THE POPULATION OF EUROPE: THE DEMOGRAPHIC TRANSITION AND AFTER

Michael R. Haines

Every modern, high-income, developed society has undergone a shift from high to low levels of fertility and mortality. This is known as the demographic transition, and it has taken place, if only partially, in many developing nations as well. It is part of the more general process of modern economic growth and modernization, which includes other features such as rising levels of education and skill (human capital); structural transformation from low-productivity, predominantly agrarian societies to high-productivity manufacturing and service economies; increasing innovation and application of new technologies; significant relocation of the population from rural to urban and suburban places; and increasing political and administrative complexity, accompanied by deepening bureaucratization.

Europe and its direct overseas offshoots (the United States, Canada, Australia, and New Zealand) were pioneers of the demographic transition. An immediate result of this process was the acceleration of population growth. Table 1 presents data on the size of the population of Europe (not including Russia) and selected European nations at dates between 1750 and 1990 and calculates the implied growth rates for the subperiods. Especially notable was the acceleration of population growth in the nineteenth century, with a slowing down in the twentieth century. Consequently, the population of Europe rose from about 16 percent of the estimated world total in 1750 to about 20 percent in 1950. But slower European growth relative to most of the rest of the world (especially many developing nations) after 1950 had reduced that share to 14 percent by 1990.

In the nineteenth century several nations that underwent rapid industrialization and urbanization also experienced high population growth rates, most notably England and Wales and Germany. But this was not always the case, as the example of France shows. Rapid growth sometimes preceded industrial and urban development, as in Germany and the Netherlands. The slower population growth in the first half of the twentieth century (relative to the nineteenth century) was due especially to declining birthrates but also to the effects of two catastrophic wars. Europe suffered almost 8 million battle deaths (including Russia) and over 4 million civilian casualties in World War I. World War II was even worse, with over 10 million battle deaths and over 25 million in civilian losses.

The acceleration of population growth in the nineteenth century was a direct consequence of declining death rates and stable or even rising fertility rates. In England rising birthrates produced much of the growth, and these were, in turn, the consequence of increased incidence of marriage and earlier age at marriage and not of rising marital fertility. Birthrates rose in Germany in the nineteenth century as well. In other cases declining mortality played a more central role.

The standard model of the demographic transition has four stages. First is the premodern era of high fertility (for example, a crude birthrate [births per 1,000 population per year] in the range of 45 to 55) and mortality that is both high (for example, a crude death rate [deaths per 1,000 population per year] in the range of 25 to 35) and fluctuating. This is the world that Thomas Robert Malthus depicted in his Essay on the Principle of Population (1798), in which population growth was checked by periodic mortality crises caused by famine, disease, and war. The second stage is the mortality transition, in which death rates stabilize and fall but birthrates remain high. The effect is a significant rise in natural increase (the excess of births over deaths) and population growth. The third phase is the fertility transition, leading finally to a decline in natural increase and population growth. The final stage is that of the demographically mature society with low birth and death rates.

There are a number of problems with this model, not the least of which is that it predicts poorly the timing and speed of both the mortality and fertility transitions in many cases. Whether the mortality transition

precedes or occurs simultaneously with the fertility decline is also debated. It fits the historical experience of Europe well in only some cases, and it does not deal with migration. Nonetheless, it does provide a convenient framework for discussion.

THE FERTILITY TRANSITION

The fertility transition in Europe is now well documented by a substantial study, the European Fertility Project, completed in the 1980s. The study provides a set of standard measures of fertility and nuptiality for over twelve hundred provinces of Europe from the middle of the nineteenth century to 1960. The standard measures are the indices of overall fertility (I _f), marital fertility (I _g), nonmarital fertility (I _h), and the proportions of women married (I _m). The indices compare the actual number of births in a nation or geographic subunit with the number that would be produced if all the women had the birthrates of the highest fertility population ever observed—married Hutterite women (members of an Anabaptist sect) in North America in the 1920s. Specifically, I _f gives the ratio of actual births for a given population of women to the births that the same group of women would have experienced if they had had the fertility of married Hutterite women. I _g measures the same for married women in the given population, and I _h provides an index for unmarried women. The fertility indices thus furnish a form of indirect standardization with a value of 1.0 being historically close to maximum human reproduction. I _m is different, being ratios of the weighted age distributions of married women in the given population to the weighted age distribution of total women in the given population. While these indices are merely a form of indirect standardization, their modest data requirements, easy intuitive interpretation, ease of calculation, and current wide utilization are real advantages. Also, it is useful to note that when nonmarital fertility is low (as it was in most of Europe in the late nineteenth and early twentieth centuries), I _f is approximately equal to I _g multiplied by I _m.

