below. The “consol rate” measures the interest rate paid by the national government on government bonds, and so provides a measure of the overall cost of borrowing in the economy. As this rate declined due to macroeconomic factors, town councils were able to borrow more cheaply leading to higher aggregate debt (left hand panel), more towns borrowing, and higher average loans (right hand panel). 

This general pattern masks considerable variation in the interest rates different towns paid on their borrowing, as we can see in Figure 2 below. Throughout the period, towns with the highest interest rates paid approximately 2 percentage points—or 40%—more than those paying cheaper loans. In principle, all councils could borrow from both private lenders—generally through the stock market, from insurance companies and banks, or from wealthy individuals—or the government. However, some found it easier to access private capital than others—due to town wealth, size, local government quality, or the depth of local credit markets. Consequently, some municipalities had access to cheaper borrowing, and were able to invest more cheaply in sanitation at an earlier date.

Statistical analysis demonstrates that lower interest rates stimulated investment in sanitation public goods, and consequently expedited Britain’s mortality decline. Regression estimates suggest that around 8% of sanitation investment in 1903 was a consequence of falling interest rates between 1887 and 1903 alone. In smaller towns, most affected by declining rates at this time, falling interest rates explain more than 20% of infrastructure investment. Furthermore, the analysis shows that more sanitation investment translated into lower infant mortality: cheaper borrowing allowed town councils to improve sanitary environments, and hence prevent deaths from diseases such as typhoid and infant diarrhoea. Moreover, data limitations means that the effect of low interest rates on borrowing by the large towns is largely excluded from this analysis—as such the estimates likely under-estimate the contribution of low borrowing costs to the overall development of Britain’s sanitation infrastructure.

These results raise the question of whether policymakers in Westminster could have done more to stimulate borrowing and hence improve public health. There was a recognition of the importance of cheap funds, and central government sought to overcome barriers to town investment by providing loan facilities through the Public Works Loan Board (PWLB). This authority offered loans for sanitary purposes to urban councils from the 1860s onward, funding almost half of local spending on health on water and sewers between 1872 and 1876. As we can see in the right-hand panel of Figure 2, at the start of our period even the larger towns were paying higher interest rates than the middle of the range offered by the PWLB and as a result, even major cities, including Manchester and Birmingham, took out government loans. PWLB loans were attractive at this point both because of the difficulty in raising funds elsewhere and the fact that interest rates offered by the PWLB were below the market rate. 

The high rate of borrowing from the PWLB led to intense debate within Westminster as to whether such loans should be subsidized. On one hand, public health reformers pushed for cheap finance to encourage investment while, on the other, the “Treasury view” worried that low rates would lead to over indebtedness. Consequently, while PWLB loans were initially cheap—even for the largest towns—by the 1890s they were prohibitively expensive, and towns sought to use private borrowing to repay these loans where possible. In fact, borrowing from the PWLB inhibited further investment in the 1890s as private lenders feared the government would be prioritized in the event of a default. The unwillingness to subsidize loans thus came at the cost of higher infant mortality.

Conclusion

The need to finance investment in sanitation infrastructure was a pressing concern for town councils in nineteenth-century Britain, as it is in developing countries today. Demands for unprecedented levels of investment went hand-in-hand with technological uncertainty and hence ambiguity about the potential costs of new projects. Towns that were able to access cheap finance were more able to overcome these barriers, benefit public health, and reduce infant mortality. Greater willingness by Parliament to subsidize borrowing could thus have expedited Britain’s mortality decline.

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It has long been known that mortality is affected by seasonality. Ancient Chinese, Greek, and Indian medical works already recognized the influence of seasonal changes on human health (Dong 2011). In particular in the 19^th century, many medical doctors and statisticians across Europe stimulated their national statistical offices to collect data on seasonal patterns in mortality (Breschi & Livi-Bacci 1997). Historical demographers and social historians have widely used these data to study the influence of seasonality on infant and (early) childhood mortality. Now that more refined microdata have become available over long periods of time and for larger regions, there are new opportunities to study the long-term and area-specific relationship between seasonality and childhood mortality. This article presents some selected outcomes on temporal, regional and social variation in the seasonal patterns of infant and early childhood mortality in the Netherlands based on Van Poppel et al. (2018). The study used a large microdata set of three of the eleven Dutch provinces (~1.6 million live born children), containing information on the mortality and background characteristics of children born between 1812 and 1912.

Seasonal mortality patterns

Results are shown for the province of Zeeland, a predominantly rural region located in the southwest of the Netherland. Zeeland was characterized by very high infant mortality, in many parts even higher than 300 deaths per 1,000 live births. Figure 1 shows early childhood mortality rates by consecutive month of birth from January to December during the first 24 months of life. Infant mortality in the first month of life (the dots in the graph) shows a seasonal pattern with the highest risks (hazard rates) for those born in summer and winter. Mortality risks for those born in the summer were higher than for those born in the winter. Although mortality risks were roughly declining as children grew older, cohort mortality rates did not show a continuous decline over time. In particular, in the first summer after birth, mortality rates increased again. Mortality rates in August were even higher for those born in May and June than in their month of birth. Although mortality rates in general declined again after the summer mortality peak, this again was not a continuous decline. 

However, this cannot be easily read from Figure 1. Therefore, Figure 2 shows the same data by month of birth and calendar month in a two-dimensional heat map table. The heat map clearly shows the summer mortality peaks, but also reveals a cohort mortality increase that clusters in the diagonal of higher mortality twelve to thirteen months after birth. Children born in the summer showed no increased risk entering their second summer period.

Seasonal patterns were similar for separate social classes (not shown). Mortality differences in the first month of life were similar for children born to workers, farmers and the middle class. However, the mortality risks in the first summer after birth were much lower (around 40%) for children from farmers and slightly lower (around 13%) for middle-class children than for working-class children.

What explains regional differences in seasonal mortality?

Seasonal effects in early childhood mortality over the period 1812-1912 were quite strong in the province of Zeeland. Seasonal patterns in other provinces, in the northeast of the country, were much weaker. Similar regional differences were found for Italy by Breschi et al. (1997) and Germany by Knodel (1983). Such large differences in seasonal patterns, even in a relatively small country like the Netherlands, with only small differences in weather conditions, suggest that social, economic and ecological conditions and cultural practices might be more relevant than temperature. The high summer peak in mortality in the rural province of Zeeland might be explained by the relatively high participation of women in agricultural activities, which peak in the summer. These women were often away from home, causing early weaning or irregular breastfeeding of children and a lesser degree of care and protection. An additional factor was the difference in the sanitary situation across the country. Due to the gradual salinization of surface and ground water and the high groundwater level in Zeeland, the sanitary situation in Zeeland was generally worse than in many other regions in the Netherlands, providing an ideal environment for the malaria-carrying mosquito. Where breastfeeding was absent or irregular and artificial feeding was practiced, the salinization and the high level of environmental contamination of the water strongly increased the risk of diarrhœa, the main cause of death among infants. It thus was the interaction between low incidence of breastfeeding and the atrocious condition of the drinking water and sanitation that led to high summer mortality in Zeeland, not only for children born in summer but also for children born a few months before summer.

Extreme weather conditions and health vulnerability: An ongoing challenge

While in general social, economic and ecological conditions and cultural practices might have been more relevant than temperature, more extreme climatic conditions, like heat waves and cold spells, did affect mortality. Ekamper et al. (2009, 2011) found that in the Netherlands in the 19^th and early 20^th century, young children were by far the most vulnerable group when temperatures reached extremely high or low values. In particular in the province of Zeeland infants and young children endured strongly increased mortality rates during extreme weather conditions. Here, again, the lowest social classes were the most vulnerable to heat waves and cold spells. Over time, however, infants and young children became less and less sensitive to temperature fluctuations. Nowadays, in Europe the elderly population has become the most vulnerable to extreme temperatures (Masselot et al. 2023). However, in other parts of the world, such as Africa, children still are among the most vulnerable (Chapman et al. 2022).

