Mortality in England in the Eighteenth and Nineteenth Centuries: A Reply to Sumit Guha
Citation: Szreter (1994) Mortality in England in the Eighteenth and Nineteenth Centuries: A Reply to Sumit Guha.
This article is a response to Guha's critique of Szreter 1988 (in the 663 syllabus), which, of course, busts on McKeown. (Not a direct quote from the article!)
Szreter's responses to Guha's 4 main critiques are: 1. According to Szreter, Guha claims that Szreters's thesis is that urban mortality in any time or place can only improve through medical or sanitary interventions. Szreter points out that his emphasis on public health measures in the later 19th and 20th centuries was period-specific. It is central to Szreter's (1988) argument that an 18th-century decline in mortality was curtailed by the new health dangers arising from an unprecedented rapidity of provincial urban growth in centers of industry, even resulting in the appearance of new kinds of disease; the disease ecology of urban England was very different in the 19th and 18th centuries. 2. Guha supports McKeown's thesis regarding standards of living and criticizes Szreter (1988) regarding the epidemiological record of respiratory TB in 19th century. However, as Szreter points out, there was no net rise in real wages in London from the 1740s to 1840s, which according to McKeown and Guha was associated with a drop in respiratory TB due to nutritional improvements. Moreover, there was a substantial absolute rise in fatal incidence of bronchitis/pneumonia/flu at the time, which Guha confirms. Moreover, the drop in respiratory TB didn't start until 1867. 3.
Guha supports McKeown's analytical framework, distinguishing between those factors related to initial exposure to the micro-organisms, those related to an individual's contraction of disease symptoms, and those related to a fatal outcome. Szreter argues that although these can be formulated in language as three separable logical gates, it is not legitimate to assume that their empirical outcomes are causally independent of each other. In another misleading representation of Szreter, Guha argues that Szreter's (1988) argument was disproved by its supposed failure to account for the historical course take by infantile diarrhea mortality. However, Szreter (1988) states in his argument that such mortality is due to personal and domestic hygiene rather than classic sanitation. Therefore, it does not contradict the reduction of other infectious diseases related to improvements in public health. The continued prevalence of diarrheal diseases signified the limit of what was achievable at the strategic level alone, without a more probing and comprehensive form of social intervention against mortality, such as the public health movement, politicians, and the populace at large were finally developing around the turn of the century