Table 2 provides measures of fertility and mortality for a set of European nations selected because of their size, historical importance, and regional representativeness. The table gives one measure of marital fertility (I _g), one measure of nuptiality (I _m), and two commonly used measures of mortality, the infant mortality rate (infant deaths per thousand live births per year) and the expectation of life at birth (e [0]). The upper three panels describe the fertility transition. Several things are noteworthy. First, the transition in overall fertility (I _f) was due to declining marital fertility (I _g) and not changes in nuptiality (I _m). Marriage actually increased, at least after 1900. Second, France by 1870 already had relatively moderate levels of overall and marital fertility (with an I _g of .494). In contrast, other nations still had high levels, such as Germany (.760), Sweden (.700), and the Netherlands (.845). Third, Russia (and most of eastern Europe and the Balkans) had a delayed decline, though not by too much. Finally, although not seen in this table, there was a nuptiality "frontier" in Europe in the late nineteenth century, running from southwest to northeast from around Trieste at the northern end of the Adriatic to the eastern end of the Baltic. Areas north and west of this line were dominated by what John Hajnal has called the "western European marriage pattern." It was characterized by late ages at first marriage (23 to 28 years) and high proportions of the population never marrying (often above 10 percent of the population aged 45 to 54 years). South and east of the line, first marriage was much earlier (18 to 22 years) and the rate of permanent nonmarriage significantly lower (below 10 percent of the population aged 45 to 54 years).

Summarizing the main results of the European Fertility Project, John Knodel and Etienne van de Walle (1982) drew six major conclusions. First, the modern fertility transition in Europe was caused proximately by reductions in marital fertility and not by changes in marriage or nonmarital fertility. Second, prior to the transition, Europe's populations were characterized by natural fertility, that is, by fertility not subject to deliberate limitation. Third, once under way, the decline was irreversible. Fourth, with the exception of France, the irreversible decline commenced roughly in the period 1870 to 1920. Fifth, the transition took place within a wide variety of social and economic conditions. Sixth, cultural settings exercised a significant influence.

Socioeconomic and cultural explanations. These data raise the issue of what causes families to decide whether, when, and how to have fewer children. The conventional explanations emphasize structural factors associated with socioeconomic development. The decline of infant and child mortality reduced the need for as many births to generate a target number of surviving children. The costs of children rose and their direct economic benefits fell for a variety of reasons, including the relative decline of agriculture and self-employment, the improved status of women (increasing the opportunity cost of their time, including the care and rearing of children), increased female employment outside the home, laws restricting child labor, compulsory schooling laws, the rise of institutional retirement insurance (reducing the value of children for that end), and rising housing and subsistence costs associated with urbanization. As more education brought higher returns, parents were led to invest in more quality per child and to reduce the numbers of children to make this possible. In addition, the cost, availability, and technology of family limitation methods improved from the late nineteenth century onward.

There is now evidence, however, that these explanations are insufficient. One finding of the European

Fertility Project was that the irreversible decline in marital fertility began under a wide variety of socioeconomic conditions. For example, England and Wales, taken as a single nation, was the most modernized nation in Europe in the late nineteenth century, but its sustained decline in marital fertility only began around 1890. At that time it had an infant mortality rate of 149, 15 percent of the male labor force in agriculture, 72 percent of the population urban (and 57 percent living in cities of twenty thousand or more), and low illiteracy. In sharp contrast, Bulgaria began its sustained transition around 1910 (merely twenty years later) with a similar infant mortality rate (159), but at a much lower level of socioeconomic development: 70 percent of the male labor force in agriculture, only 18 percent urban (and only 7 percent in cities of twenty thousand or more), and 60 percent of the adult population illiterate. France, the most unusual case, began its transition very early (from at least 1800), with an infant mortality rate of 185, 70 percent of the male labor force in agriculture, 19 percent urban (and 7 percent in cities of twenty thousand or more), and high illiteracy. These examples can be multiplied. In other words, the standard structural variables did not predict when the European fertility transition would set in.