• Chapman, S., Birch, C.E., Marsham, J.H. et al. (2022), Past and projected climate change impacts on heat-related child mortality in Africa. Environmental Research Letters, 17 (7): 074028. https://doi.org/10.1088/1748-9326/ac7ac5 
• Dong, Q. (2011), Seasonal changes and seasonal regimen in Hippocrates. Journal of Cambridge Studies, 6 (4): 128-144. https://doi.org/10.17863/CAM.1407 
• Breschi, M. & Livi-Bacci, M. (1997), Month of birth as a factor in children’s survival. In: A. Bideau, B. Desjardins & H. Pérez-Brignoli (Eds.), Infant and Child Mortality in the Past. Oxford: Clarendon press, p. 157-173.
• Ekamper, P., Van Poppel, F., Van Duin, C. & Garssen, J. (2009), 150 Years of temperature-related excess mortality in the Netherlands. Demographic Research, 21 (14): 385-426. https://www.doi.org/10.4054/DemRes.2009.21.14 
• Ekamper, P., Van Poppel, F., Van, Duin, C., Mandemakers, K. (2011), Heat waves and cold spells and their effect on mortality: An analysis of micro-data for the Netherlands in the nineteenth and twentieth centuries. Annales de Démographie Historique, (120): 55-104. https://www.doi.org/10.3917/adh.120.0055 
• Knodel, J. (1983), Seasonal variation in infant mortality: An approach with applications. Annales de Démographie Historique: 208-230.
• Masselot, P., Mistry, M., Vanoli, J. et al. (2023), Excess mortality attributed to heat and cold: A health impact assessment study in 854 cities in Europe. The Lancet Planetary Health, 7 (4): E271-E281. https://doi.org/10.1016/S2542-5196(23)00023-2 
• Van Poppel, F., Ekamper, P. & Mandemakers, K. (2018), Season of birth and early childhood mortality: A review of the debate and a case study for the Netherlands, 1812-1912. In: P. Puschmann & T. Riswick (Eds.), Building Bridges. Scholars, History and Historical Demography. Nijmegen: Valkhof Pers, p. 590-625. http://publ.nidi.nl/output/2018/buildingbridges-2018-ch15-vanpoppel.pdf

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Mortality started to decline among some populations in northern Europe as early as the eighteenth century. Mediterranean Europe, on the other hand, still exhibited high mortality levels even until the beginning of the twentieth century, as a result of the very high infant and/or early childhood mortality, as well as the high prevalence of infectious diseases. A main characteristic of the mortality regime in the nineteenth century were the great discrepancies between rural and urban populations. Cities faced an ‘urban penalty’ which reduced survival probabilities for their inhabitants and resulted in a great number of deaths, most significantly among infants. The main conditions responsible for excess urban mortality included the high population density leading to the rapid spread of infectious diseases and the lack of sanitary reforms. This urban-rural mortality gap seems to have narrowed significantly by the early twentieth century in most European populations and was then followed by an urban advantage.

Only little evidence is available about changes in mortality in modern Greece prior to the 1960s. Apart from a few studies which have attempted to estimate national mortality levels (though on the basis of indirect techniques and extensive assumptions) and several studies that refer to non-urban populations, cover short periods of time, or employ rather superficial demographic methods, there remains a significant lack of studies focusing solely on urban mortality patterns in Greece with a long-term perspective.

In this study, I examine the patterns of mortality decline in the Greek urban centre of Hermoupolis on the Greek island of Syros, and, by employing a variety of sources (i.e., death records, census data, local press, public health reports, and oral interviews), I investigate the pathways that facilitated such decline. Hermoupolis is the capital city of the island of Syros and of the Cycladic group of islands. Hermoupolis, in particular, was chosen not only because it was one of the most important nineteenth-century Greek cities experiencing very high mortality, but also because of the unique civil registration sources which it possesses at the individual level. A series of abridged life tables is constructed for the first time for a Greek urban settlement, enabling the calculation of age- and sex-specific mortality rates and life expectancies (see detailed description of methodology, results, and interpretation here).

Mortality patterns

Mortality in Hermoupolis was much higher than the national average and, moreover, the highest rate calculated for Greece in almost every census year from the mid-nineteenth century until 1940; see figure below. Comparisons of Hermoupolis with other semi-urban and rural Greek populations suggest that an ‘urban penalty’ was clearly operating in Greece even during the first decades of the twentieth century, most likely as a result of insufficient sanitary infrastructure, high population density, bad housing, low living standards, unhealthy working conditions, and in-migration. 

Life expectancy at birth in Hermoupolis is significantly lower than any other available rate that has been calculated for Greek populations. When age-specific death rates are plotted, the generally expected U-shaped curve is clearly visible in every census year for which life tables are constructed; see figure below. 

Overall levels of infant mortality remained remarkably stable, but still at relatively high levels, which did not exceed 200 per 1,000, throughout the first 20-year period; see figure 3. Subsequently, infant mortality followed an increasing trend, which lasted up to the turn of the twentieth century. Such an increase is assumed to have been the product of Hermoupolis’ economic decline, the worsening of working conditions and the very low living standards among the lower strata. During the first half of the twentieth century, infant mortality rate (IMR) followed an almost continuous decline (for a detailed analysis of cause-specific mortality during infancy in particular, see here and here).  Early childhood mortality (1-4 years), on the other hand, was initially at greater levels than that of infants, following the typical Mediterranean model but also that of the major nineteenth-century urban populations, then exhibited a significant decline in the late 1880s. Such decline coincided with the timing of mass immunisation practices which started in the late 1880s and possibly contributed to increasing the survival of those in this age group. 

Confirming the assumptions made by others about the timing of the mortality decline, time series for Hermoupolis show that a declining trend was underway by the beginning of the twentieth century or even the late nineteenth century: young children benefited initially, adults and infants followed. Life expectancy at birth had increased from 36 years in 1861 to almost 46 years of age in 1928. The mortality decline was only interrupted in the years around the 1918/19 influenza pandemic and the arrival of the Asia Minor refugees around 1922, which has been associated with increases in mortality throughout the country; see figure 2. During the 1918/19 influenza pandemic, in particular, mortality increased within every age group, however, young adults and adults experienced the largest excess mortality, while short increases occurred among the very young and elderly due to their pre-existing high mortality risk most likely due to the aftermaths of the 1916-17 naval blockade in the country, which has not been properly studied yet (here).

Why did mortality decline?

A combination of factors was found to be responsible for the mortality decline in Hermoupolis, including changes in the registration system; mass immunisation; improvements in living standards and nutrition among lower strata infants; improvements in maternal literacy; the mortality-fertility interaction during the demographic transition; and wider access to water, as an underground water supply system was introduced in the mid-1920s, and although not expanded across the whole city, it may have enabled improvements in personal hygiene among the residents of the city (for a detailed discussion on public health in Hermoupolis, see here). The study, supports the idea that cultural factors may have played a crucial role in the changes in mortality in Hermoupolis during the period under study. This aspect has been under-examined, or at least underestimated, in previous demographic studies, but it seems to be of very special importance in Greece.

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In an effort to develop their colonies, France implemented  an extensive medical campaign for sleeping sickness between the 1920s and 1950s. These consisted of forced medical examinations and injections of drugs which had dangerous and sometimes lethal side effects. Such terrible experiences may have create a lasting impact in those communities that were exposed to modern (Western) medicine for the first time. In fact, they could explain why in large parts of Africa there is a very low feeling of trust in modern medicine which has hindered the potential growth of health care in these areas. Also, research shows that when there is enough availability of health care, the demand remains puzzlingly low. 

The article by Lowes and Montero (2021) aims at researching this. They hypothesize that colonial medical campaigns may have had a series of unintended effects on both beliefs about modern medicine and the success of health interventions. In the following, I summarize their main findings. 

Linking colonial medical campaigns and current outcomes

Lowes and Montero (2021) test their hypothesis by examining how historical colonial medical campaigns influence present-day vaccination rates, trust in medicine and the success of the World Bank health projects.  