Furthermore, this process occurred in different ways for different groups, and other factors could be involved. Middle-class groups were often among the first to reduce birthrates because of their early commitment to higher levels of education and therefore to the ensuing costs. Too many children jeopardized the fairly high standard of living that middle-class families sought to maintain. Peasants usually made the turn to lower fertility later, for children's work continued to seem useful. But in special cases where concern for the preservation of property against inheritance divisions was a factor, as in France, peasant birthrate reductions could begin early. Urban workers, under pressures of economic insecurity, usually began to reduce birthrates after the middle class.

Another finding of the European Fertility Project was that cultural settings made a difference. This is illustrated by several examples. Belgium is divided by a linguistic boundary, with Flemish predominantly spoken on one side (roughly northern and western Belgium) and French on the other (roughly south and southeast Belgium). Along that boundary, socioeconomic conditions were similar, but fertility was demonstrably higher on the Flemish-speaking side. It was also found that excellent predictors of early fertility decline among the arrondissements of Belgium were the proportion voting socialist in 1919 (a positive predictor) and the proportion making their Easter duties in the Roman Catholic Church (a negative predictor). This phenomenon was titled "secularization" by Ron Lesthaeghe. In France, also, areas of religious fervor long displayed higher-than-average birthrates. Similarly, a map of marital fertility in Spain around 1900 bears a strong resemblance to a linguistic map of the same country. The rapid spread of the idea of family limitation in the late nineteenth and early twentieth centuries across a variety of socioeconomic settings supports the notion that it was as much a change in worldview as a change in underlying material conditions that initiated the fertility transition. Ansley Coale (1967) has noted that three preconditions are necessary for a fertility transition: first, fertility control must be within the calculus of conscious choice; second, family limitation must be socially and economically advantageous to the individuals concerned; and third, the means must be available, inexpensive, and acceptable. Much of the research has focused on the second condition. But the cultural explanation asserts that the first condition was not fulfilled in most of Europe until the late nineteenth or early twentieth centuries.

In the long run, of course, birthrate reductions also responded to the drop in infant mortality, but the latter usually occurred after the former had begun. Some historians argue that, having fewer children, families became more alert to protecting the health of those who were born.

Birthrate reductions were often initially based on sexual restraint (this was true for workers into the twentieth century, in places like Britain). In some cases women may have taken the lead, out of a concern for their own health and also because, since they were responsible for household budgets, they were particularly aware of children's costs. The impact of this part of the demographic transition on family life and on the self-perceptions of mothers and fathers have stimulated further analysis. The process was clear, but not necessarily easy.

Declining reproduction rates. Birthrates by the end of the twentieth century had declined to the point that many populations in Europe were not, in the long run (fifty to seventy years), reproducing themselves. The gross reproduction rate is a measure of that reproductive capacity. A value greater than 1.0 indicates that, in the long run, natural increase (the surplus of births over deaths) will be positive; a value of 1.0 means that natural increase will eventually be zero; and a value less than 1.0 points to eventual negative natural increase. The gross reproduction rate by the 1990s was below 1.0 in most western European nations: England and Wales (.856 in 1985), Germany (.629 in 1996), France (.828 in 1996), Italy (.581 in 1994), the Netherlands (.730 in 1996), Spain (.552 in 1995), Sweden (.916 in 1994), and the Russian Federation (.633 in 1995). In several cases (Germany, Italy, the Russian Federation, Bulgaria, the Czech Republic, Hungary, the Ukraine) natural increase is already negative. Without net immigration, these nations will have declining populations (and several do). This decline has occurred despite the "baby boom" that many of these countries experienced after World War II. Peak gross reproduction rates came in the early 1960s: England and Wales (1.66), West Germany (1.18), France (1.37), Italy (1.22), the Netherlands (1.52), Spain (1.38), Sweden (1.18), and the Russian Federation (1.21).

The reasons for this fertility "boom" and "bust" since 1945 are complex, and consensus is still not fully achieved. But the small age groups (age cohorts) of young adults in the prime childbearing years (ages eighteen to thirty-five) experienced very favorable labor market conditions in the 1950s and early 1960s: high wages, low unemployment, growing real incomes. This interacted with their modest consumer aspirations, created during the lean years of depression, war, and postwar recovery in the 1930s and 1940s, to produce a desire for more goods and services as well as more and better-educated children. The result was rising birthrates from the late 1940s to the early 1960s in many European societies (as well as in the United States, Canada, Australia, and New Zealand). The "baby bust" began in the mid 1960s as real wages and income failed to keep pace with consumption aspirations and has continued to the present.

There are now strong concerns about possible population declines and also about the rapidly aging population. A proportionately older population creates greater strains on currently funded retirement systems as it adds more recipients and fewer net contributors. The systems of medical facilities and insurance are also burdened with greater care for the elderly and similar erosion of the tax base. Population analysis shows that the demographic age structure depends (in the absence of significant international migration) largely on fertility and not on mortality. Although mortality does have some effect, especially in the last decades of the twentieth century as death rates declined rapidly among the elderly, it really operates at all levels of the population age pyramid. Fertility, in contrast, works only at the bottom of the age pyramid, among the youngest age cohorts. Low and declining birthrates produce a proportionately older population. For example, in 1861 Italy had 5.7 percent of its population aged sixty and over. By 1951 this figure was 12.2 percent, and it had risen to 20.9 percent in 1991. It is projected to be about 30 percent in 2025. Similarly, England and Wales had an elderly population (aged sixty and over) of 7.3 percent of the total in 1851. This had risen to 15.9 percent in 1951 and 20.9 percent in 1991. The projection for the United Kingdom for 2025 is about 27 percent. Approximately the same is true for all other European nations. One of the most important population welfare challenges of the twenty-first century will be to find ways to fund retirement and health care for these aging populations despite a relatively shrinking tax base.

THE MORTALITY TRANSITION

The mortality transition is the other part of the European demographic transition. This has become known as the "epidemiological transition," following Abdel Omran (1971), who divides the history of mortality into three broad phases. The first is the "age of pestilence and famine," in which the expectation of life at birth (e [0]) is in the range of about twenty to forty years and the annual death rate is quite variable. This was true for Europe before about 1750 or 1800. The great variability is characteristic of a Malthusian world in which population growth is checked by periodic mortality crises caused by epidemics, famines, wars, and political disturbances. However, not all areas experienced these crises. France did in the seventeenth and eighteenth centuries, for example, but English population growth was more often checked by adjustments to fertility via marriage in the same period. The second period is the "age of receding pandemics," in which the e (0) rises to the range thirty to fifty years and during which the extreme mortality peaks diminish in both frequency and severity. This era began in Europe in the late eighteenth century and predominated by the late nineteenth century. Finally, we are now in the "age of degenerative and man-made diseases," in which the e (0) rises above fifty years. Europe entered this period in the twentieth century. Similarly, work by Richard Easterlin (1999) dates the modern mortality transition in Europe from the late nineteenth and early twentieth centuries: England and Wales from 1871 with an e (0) of 41 years, Sweden from 1875 with an e (0) of 44.9 years, and France from 1893 with an e (0) of 45.4 years.

Mortality rates. The course of the modern mortality transition in the eight countries used as examples here is outlined in the last two panels of table 2. They present the infant mortality rate (deaths in the first year of life per thousand live births per year) and the e (0) for both sexes combined. Although mortality had already been declining from the eighteenth century, the modern transition commenced in the late nineteenth and early twentieth centuries. So, for example, e (0) rose from about thirty-seven years around 1780 in Sweden to about forty-five years around 1875. But it then increased to approximately seventy-five years by 1975. Sweden thus gained only 4.6 years of e (0) in the fifty years prior to 1875 but 17.2 years in the fifty years thereafter. England and France also experienced accelerations in the rate of mortality decline in the late nineteenth century, England from about 1870 and France from about 1890.

The transition in the infant mortality rate accompanied this decline, although the modern transition was often delayed by several decades. (Note that infant mortality is an important component of e [0].) The basic factors affecting infant mortality were often quite different from those affecting general mortality rates: practices of infant feeding (including breastfeeding), weaning, and infant care as well as the types of diseases were wholly or significantly unrelated to the factors affecting survival for older children, teenagers, and adults. The infant mortality transition was truly dramatic. Around 1870, between 13 and 30 percent of all infants did not survive their first year of life. By 1980 this was down to between .7 and 2.7 percent, and it has continued to improve. But it is also apparent that in some countries (England and Wales, Germany, Spain) little progress was made until after 1900. Interestingly, a country's level of development was not decisive in predicting either the initial level or the timing of decline: England and Wales and Germany were quite economically advanced but did poorly. Sweden was not especially developed by the 1870s but did quite well in terms of lower levels of infant mortality and an early transition. England and Germany were impeded to some degree by their high and growing levels of urbanization.