First, they construct a dataset on medical campaigns using data from French military archives for five countries, namely The colonial governments of Cameroon, Central African Republic, Chad, Gabon, and the Republic of Congo. The historical reports consist of detailed descriptions of the places visited by the sleeping sickness medical teams and the types of treatments administered between 1921 and 1956. The figure below shows the frequencies of the visits in the region. 

Second, they match these data with information from the Demographic and Health Surveys (DHS) from recent years. The authors construct a vaccination index for children under five years old and also obtain information on whether the child has completed (all, multiple or none of) the nine different vaccines: polio, tuberculous, diphtheria, tetanus pertussis and measles. 

Third, they proxy for trust in medicine by whether an individual consents to a free and non-invasive blood test (either for anemia or HIV). A refusal to the blood test is considered as a proxy for mistrust in modern medicine.

At last, they used data from AidData on the location of World Bank projects approved between 1995 and 2014 to examine their successful implementation. The World Bank classifies its projects in five sectors: “health, central government administration, general public administration, other social services, railways, and roads and highways”. Since the World Bank rates their projects from “highly unsatisfactory” to “highly satisfactory”, they were able to compare the results for health projects with the data on the intensity of the sleeping sickness campaigns.

Main findings

Results show that a greater exposure to the sleeping sickness campaigns is associated with lower vaccinations rates for children. To be precise, when an area has an average of 15 years being visited by the campaigns, it is associated with a 5.8 percentage point decrease in the vaccination index. Second, their analysis show that increased exposure to the sleeping sickness campaigns is correlated with lower levels of trust in medicine today. When an area has been visited for 15 years by the medical campaigns it increases refusal of blood tests by 5.4 percentage points. The figure below show the latter result graphically. 

Both results cannot identify the causal effect of medical campaigns on vaccination and trust in medicine, since there might be another variable which determines the outcomes of both of our examined variables. To address this concern, the authors take an instrumental variable approach. The instrument used is the log suitability for cassava compared to the log suitability for millet. The results obtained with this empirical strategy are then similar and thus strengthen a causal interpretation of their findings. 

At last, the authors find that greater exposure to the campaigns is correlated with less successful health projects. However the projects in other domains are not negatively affected by the exposure to the medical campaigns. The size of this effect is as big as the rate changing from moderately satisfactory to moderately unsatisfactory.

Lowes and Montero have found sizeable and significant results for vaccination rates, trust in medicine and the successfulness of World Bank health interventions. But how can we further explain these results? They discuss two mechanisms that might be at play. First, they show that the exposure to the medical campaigns only affects trust in medicine, and not other trust-related measures. Second, they suggest that mistrust in medicine is mostly transmitted vertically (horizontal transmission is not ruled out) because the effect of exposure to the medical campaigns is twice as large for an individual’s own ethnic group as compared to others’ exposure. 

Conclusion

These results remind us of the importance historical events can have on present-day events. The colonial medical campaigns still influence the health of communities they visited on an individual and communal level, through their negative consequences on vaccination rates and trust in modern medicine. This can have serious complications for the overall health individuals living in these areas, since they are less likely to seek medical help even when it is available to them. Thus, building the demand for medical help will need more attention on rebuilding trust in modern medicine, instead of solely focusing on informing these communities about their availability.

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Public health in major urban areas became a matter for major concern during the second half of the nineteenth century. Industrialization and the need for an ever increasing number of laborers had contributed to mass urbanization and with the rapid growth of cities came widespread waste and pollution. As a result of the urge to provide clean drinking water to the population  and expanding technical knowhow stemming from the industrial revolution, waterworks were constructed in many Dutch cities. 

However, the timing varied throughout municipalities. Why was this the case? This post will give insights into when and why waterworks were built in the Netherlands during the late 19^th century, by reconstructing relevant parts of popular debates based on contemporary newspaper articles and other sources. 

An urban revolution 

A revolution in water supply during the 19the century was facilitated by the machinery invented during the Industrial revolution and after ca. 1850 the construction of waterworks became a worldwide phenomenon. The invention and application of steam engines made it possible for cities to access clean sources of water in their surroundings that could be stored in towers and reservoirs; this also led to a more reliable supply even in periods of drought. Furthermore, water quality greatly improved with the invention of filtration systems, in which layers of sand and gravel filtered out impurities and reduced the risk of water borne diseases. All these inventions also led significant changes in the way societies thought about the relation between hygiene illness and sanitary conditions.

The water supply revolution in the Netherlands started in Amsterdam in 1853, when the first large-scale provision system was completed. From there, it spread throughout the country in subsequent decades. In the following, I focus on the largest Dutch cities and identify some interesting patterns in the diffusion pattern. First, there is a significant pause in completing waterworks between 1856 and 1874, when those in Rotterdam and The Hague were finished (see table below). The second pattern I identify has to do with company ownership, which was mostly private with the exception of Rotterdam, The Hague, Nijmegen, Dordrecht, Haarlem and s- Hertogenbosch. And third, not all early adaptors were large cities and not all large cities were early adaptors. For instance, Den Helder was really early with waterworks operational (1856) and had a small population of about 15 thousand inhabitants in 1859, while Haarlem had about 27 thousand citizens in 1859  but only started supplying piped water in 1898.

Drivers of investment in waterworks

How can we make sense of some of the patterns discussed above? Consider the timing difference between Amsterdam and the two next largest Dutch cities: Rotterdam and The Hague. Looking into newspaper articles, there seems to be some overlap in discourse as they both acknowledge the importance of waterworks and were actively looking for investors, mostly in vain. This resembles the experience of Amsterdam, where the construction of waterworks almost had been cancelled due to a lack in funds, but at the lats moment British investors were found. 

Looking at the discourse in the papers it seems that concessions written by the city councils were very strict, as they requested large non-completion deposits and absolved the city of much of the investment risk and shifting it to investors. We can clearly see the fear of being swindled by foreign investors in a letter of the Amsterdamsche Duinwaterleiding Maatschappij when they had to deposit a large sum for non-completion when they asked for permission to expand the number of water taps inside the city. According to the letter: “these conditions of overprotection cause that many of the necessary developments [of waterworks] in the Netherlands and in the city of Amsterdam are delayed or all together stopped despite their apparent necessity”. This text further states that a majority of shareholders living abroad should no longer be seen as a reason for distrust, since they had proven by their earlier works that they could be trusted. In the end, The Hague and Rotterdam decided to finance and exploit their own waterworks, creating the first two public systems, after private companies gave up the concession negotiations due to the aforementioned strict rules. 

Financial considerations, and not necessarily public health concern, also explain why rather small municipalities built these systems earlier. Consider the example of Den Helder given above. In this city, the construction of waterworks did not have as its primary aim to provide clean drinking water for its inhabitants, but rather to offer this resource to ships docking in its harbor with the aim of gaining some extra advantage over the neighboring ones.

Why was private initiative so significant in the Netherlands? As discussed above the main obstacle of infrastructural improvement was finance. For a city council to build and exploit such a large project was full of risk. To circumvent this, private investors were a logical alternative. However, this also seemed to have been one of the factors delaying diffusion, as most private companies were financed with foreign capital which meant that profits to shareholders would go abroad. This increased the likelihood that the next investment needed foreign backing, and Dutch investors simply did not profit as much from these companies. But even in the case where Dutch capital financed the project, as in Maastricht, true local ownership remained lacking. In January of 1886 stocks were sold to finance the first part of the waterworks, when the local newspaper published an article consisting of one sentence “The loan for the waterworks in Maastricht did not find a single financer in this city” (De geldleening ten behoeve der waterleiding te Maastricht heeft daar ter stede geen enkele inschrijver gevonden). 

Conclusion

The diffusion of waterworks during the 19^th century in the Netherlands is a story that is marked by mainly problems in financing. Starting with the waterworks in Amsterdam, there seems to have been very little local ownership leading to some distrust between the city council and the private (foreign) investors. This distrust was also shown in strict concession rules making it unappealing for many investors to start similar projects. 

The lack of local ownership also established profit as the first priority for investors, and not the health of citizens. Probably as a result of within-city political inequalities, the cholera epidemic of 1866 did not create substantial momentum for large cities to invest in waterworks; instead they seemed to have been more interested in easy and quick fixes to their public health problems.

• Apers, J. “Begin Van De Drinkwatervoorziening in Amsterdam : Water Gebeurde Er Sinds 1853? [Themanummer: 150 Jaar Drinkwater Voor Amsterdam].” H Twee O : Tijdschrift Voor Watervoorziening En Afvalwaterbehandeling 36 (17) : 12 – 15, 2003. https://edepot.wur.nl/368073.
• Groen, J.A, and Gemeentewaterleidingen Amsterdam. Een Cent Per Emmer : Het Amsterdamse Drinkwater Door De Eeuwen Heen. Amsterdam: Gemeente waterleidingen, 1978.
• Geels, Frank W. “From Sectoral Systems of Innovation to Socio-Technical Systems: Insights About Dynamics and Change from Sociology and Institutional Theory.” Research Policy 33, no. 6 (2004): 897–920. https://doi.org/10.1016/j.respol.2004.01.015.
• Noort, Jan van den. “Pion of Pionier : Rotterdam, Gemeentelijke Bedrijvigheid in De Negentiende Eeuw.” Dissertation, Stichting PK, 1990.

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One of the key goals of the international development agenda is to promote healthy lives through universal access to sanitary services (see here).  Safe water and sanitation, among other essentials, play an important role in curtailing the transmission of fecal-oral diseases, such as diarrhea, which still exact a high toll on some populations. Centralized systems of piped water provision and waste disposal through sewers are more modern than many think and their origins, as I will argue here, are closely related to the blessings and curses unleashed by the industrial revolution during the 19^th century.

The industrial revolution, directly and indirectly, set in motion three processes that radically transformed the urban landscape of Europe and North America since the late 19^th century: a paradigm shift in perspectives on public health, an increasing demand for water and sanitation, and the invention of new technologies applicable to urban infrastructures. I elaborate on these below.

Medicine blames the environment for the spread of disease

Industrialization and rapid population growth became an increasing source of concern during the 1820s and 1830s. Deadly epidemics, such as cholera, wreaked havoc and instilled fear among both the working classes and elites. Established notions regarding the origins of disease came under scrutiny, prompting the medical field to refined its very imperfect epidemiological knowledge. In their search for the source of disease, doctors shifted their focus from the individual, who was often blamed for her morals and habits, to the natural environment and factors beyond the control of citizens, such as residency or social class (see here). 

How did ideas about disease causation change? A crucial development was the use of data collection as a tool to compile empirical facts and generate hypotheses that could be subsequently tested with different theories. A compelling example is the work of Louis René Villermé, a French physician that became interested in social epidemiology. He conducted an important study in 1828 to determine the underlying causes of mortality differentials among districts in Paris, employing correlation techniques. Across the English channel, Edwin Chadwick published a report in 1842 that resonated with public health officials across Europe and North America. His report highlighted the poor sanitary conditions endured by English workers and called for greater attention to environmental factors. Chadwick’s proposal included the construction of complex networks of pipes and sewers to deliver clean water and efficiently dispose waste. The idea that human intervention and sanitary reform could enhance public health gradually began to permeate different layers of society. For instance, France and Germany later committed to promote public health via state regulation and funding. 

Certainly, we should not overstate the reach and influence of novel ideas about disease diffusion, since there was substantial debate and disagreement among sanitarians and medical experts at the time. However, it is undeniable that there was a growing feeling among communities during the 19^th century that they were in charge of their health prospects. In this narrative, the civil engineer, armed with novel waterworks and sewerage systems, emerged as a doctor that could cure the ills of the city.

Escalating demand for water and sanitation 

The industrial revolution increased the need for water and sanitation services. As previously mentioned, industrialization was accompanied, and fueled, by population growth. Burgeoning urban populations placed increasing pressure on traditional systems of water provision that struggled to meet these new requirements, such as wells, rivers or lakes. Compounding this issue, these water sources often became contaminated by the mounting volumes of human waste that piled up within the expanding cities. Next to consumption for drinking purposes, water was needed to combat fires, which became more risky due to the uncontrolled expansion of cities and slums. Traditional sources of water were not enough in big cities, as illustrated by the Great Fire of Hamburg in 1842, when the flames ravaged for 3 days and nights. Lastly, emerging industrial businesses required large amounts of clean and soft water for cooling steam engines various textile production processes.

Addressing these three urban  challenges required the implementation of large-scale centralized infrastructures that connected individual households and factories with pipe and sewer networks. These pioneering systems were capable of moving unprecedented volumes of water and waste throughout the city, thereby accommodating the burgeoning demand. The cities of Boston and Chicago are illustrative of this trend: residents increased their daily consumption from about 100 gallons per capita in 1880 to 200 gallons in 1905, respectively. 

Advances in urban infrastructure technology 

Centralized water supply and sewerage have been available for hundreds of years, but their capacity was rather low. Innovations stemming from the industrial revolution changed this. Steam engines boosted the efficiency of water pumping stations, previously powered by river currents or horses, to unprecedented levels. Early technologies were clunky and inefficient, but over the course of the 19^th century their productivity increased dramatically (see here for a nice historical account of this process). Also, the adoption of iron and lead pipes, replacing wood, could handle escalating levels of water pressure. In the realm of waste management, the surging volumes of water flowing to cities were harnessed to carry away urban waste by linking water closets with sewers. This was an enormous improvement over earlier unsafe methods to store fecal matter, such as cesspits, privies or pail closets. 

It is important to note that early water supply and sewerage systems were far from perfect and they could even pose a threat to public health, as the case of Hamburg shows (see here). Nevertheless, their safety steadily improved through the implementation of filtration and chemical disinfection of water and waste. The development of these techniques can also, at least indirectly, be traced back to the wave of technological innovation unleashed by the industrial revolution.

Is a sanitary revolution possible without an industrial revolution?

The answer to this question is negative, but it requires some nuanced clarification. The industrial revolution was necessary to trigger the urban sanitary transformation underwent in Europe and North America since the late 19^th century. It offered an efficient technical solution capable of meeting the increasing urban demands for drinking water, firefighting resources, and support for industrial production. At the same time, industrialization in itself was not sufficient for sanitary reform. A fundamental shift in the conceptualization and understanding of disease causation was needed. This shift, in turn, encouraged local politicians to commit substantial resources to the construction of expensive waterworks and sewerage systems throughout a country. Of course, this process was fraught with difficulties and marked by periods of progress and regression, but that is a subject that deserves another post.

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Academics, policymakers, and journalists occasionally invoke a Caribbean island as evidence that substantial improvements in health can be achieved without high per capita income. That island, of course, is Cuba. However, there is another Caribbean island that achieved an arguably more impressive health miracle during a similar stage of development: Puerto Rico. Between 1930 and 1960, life expectancy in Puerto Rico increased by nearly 29 years, a rate unprecedented and since rarely exceeded in world history. By 1960, Puerto Rico was a world leader in health outcomes, with life expectancy on par with the United States mainland despite a GDP per capita less than one-fifth the US level. Puerto Rico became the first area of the tropics to reach a modern level of life expectancy. In the 1960s, a commissioner of health declared ‘‘[T]he progress of Puerto Rico in public health has no parallel in any other country’’ (Bourne and Bourne, 1966, p. 81). 

This history is largely forgotten because Puerto Rico—a US territory since 1898—typically does not figure into American history, since it is not a state, or Latin America history, since it is not an independent country. Yet, the achievements of Puerto Rico in improving health outcomes in the early and mid-20^th century are nothing short of miraculous and ought to receive greater attention from economic historians as well as health and development economists.