Causes of death. The model of the epidemiological transition emphasizes causes of death. The earliest period is dominated by infectious and parasitic diseases, whether epidemic or endemic. These would include smallpox, measles, scarlet fever, diphtheria, cholera, malaria, typhoid fever, typhus, whooping cough, tuberculosis, pneumonia, and such generic conditions as bronchitis, gastritis, and enteritis. Causes of death then progressively shifted to so-called degenerative diseases such as cancer, heart disease, cerebrovascular disease (of which stroke is the most prevalent), and diabetes. Unfortunately for historical research, cause of death information is neither abundant nor often of good quality. Systematic collection of cause of death data did not commence until the mid-nineteenth century, and then medical theories most often suggested causes based on symptoms rather than on underlying disease processes. Some designations were uninformative or even absurd (such as senility, teething, failure to thrive). The First International List of Cause of Death (ICD-1) was not accepted until 1899. Since then there have been eight revisions, moving more in the direction of disease processes rather than symptoms. Thus the categories have had shifting boundaries over time.

Nevertheless, a pioneering effort to look at the modern mortality transition from the perspective of cause of death was undertaken by Samuel Preston, Nathan Keyfitz, and Robert Schoen (1972; also Preston, 1976). They documented two of the earliest populations in Europe with acceptable data: England and Wales from 1861 and Italy from 1881. For England and Wales, the share of diseases demonstrably caused by pathogenic microorganisms (respiratory tuberculosis; other infectious and parasitic diseases; influenza, pneumonia, bronchitis; and diarrheal diseases) declined from 69 percent of known causes (for both sexes combined) in 1861 to 13 percent in 1964. Correspondingly, the share of degenerative diseases (neoplasms [cancer], cardiovascular, and certain other degenerative diseases) rose from 17 to 80 percent over the same period. For Italy, the decline in the share of infectious disease was from 70 percent in 1881 to 11 percent in 1964 (of known causes), and the increase in the share of degenerative disease was from 16 to 78 percent for the same time span. Some of this shift was due to the aging of the population, but most of it was a change in the underlying cause structure of mortality. (As an indicator of problems with the data, however, the share of causes in the category "other and unknown" fell from 31 percent of all deaths in 1861 to only 8 percent in England and Wales over the hundred years from 1861 to 1964. Italy experienced a similar improvement in data quality, with a decline in the share of "other and unknown" causes from 23 to 11 percent from 1881 to 1964.)

Causes of the transition. The causes of the mortality transition are complex and operated over a longer time period than the factors affecting fertility decline. Prior to the middle of the nineteenth century, some changes did take place that improved the chances of human survival. The bubonic plague ceased to be a serious epidemic threat after the last major outbreak in southern France in the years 1720–1722. The reasons are unclear, but exogenous changes in the etiology of the disease probably occurred (that is, the rat population changed its composition). The role of effective quarantine made possible by the growth of the modern nation-state and its bureaucracy must also be considered. Another development was the progressive control of smallpox, first through inoculation in the eighteenth century (which gives the patient a case of the disease under controlled conditions) and then vaccination in the late eighteenth and early nineteenth centuries.

But gains in longevity from medical and public health advances and improvements in the standard of living were often offset by the growth of urban environments that accompanied modern economic growth. In England and Wales and in France, the expectation of life at birth was about ten years lower in cities than it was in rural areas in the early nineteenth century. Although the underlying relationship between development (and especially real income per capita) and mortality was probably positive by the early nineteenth century, the correlation might not have been very strong, partly because of urbanization and also because extra income could not "buy" much in terms of extra years of life. Urban mortality rates did not converge with rural death rates until the interwar period, although today cities often have better longevity because of superior health care.

The origins of the "epidemiological transition" in Europe were influenced by a variety of factors. They may be grouped into ecobiological, public-health, medical, and socioeconomic factors. These categories are not mutually exclusive, since, for example, economic growth can make resources available for public-health projects, and advances in medical science can inform the effectiveness of public health. Ecobiological factors were generally not too important. Although there were favorable changes in the etiology of a few specific diseases or conditions in the nineteenth century (notably scarlet fever and possibly diphtheria), reduced disease virulence or changes in transmission mechanisms were not apparent. One important new epidemic disease, cholera, made its appearance in Europe for the first time in the 1820s and early 1830s.