Public Health Units and Mortality in Puerto Rico

Puerto Rico’s mortality transition is not only forgotten but also poorly understood. In a recent paper (see here) and an accompanying book chapter (see here), I examine the role of public health units (PHUs, or county health departments) through 1945—that is, during the early years of the mortality transition. PHUs opened in every county (or equivalently, municipality) of Puerto Rico at different times between 1926 and 1937, having been transplanted from the US with guidance and some funding from the Rockefeller Foundation (for research on county health departments in the US, see Hoehn-Velasco (2018) and Hoehn-Velasco and Wrigley-Field (2022)). They provided free, mostly preventative services aimed primarily at combatting infant and tuberculosis (TB) mortality. Services included, but were not limited to, prenatal care and nurse home visits, as well as testing and contract tracing for TB. PHUs also administered a program of midwife supervision that instructed those attending births in basic hygiene. More generally, PHUs coordinated all community health efforts, public or private, at the local level; each municipality was to tailor the Department of Health’s policies to local conditions, although units eventually offered more or less the same programs.

To estimate the effect of health units on mortality, I collected annual, municipal-level mortality data for all of Puerto Rico from 1923 to 1945 from reports of the Puerto Rico Department of Health. I then compare the evolution of mortality after the opening of PHUs in communities with a unit to those where a unit had not yet opened in an event study, or difference-in-differences, framework. I find that health units reduced infant and TB mortality by more than 10 percent after several years, accounting for around half of the decline in these forms of mortality through 1945. Similar results have been found for historical interventions in the United States and Scandinavia for pre- and postnatal care (e.g., Wüst, 2012) and tuberculosis dispensaries (Hansen et al., 2020). The evidence also suggests that PHUs likely played an important role in reducing stillbirths and maternal mortality. In descriptive analysis, I show that municipalities that licensed more midwives per capita—presumably broadening access to trained services for childbirth—saw larger declines in maternal mortality, in line with evidence from other historical contexts (e.g., Anderson et al., 2020). Consistent with the historical record, I find that PHUs did not affect malaria mortality, which was not effectively combatted until the federal government intervened around World War II to protect troops on the island. In sum, the event study demonstrates that PHUs succeeded in reducing the outcomes that they targeted—principally, infant and TB mortality—and had no effect on an outcome that they lacked the human and financial resources to deal with, namely malaria mortality.

Remarkably, the reduction in mortality brought about by PHUs came at little additional cost to taxpayers. The financial resources commanded by the Department of Health did not markedly grow until after the rollout of PHUs. The constraints imposed by the Great Depression prompted the department to simplify its organization and reduce expenses. Programs were evaluated periodically, and unproductive efforts were discontinued or phased out. In a back-of-envelope calculation, which bases benefits on the number of life-years saved and the value of statistical life in 1940, I estimate that the benefits of PHUs exceeded costs by a ratio of 12 to 1. 

Learning from Puerto Rico

The mortality transition in Puerto Rico was one of the most successful in world history and offers lessons for economists. My research demonstrates that public health units played an important role in the early years of the mortality transition. However, it is important to keep in mind that Puerto Rico’s rapid improvements were the result of several other factors as well, including the eradication of malaria, the advent of antibiotics, postwar economic growth, and public investments in water treatment.

Puerto Rico is often excluded from discussions of Latin America because its political relationship with the United States has shaped a very different pattern of development. Without question, Puerto Rico received various forms of aid from the US, and PHUs opened under a regime of direct rule by the US. However, public health in the era that I study was administered primarily by local doctors and nurses and funded mostly by domestic taxes. Puerto Rico, therefore, can serve as a useful example for other developing contexts. 

Additionally, practically all countries of Latin America opened public health units after Puerto Rico, so this investigation provides a window into public health in Latin America more broadly. Local health services in Puerto Rico and throughout much of Latin America were realized with the technical and financial aid of the Rockefeller Foundation and US federal agencies. Future research might directly explore public health throughout the region, which likewise enjoyed better health outcomes than would be expected given their level of economic development. 

• Anderson, D. M., Brown, R., Charles, K. K., and Rees, D. I. 2020. Occupational licensing and maternal health: Evidence from early midwifery laws. Journal of Political Economy, 128(11).
• Bourne, D.D. and Bourne, J.R. 1966. Thirty Years of Change in Puerto Rico: A Case Study of Ten Selected Rural Areas. New York: Frederick A. Praeger Publishers. 
• Hansen, C. W., Jensen, P. S., and Madsen, P. E. (2020). Preventing the white death: Tuberculosis dispensaries. Economic Journal, 130(629):1288–1316.
• Hoehn-Velasco, L., 2018. Explaining declines in US rural mortality, 1910–1933: The role of county health departments. Explorations in Economic History, 70, 42–72.
• Hoehn-Velasco, L., Wrigley-Field, E., 2022. City health departments, public health expenditures, and urban mortality over 1910–1940. Economic Inquiry, 60 (2), 929–953.
• Marein, B. 2022. Foreign (Aid) in a Domestic Sense. In R.A. Candela, K.R. Collins, and C.J. Coyne (Eds.), Market Process and Market Order: From Human Action, But Not of Human Design (pp. 129-153). Lanham, MD: Rowman and Littlefield. 
• Marein, B. 2023. Public health departments and the mortality transition in Latin America: Evidence from Puerto Rico. Journal of Development Economics, 160.Wüst, M. (2012). Early interventions and infant health: Evidence from the Danish home visiting program. Labour Economics, 19(4):484–495.

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Sleeping sickness (or African trypanosomiases) is a disease caused by a parasite transmitted by the Tsetse Fly. The disease has been endemic to Africa for hundreds of years and over time communities learned how to avoid tsetse fly infested areas. To be sure, there were the occasional epidemics, but deaths due to sleeping sickness stayed relatively low. This equilibrium was deeply altered when European colonisers started invading the African continent. They contributed to a long sequence of sleeping sickness epidemics that afflicted East and Central Africa in the 20th century. How did these epidemics happen and which efforts did European scientists make to understand and get control over the disease? This blog post answers these questions summarizing the article by Headrick (2014).

Sleeping sickness came upon the European colonisers radar in the beginning of the 19th century, when a big epidemic broke out in East Africa. It cannot be said with certainty, but the author argues that the outbreak of the epidemic is probably related to the introduction of the rinderpest on the African continent with the Italian invasion of Eritrea in 1889. Rinderpest quickly became epizootic since cattle and wild animals had no resistance against it, therefore between 90-95% of them were killed. Because these animals disappeared, big pieces of land were suddenly uninhabited and nature started reconquering the land which made the Tsetse fly infested areas bigger. Also, cattle herders now had to hunt for their food thus being forced to enter these tsetse fly infested areas. Meanwhile an epidemic in French Congo and Ubangi-Shari (now the Central African Republic) broke out. The population there relied on canoe and waterways for transport because of the swampy area, an environment where Tsetse flies also thrive. These epidemics took a lot of lives and caused people to flee from their homes. 

Scientific missions

As a response to the epidemics, European colonisers decided to send renowned scientists to Africa to study the diseases. These visits to the tropics were at its peak between 1901 and 1913, with a total of fifteen medical research missions. The scientific missions soon started getting results, as the complex life of the trypanosome in the digestive track of the Tsetse fly was finally unravelled in 1909. In 1910, a second and more lethal variant that killed patients within months, instead of years, was discovered. Headrick argues that these scientific findings were possible because of international cooperation between the European researchers and physicians. This collaboration was partly fostered by major international congresses about sleeping sickness, which became popular during that time. To be sure, the research missions to Africa were also motivated by political reasons. For example, Portugal embarked on these missions to display how there were able to compete with England. 

There was also collaboration at a diplomatic level. Germany and England signed an agreement in 1908 to prevent border crossings by infected Africans and in 1911 they made an agreement to combat sleeping sickness in West Africa. However this cooperation came to a standstill when the First World War broke out in 1914. When the war ended it took years before efforts in cooperation resumed since the conflict caused substantial hostility between France and Germany. 

Despite the international cooperation between researchers and physicians, they were not able to develop effective treatments or preventive measures. Multiple medicines were developed, but none of them were able to reverse the course of the disease in the second phase, when the trypanosomes have entered the blood-brain barrier. Different types of medications were produced, although only atoxyl was commonly used, which was very toxic and caused partial to total blindness in 20% of patients. The chemotherapeutic dose was close to one, meaning that in order to get rid of the trypanosomes an amount close to a lethal dose had to be injected. Atoxyl was relatively cheap, useful in the tropics and easy to inject, therefore it was kept in use long after safer alternatives were developed. 

Different approaches to combat sleeping sickness from colonisers 

When the epidemic broke out in their colonies, European colonisers reacted quickly for multiple reasons. First, because of a humanitarian motive: “Saving the helpless Africans from this disease”. Second, there was an economic motivation as Africa (especially the equatorial zone) was already thinly populated, labour was needed for transport and agriculture, and cattle could not live in the tsetse fly infested areas. So, Headrick argues that the epidemic was a threat to workers and threat to economic prosperity. Finally, there was also a scientific motivation. Micro-biology was at its peak at the turn of the century and European scientists were extremely interested in identifying and understanding tropical diseases. 

Even though the European colonisers had similar motives, they had different approaches to combat sleeping sickness. Headrick highlights two distinct strategies. The first is the ‘environmental’ approach which focuses on physically separating humans from Tsetse flies. The second is the ‘medical’ approach that consists of attacking the trypanosomes to cure the sick and prevent the spread of pathogens to the healthy.  

The British chose an environmental approach in East Africa because of the advice of scientists. In 1906 the governor of Uganda ordered that everyone must move out of a two mile radius from the lake shores and islands of Lake Victoria because those areas were highly infected with Tsetse flies. It was also forbidden to go fishing, foraging or hunting in those regions. In addition, the governor set up isolation camps were the sick would be treated. Furthermore, efforts were made to destroy the breeding places of the flies and killing wildlife, which was believed to harbour the pathogen. However, some of these measures had a limited effect. For instance, Ugandans resisted forced displacement and controlling hunting practices was discussed but never enforced. In any case, the number of deaths due to sleeping sickness dropped substantially between 1905-1909 and by 1910 the epidemic had receded. 

In contrast to the British, the French applied a medical approach. Eugène Jamot made substantial efforts to set up a vertical health care system to treat sleeping sickness. There were mobile medical teams with the aim of eradicating trypanosomes from the entire population to reduce the risk of infecting the healthy. These teams visited villages and forced people to undergo examination and they injected patients with atoxyl. Whereas these measures had led to great resistance in German East Africa, and eventually the end to their sleeping sickness policy, the French were able to persist with their campaigns. 

The examinations done by the teams were not always humane. They often chose to inject everyone with atoxyl in highly affected areas, even if people did not present symptoms of suffering from sleeping sickness. Also, the teams used Atoxyl long after better and safer drugs had become available. Many tried to flee from these examinations by hiding in bushes when the medical teams approached. 

Conclusion

When European colonisers invaded the African continent they shattered the equilibrium between African communities and nature, creating a great sleeping sickness epidemic in the African continent. Each colonial power then responded differently to this public health challenge. 

The British followed the environmental approach, based on physically separating Africans from the Tsetse fly. The French, on the other hand, focused on eradicating the trypanosomes with atoxyl injections to prevent the healthy from getting infected. Both methods had their drawbacks and were based on coercion, therefore they were met with resistance by locals.

The success of (almost) eradicating sleeping sickness in 1940 put an end to the decline in the health of Africans in the preceding 50 years. After independence new epidemics broke out because of political unrest, civil disorder and population growth. Accurate and recent infection rates of sleeping sickness are hard to come by because of lack of sufficient information, so the struggle with the disease still continues. 

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Motivation

After the Covid-19 pandemic, its impact on mental health has received substantial focus, a sign of how important this part of general health care has become in the last decades. However, this was not always the case. The emotional aspect of individuals’ health became more prominent in 1900. To illustrate this, this post focuses on Germany that was a leading country in some respects concerning the awareness of mental health and it turned the discipline of psychiatry into a medical profession rather than a way of thinking.

Nosology

Unlike regular medicine, psychiatrists did not have a proper classification of diseases (nosology). One of the reasons was because of the seclusion of asylums and the limited exchange of knowledge. This created difficulties for the profession to be taken seriously by others in the medical field, as their knowledge basis and actions seemed less scientific. An additional complication happened when teaching psychiatry, since there were different ideas about the nature of mental illnesses and a consensus had not emerged yet. 

A predominant theory was introduced by Neumann, who argued that there was only one mental disease and that everything they observed were different stages: he called this the ‘Einheitspsychose’. This theory resulted in sooner admittance in asylums, as he claimed there were no different diseases, but the reaction time of the psychiatrists. Kahlbaum, on the other hand, criticised the Einheitspsychose. Instead, he proposed an elaborate framework that, in the end, was never used. Griesinger advocated a different system as well. He wanted to reduce the patriarchal nature of asylums and remove the focus on the asylum as treatment in itself, to focus on techniques that saw madness as a mental disease. In the end, none of these caught on and Einheitpsychose remained the preferred theory. 

The asylum

The first asylums in Germany were placed into existing buildings, such as abandoned churches. As these were often found in the countryside, this meant that the first asylums were placed in a rural setting. This was considered beneficial, as people first had to get back to nature and simplicity to recover. 

While psychiatrists believed that patients would recover the best in facilities placed in rural surroundings, they also considered asylums in the city ill-equipped to help patients. According to them, patients needed seclusion from family and society, before they could start to heal. The admittance and seclusion into the asylum was considered the best form of treatment and often it was considered more important than the therapy applied to patients by psychiatrists. At the same, not everyone agreed with this approach. Griesinger, a German psychiatrist, advocated letting people in their own environment and not admitting them in asylums, especially if that involved long term hospitalization.

Patients were divided according to their gender or faith as well as the progression of a particular disease and the behaviour of the patient, as measured by their cleanliness and tendency to create disruption. Another distinction related to their funding, since they could operate with different sources of funding (public, private or a mixed of both).

How did the overall society perceive the care patients received in asylums? Sometimes, not so well. After public scandals, such as the Mellage trial involving a person who had been wrongfully admitted to an asylum (see here), the fear that one might be unjustly incarcerated increased. This made some people with actual mental problems more reluctant to ask for help. Private clinics had some aura of secrecy surrounding them, sometimes because their patients belonged to the bourgeoisie or the aristocracy. 

Overcrowding

From 1860 onwards there was a problem of overcrowding in mental asylums. While the population in Prussia grew by 48 percent from 1880 to 1910, the number of patients in psychiatric hospitals increased by more than 400 percent (from 27.000 to 143.000). Due to a large number of chronic patients, the asylums turned more into custodial facilities than therapeutic ones. According to psychiatrists, this suggested that Einheitspsychose  was a spreading disease in Germany and that more facilities needed to be build. In some cities this was indeed the case, but the moment the new asylums opened they were already filled with patients.

Overcrowding was not seen as a failure by the discipline, since they explained it as a consequence of rising population and the modern urban environment. But their approach did contribute to more admissions, since they insisted that asylums were the best places for people with mental issues. The sooner they were admitted, the better treatments could work. On top of this, if people were diagnosed too late and they could no longer be cured, they had to remain in the asylum. 

Though overcrowding problems were structural, private asylums suffered somewhat less due to the fees that had to be paid for admission. They also profited from the government, which paid them to admit patients from public institutions in an attempt to relieve some of their pressure. Another way to release some of that pressure involved relying on confessional asylums. These no longer focused on treating the patients, but rather on care and, as such, they were only suited for incurable patients.

To solve the overcrowding conditions of asylums, new ones were built. We can see this in the figure below, which shows increasing numbers of institutions, although in some cases (e.g. Aachen, Düsseldorf or Hannover) were not enough given the rapid population growth of German cities. Consequently, beds per 100.000 residents, generally, went down at the turn of the 20^th century.

Conclusion

The first asylums were placed in rural settings, which led to the isolation of both patients and psychiatrists. This made it harder for patients to reintegrate in society. For psychiatrists, the distance made it difficult to confer with colleagues. A result of this seclusion was the lack of nosology, which created room for a theory, Einheitspsychosis, arguing that all mental illnesses were the same, but with different symptoms. This meant that anyone showing any signs of mental distress could be admitted, which paired with the low rates of patients leaving the asylums, created overcrowding in urban environments. Some new asylums were built, but population growth largely exceeded those investments in some places. 