The remaining factors—socioeconomic, medical, and public-health—are often difficult to disentangle. For example, if the germ theory of disease (a medical-scientific advance of the later nineteenth century) contributed to better techniques of water filtration and purification in public-health projects, it is not easy to separate the role of medicine from that of public health. Thomas McKeown (1976) has proposed that, prior to the twentieth century, medical science contributed little to reduced mortality in Europe and elsewhere. His argument basically eliminated alternatives: if ecobiological and medical factors are eliminated, the mortality decline before the early twentieth century must have been due to socioeconomic factors, especially better diet and nutrition, as well as improved clothing and shelter (that is, standard of living). These conclusions were based particularly on the experience of England and Wales (and the available cause-of-death data back to the mid-nineteenth century), where much of the mortality decline between the 1840s and the 1930s was due to reductions in deaths from respiratory tuberculosis, other respiratory infections (such as bronchitis), and nonspecific gastrointestinal diseases (such as diarrhea and gastroenteritis). No effective medical therapies were available for these infections until well into the twentieth century. However, to cite an example of the problems with this account, the bronchitis death rate in England and Wales actually rose while that for respiratory tuberculosis was falling, indicating better diagnosis. Such results certainly vitiate McKeown's contentions.

Impact of medicine and public health. It is true that medical science did have a rather limited direct role before the twentieth century. In terms of specific therapies, smallpox vaccination was known by the late eighteenth century and diphtheria and tetanus antitoxin and rabies therapy by the 1890s. Many other treatments were symptomatic. The germ theory of disease was arguably the single most important advance in medical science in the modern era. It was put forward by Louis Pasteur in the 1860s and greatly advanced by the work of Robert Koch and others in the late nineteenth century. But it was only slowly accepted by what was a very conservative medical profession. Even after Koch conclusively identified the tuberculosis bacillus in 1882 and the cholera vibrio in 1883, various theories of miasmas and anticontagionist views were common among physicians. Hospitals, having originated as pesthouses and almshouses, were (correctly) perceived as generally unhealthy places to be. Surgery was also very dangerous before the advances in antisepsis and technique in the 1880s and 1890s. Major thoracic surgery was rarely risked and, if attempted, patients had a high probability of dying from infection or shock or both. Amputations were best done quickly to minimize risks. Although anesthesia had been introduced in the 1840s and the use of antisepsis in the operating theater had been advocated by the British surgeon Joseph Lister in the 1860s, surgery was not considered reasonably safe until the twentieth century.

Although the direct impact of medicine on mortality in Europe over this period may be questioned, public health did play an important role and thereby gave medicine an indirect role. After John Snow identified polluted water as the cause of a cholera outbreak in London in 1854, pure water and sewage disposal became important issues for municipal authorities. William Budd correctly identified the mode of transmission of typhoid fever in 1859. The specific causal agents for a number of diseases were found from about 1880 onward, and therapies and immunizations were developed. A notable example was a diphtheria vaccine (in 1892 by Emile Adolph von Behring). And the twentieth century saw the development of specific therapies (such as Salvarsan for syphilis) and general antimicrobial drugs (sulfanomides and broad-spectrum antibiotics) from the 1930s onward.

A pattern was emerging in the late nineteenth century: massive public-works projects in larger metropolitan areas provided clean water and proper sewage disposal. But progress was uneven. As time went along, filtration and chlorination were added to remove or neutralize particulate matter and microorganisms. This was a consequence of the acceptance of the findings of the new science of bacteriology. Public-health officials were often much more cognizant of the need to use bacteriology than were physicians, who sometimes saw public-health officials as a professional threat. Marshaling resources and political support to pay for many of these public-works and public-health projects could slow their development. Much of the development was locally funded, leading to uneven and intermittent progress toward water and sewer systems, public-health departments, and so on. A famous case that convinced many of the skeptics took place in Hamburg during the cholera epidemic of 1892. The city of Hamburg, which had a somewhat antiquated water system not equipped to protect the city from water-borne disease, experienced a devastating epidemic, while the adjacent Prussian city of Altona, which had a sanitary system, had no dramatic increase in deaths.