• Engstrom, E. J. (2019). Clinical Psychiatry in Imperial Germany. In Clinical Psychiatry in Imperial Germany. https://doi.org/10.7591/9781501723940
• Goldberg, A. (2002). The Mellage Trial and the Politics of Insane Asylums in Wilhelmine Germany. The Journal of Modern History, 74(1). https://doi.org/10.1086/343366
• Rössler, W., Riecher-Rössler, A., & Meise, U. (1994). Wilhelm Griesinger and the concept of community care in 19th-century Germany. Hospital & Community Psychiatry, 45(8). https://doi.org/10.1176/ps.45.8.818
• The data from the graphs was taken from the Statisches Jahrbuch Deutscher Städte.

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Sleeping sickness had been endemic to the African continent for decades before European colonisers invaded Africa at the turn of the 20^th century. By invading they destroyed an equilibrium the indigenous communities had created between them and nature, which kept diseases from becoming epidemic (Headrick, 2014). The disease was first discovered by colonisers at the end of the 19^th century, however at the beginning of the 20^th century it had already become epidemic. It took France until 1917 before actual measures were taken in their colonies and a few decades more for the epidemic to do die out. This is relatively late when compared to British Africa, that had the epidemic already under control in the 1910s (Headrick, 2014, pp. 5-6). Why did they differ in their response? This essay will try to answer this question by first discussing their approach to dealing with sleeping sickness in greater detail and then putting forward three factors that can explain their different strategies.

This question is relevant for two main reasons. First, sleeping sickness is still a public health concern in Africa. During the last epidemic in 1998, 40,000 cases were reported and an estimated 30,000 more went undiagnosed. Since then a lot has changed, in 2009 the number cases dropped below 10,000 for the first time in 50 years. In 2019 and 2020 the number of cases stayed below 1,000 a year thanks to bilateral collaboration between the WHO, NGO’s and national policy (World Health Organization, 2022). The second reason is historical: the legacy of medical campaigns has left a big scar in African countries. They were designed and implemented by colonisers in the early 20^th century using coercion to force the indigenous population to undergo painful treatments. According to Lowes and Montero (2021), these campaigns caused mistrust in modern medicine which is still very noticeable today. For example, communities do not access healthcare even when it is available and of good quality. Furthermore health projects of the WHO are not as successful in areas formerly targeted by colonial medical campaigns (Lowes & Montero, 2021).

Sleeping sickness

Sleeping Sickness, or Human African trypanosomiasis, is an illness caused by a parasitic infection. The vector is the tsetse fly, which is native to the African continent and does not exist anywhere else. Its habitat consists of certain bushes (Soff, 1969, p. 262) which thrive in tropical and savannah climate zones (Webel, 2019, pp. 266-267). 

When the fly bites a patient a trypanosome parasite enters the body, causing weakness, malaise, headaches, fever and the swelling of lymph nodes. Eventually it will affect the central nerve system and cause disruptions in the temperature and sleep pattern of its host, with effects as lethargy and insanity. At last, the patient goes into a coma and eventually dies, hence its popular name: sleeping sickness (Webel, 2019, pp. 266-267; Headrick, 2014, p. 1). As described by Headrick (2014, p. 1) the disease consists of two varieties of trypanosomes. The first, and most common, is Trypanosoma brucei gambiense (Worboys, 1994, p. 90) that causes a chronic illness with relatively mild symptoms for months to years before it enters the central nervous system and becomes fatal. The second variety is Trypanosoma brucei rhodesiense and it is much more acute and will be fatal within three to twelve months of infection. 

Epidemics in the colonies

Uganda

In order to discuss the British response, I’ve chosen the Uganda as a case study, one of the most successful colonies fighting against sleeping sickness, which I will discuss more in depth later. Furthermore, the shores of Lake Victoria in Uganda were very much affected by the disease and, therefore, a lot has been written on the region and its response to the epidemic (Worboys, 1994; Soff 1969; Headrick, 2014; Webel, 2019). 

The response from the government in London to the epidemic in Uganda was slow. When in 1902 the epidemic broke out (Worboys, 1994, p. 90) the government decided to set up a research team to search for technical solutions focusing on vector control, but also search for possible therapeutic agents. The progress, which was similar to what we call nowadays biological control methods (Worboys, 1994, p. 92), was slow and in 1906 there were still no answers. 

Meanwhile, the epidemic had been going on for several years costing many lives and the governor of Uganda Hesketh Bell decided to act. He designed a set of measures focused on the vector and the displacement of people. He was initially against the latter since large groups of individuals can be difficult to control and manoeuvre around (Worboys, 1994, p. 91). However, since there weren’t enough technical solutions yet, Bell realised that person control would be necessary. A plan was devised to move communities out of the risk area: a two mile radius from the Victoria lake shores (Soff, 1969). When they encountered people who were infected with the disease, they were sent to isolation camps and often treated with atoxyl (Soff, 1969, p. 263). The forced displacement was met with resistance from these communities. However with cooperation from local leaders, financial compensation and a “long” moving period it turned out possible. 

The implemented measures were a success in Uganda. In 1910 the epidemic had mostly died down and had become such a routine aspect of Uganda medical care that the measures were not enforced anymore (Headrick, 2014; Worboys, 1994). 

French Equatorial Africa

To discuss the French case, I chose French Equatorial Africa (AEF), a federation formed in 1910 that consisted of four French African Colonies: Gabon, Chad, Central African Republic and the Republic of Congo (Thompson & Richard, 1960, p. 12). Since France started effectively treating sleeping sickness after 1910, it makes the most sense to use the AEF as our starting point for my analysis. 

The imperial and colonial government had a hard time with designing and enforcing effective measures to combat the epidemic. However, Dr. Eugène Jamot (director of the Pasteur Institute in Brazzaville) was able to in this situation. In 1917, he created medical teams to be able to travel to villages in order to medically examine and treat people with sleeping sickness. The teams consisted out of French doctors, African nurses trained at the Pasteur Institute, French colonels and African soldiers. The system was an example of vertical health care and thus solely focused on sleeping sickness (Doyle, 2022, pp. 10-11).  

Whereas the British focused on freeing the vector from the trypanosomes, the goal of the French medical teams was to kill the trypanosomes in the entire population in order to protect the healthy (Headrick, 2014, p. 5). Medical teams would travel to villages in order to identify the sick and treat them with atoxyl, sometimes entire villages, even though more effective and safer drugs were already developed at that point. Research had pointed out that atoxyl caused blindness in up to 20% of its patients. Making things worse, after a while trypanosomes even started to build resistance to atoxyl and similar drugs (Headrick, 2014, pp. 3-4). However, the drug was cheap and easy to inject, so the government in AEF disregarded the side effects and kept using it. After Jamot’s success in French Congo he was stationed in Cameroon to implement the same measures. The Colonial administration in Congo opened up a clinic in 1927 specialising in sleeping sickness which eventually replaced the medical teams. The clinic caused a rise in the number of doctors and nurses. Ultimately, the French government finally got a control over the epidemic in 1930. 

Why did the approaches differ?

The responses by both colonial powers were very different. The medical approach used by the French was based on curing patients, most often by injecting them with atoxyl (Headrick, 2014), whereas the environmental approach of the British focused on distancing the vector from the people. Why did they differ? This section highlights the role of three key factors that I elaborate on in the following. 

Scientific influence on policy

The history of tropical medicine is strongly influenced by the history of sleeping sickness, both impacted by growing internationalism and imperial European powers. Indeed, when the aforementioned epidemic began to grow larger and mortality rates kept rising, the interest by imperial governments and researchers grew just as much (Webel, 2019, pp. 267-269). There was little experience and knowledge on tropical diseases at first, so when scientific findings appeared they had an influence on colonial policies. Scientific knowledge and how it was communicated to governments, therefore can be used to explain differences between the sleeping sickness policies of Britain and France.  