Progress in public health was not confined to water and sewer systems, though they were among the most effective weapons in the fight to prolong and enhance human life. Simply by reducing the incidence and exposure to disease in any way, public-health measures improved overall health, net nutritional status, and resistance to disease. Other areas of public-health activity from the late nineteenth century onward included vaccination against smallpox; use of diphtheria and tetanus antitoxins (from the 1890s); more extensive use of quarantine, as more diseases were identified as contagious; cleaning urban streets and public areas to reduce disease foci; physical examinations for school children; health education; improved child labor and workplace health and safety laws; legislation and enforcement efforts to reduce food adulteration and especially to obtain pure milk; measures to eliminate ineffective or dangerous medications; increased knowledge of and education concerning nutrition; stricter licensing of physicians, nurses, and midwives; more rigorous medical education; building codes to improve heat, plumbing, and ventilation in housing; measures to alleviate air pollution in urban settings; and the creation of state and local boards of health to oversee and administer these programs. The new knowledge also caused personal health behaviors to change in effective ways.

Public health proceeded on a broad front, but not without delays and considerable unevenness in enforcement and effectiveness. Regarding the case of pure milk, it became apparent that pasteurization (heating the milk to a temperature below boiling for a period of time), known since the 1860s, was the only effective means of ensuring a bacteria-free product. Certification or inspection of dairy herds was insufficient. Pasteurization was resisted by milk sellers, however, and it only came into common practice just before World War I.

Public health and public policy can thus be seen as having played an indispensable part in the mortality transition. The role of nutrition and rising standards of living cannot be discounted, but applied science was much more important than allowed by McKeown. Work by Preston (1976, 1980) has demonstrated that up to three-quarters of the improvement in e (0) in the twentieth century was not due to economic development (that is, improvements in real income per capita) but rather to shifts in the relationship of development to mortality, much of which can be attributed to public-health and medical intervention.

But there were interactions between reduced incidence of infectious and parasitic disease and improvements in general health. An indicator of health status is final adult stature. A population may have reasonable levels of food intake, but a virulent disease environment will impair net nutritional status—the amount of nutrients available for replacement and augmentation of tissue. Repeated bouts of infectious disease, especially gastrointestinal infections, impair the body's ability to absorb nutrients and divert calories, proteins, vitamins, and minerals in the diet to fighting the infection rather than to tissue construction or reconstruction. Research in the 1980s and 1990s indicated increases in stature (based largely on military records) since the nineteenth century. For example, between the third quarter of the eighteenth century and the third quarter of the nineteenth, adult male heights increased by only 1.1 centimeters on average in six European nations (Great Britain, France, Norway, Sweden, Denmark, and Hungary). But after the mortality transition had begun, stature grew by an average of 7.7 centimeters in the following century.

MIGRATION

An issue not usually addressed by the demographic transition is migration. Historically, the movement of peoples was very important in Europe. By the early nineteenth century, large numbers of Europeans began leaving their countries, in many cases destined for the United States and other overseas areas (Canada, Australia, New Zealand, Argentina). This was a major factor in reducing population growth rates. Between 1820 and 1970, Europe sent approximately 36 million people to the United States alone. After the potato famine of the 1840s Ireland lost so many people to migration (4.5 million to the United States between 1840 and 1970) that the population declined for over a century, from over 8 million in 1841 to about 4.3 million in 1951. Lesser known is the fact that Norway had the second highest out-migration rate in Europe. By 1910, 14.7 percent of the population of the United States (and 22 percent of the Canadian population) was foreign-born.

By the late twentieth century Europe had changed from a region of net emigration to one of net immigration. People from the Third World and from areas of Europe outside the foci of rapid economic growth (the Balkans, eastern Europe, Russia) migrated to western Europe in substantial numbers. Besides exacerbating a number of social issues, it made more difficult the maintenance of the modern welfare state. But these new residents provided what the receiving nations needed—their labor. And the trend will continue as long as sharp wage and income gaps exist between the prosperous nations of Europe and these sending areas, as long as serious economic and political dislocations continue in the former East European bloc, and as long as the receiving nations do not close their borders to migrants.

CONCLUSION

In the past two hundred years, Europe has undergone the demographic transition from high levels of fertility and mortality to low, modern levels of birth and death rates. This led to lower rates of population growth and the aging of the populations. Increased longevity, very low infant and child mortality, and remarkably improved education and health have all been part of this modernization process. Nonetheless, the low population growth rates and progressively older populations now pose new challenges for public policy.

See alsoModernization (in this volume);Public Health (volume 3);Medical Practitioners and Medicine (volume 4);Standards of Living (volume 5); and other articles in this section.

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