Why Britain chose vector control to eradicate sleeping sickness can be partly explained by the role British scientists played. Flies and insects were a popular study subject within the British school of tropical sciences in the 1900s, so scientists soon focused on analysing the importance of the tsetse fly (Worboys, 1994, p. 91). Patrick Manson, founder of the London School of Hygiene and Tropical Medicine, and Ronald Ross, founder of the Liverpool School of Tropical Medicine, had done extensive research before into tropical medicine focusing on insects and flies (Headrick, 2014, p. 2). Manson and Ross played an important role in the research set up by the government; investigating the role of the fly in the transmission of the disease. This vector-oriented research eventually translated into policy when, in the early 1900s, sleeping sickness policy transitioned from a focus on the isolation of the patients to eventually Tsetse Fly control (Worboys, 1994, pp. 92-93). 

But Britain did not work alone on this research, since international cooperation was at that time an important part of scientific findings. Between 1901 and 1913 fifteen medical teams, of which eight British, were sent to the African continent to study the disease. A result of these research missions was international cooperation (Headrick, 2014, p. 2). For instance, British and German researchers and medical practitioners operating in the lake Victoria area regularly circulated information to learn from each other (Webel, 2019, p. 269). A prime example was the work of the Robert Koch, who was stationed in Uganda and worked closely with British researchers. Both Germany and Britain relied heavily on the results of his experiments in the hopes of finding a treatment. In 1906, Koch’s results showed that atoxyl was the most effective and non-toxic treatment (Soff, 1969, pp. 260-261).  

Compared to British scientists, the French focused their research on identifying and eradicating the pathogens (Headrick, 2014, p. 6). Even though the they were the last to send research teams to Africa, they were still part of the scientific race. French scientist namely made breakthroughs in the research of the trypanosomes. Emile Roudbaud and its team of medical entomologists in 1909 were able to unravel the life cycle of the trypanosomes in the digest track of the Tsetse fly (Headrick, 2014, p. 3). A year later, John W. W. Stevens and Harold B. Fantham discovered the second type of human African trypanosomiasis which was caused by a different parasite: T. rhodesiense (Headrick, 2014, p. 3). The focus on investigating the trypanosomes, instead of the vector, can be one of the reasons why France chose a medical approach. 

Colonial political structure

British and French colonies had different administrative structures. Headrick (2014, p. 6) describes how Britain used an indirect way of ruling, appointing native leaders on local administrative and ruling positions. This form of leadership made it possible for Hesketh Bell to act on its own when London was still indecisive on what to do. Bell did not wait on the results of the research, but decided (in the absence of technical solutions) to choose for an environmental approach. He devised measures which he thought were effective but also fair to the communities (Worboys, 1994). In other words, governors and local administrators had some form of autonomy and adapted to and worked with the local political and social systems of indigenous communities (Worboys, 1994, pp. 92-93). The indirect ruling of the colonies made it possible devise a medical approach which was not an one-fits-all solution, but paid attention to what Uganda needed.

France chose a direct way of ruling their colonies. As Headrick (2014) explains, they preferred appointing French soldiers and civil servants at all administrative levels. Medicine was dominated by French army doctors, which was very visible in the composition of the traveling medical teams used to combat sleeping sickness (Doyle, 2022, pp. 10). Whereas Britain was relatively quick to combat the epidemic, France had a hard time with setting up and enforcing effective measures. This can be explained because of the lack of resources in AEF (Headrick, 2014, p. 5). Especially when using direct rule, it can be difficult to generate enough personal and resources to combat an epidemic. Furthermore, the extensive use of force and coercion by the medical teams can be partly explained by the involvement of army doctors and soldiers within these teams. Whereas Bell tried to compensate the communities for their losses and work with them on the solutions. The French forcibly injected entire communities with atoxyl and kept them under inhumane circumstances in isolation camps (Lowes & Montero, 2021, p. 1291). The lack of attention to the humanity of the measures can be contributed to the use of soldiers and the fact that there were no indigenous people who had the power to protest it.

Population density

At last, population density is another important factor that can explain the policies implemented by the British and the French in their colonies. The AEF had a very small population density, especially compared to Uganda, which the calculations below will make clear. Because of this, certain policy measures would not be effective in AEF, whereas the opposite is true for Uganda (more on this below). 

French Equatorial Africa had a large square footage, however it was also thinly populated. It consisted of the current Republic of Congo, Central African Republic, Gabon and Chad. This area had a roughly estimated land are of 2.482.150 sq. km in 1961 (World bank, 2023). Given that the population in the AEF consisted of 6.135.33 people in 1961 (Frankema & Jerven, 2014), population density in AEF in 1961 was 2.47 persons per squared kilometer. On the other hand, Uganda had a population density of 34.95 persons per squared kilometer, which is much higher than in the AEF. Note that the numbers on land area are rough estimates of the land area of colonies which are now independent countries. So borders might have changed a little since independence and therefore have influenced the land area. However this is not so relevant, since the difference between AEF and Uganda is so large, so a small change in land area would not make a difference for our comparison. 

Differences in population density influenced the policy regarding the sleeping sickness epidemic in multiple ways. First, part of the British environmental approach consisted of moving away from the Tsetse fly habitat. However people lived more sparsely in the AEF and not in “enclosed” villages compared to Uganda. Measures focusing on the migration of communities would be considerably more complicated, expensive and less effective in the AEF. Second, the environmental approach also included the destruction of bushes in order to destroy tsetse fly breeding grounds. For the AEF this would have meant working enormous pieces of land which would have had disastrous consequences for the environment. Third, it made sense the French to use travelling medical teams as many were sparsely located. 

Conclusion

Why did the French and British differ in their approach to combat sleeping sickness in Africa? I hypothesize, drawing on the literature, that three factors can be important. 

First, science and scientists influenced policy making. The British school of tropical medicine had a big interest in insects and flies, which tilted policy towards an environmental approach focused on vector control. 

Second, the AEF had a very low population density when compared to the British colony Uganda. Therefore, measures adopted by the British, like communities being forced to move away from the shores of Lake Victoria or destroying the tsetse fly habitat, were undoable and probably not as effective in the AEF. 

And third, the French and British had a very different way of ruling their colonies. London preferred to indirectly rule the colonies drawing on native leaders. France, on the other hand, preferred direct rule. Military doctors were appointed to lead the medical teams and native people were excluded from leadership positions. This sometimes resulted in inhumane measures, such as  using a drug which was proven to be highly toxic, even though alternatives were available. To be sure, the British measures were far from perfect in that aspect, but governor Bell did make an effort to “compensate” the communities and work with them. Whether the compensation offered was fair is something open to discussion. 

Concluding, there was no right or wrong way of treating sleeping sickness, simply methods that came to be because of their time and local constraints.

• Doyle, Shane (2022). “Health in African History”, In Ewout Frankema, Ellen Hillbom, Ushehwedu Kufakurinani and Felix Meier zu Selhausen (eds.), The History of African Development: An Online Textbook for a New Generation of African Students and Teachers. African Economic History Network E-book.
• Frankema, E. and Jerven, M. (2014). African Population Database 1850–1960 (version 3.0). Retrieved from African Economic History Network database:  https://www.aehnetwork.org/data-research/african-population-database-1850-1960/
• Headrick, D. R. (2014). Sleeping sickness epidemics and colonial responses in East and Central Africa, 1900–1940. PLoS neglected tropical diseases, 8(4), e2772.
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• Webel. (2019). Trypanosomiasis, tropical medicine, and the practices of inter-colonial research at lake Victoria, 1902-07. History and Technology, 35(3), 266–292. https://doi.org/10.1080/07341512.2019.1680151
• Worboys, M. (1994). The Comparative History of Sleeping Sickness in East and Central Africa, 1900–1914. History of Science, 32(1), 89–102. https://doi.org/10.1177/007327539403200103
• World Health Organization (2022, January 10). Trypanosomiasis, human African (sleeping sickness). Retrieved from https://www.who.int/news-room/fact-sheets/detail/trypanosomiasis-human-african-(sleeping-sickness)

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