The epidemiological transition

The decline of mortality in Europe throughout the nineteenth and twentieth centuries is generally referred to as the epidemiological transition. The first phase of the transition was a decline of mortality from a period of wars, pestilence and “famine” (Meuvret 1946; Flinn 1981) that had been characterized by both structurally high levels of mortality and incidental outbursts of very high mortality peaks, mainly following bad harvest years. In the second phase, declines in deaths due to infectious diseases brought a broad mortality decline. This lasted until well into the twentieth century, when mortality decreased to a low and stable level. During the third phase it was not the level of mortality that changed, but rather the character. Malnutrition and infectious diseases ceased to be the main causes of death. Instead, cardio-vascular diseases and cancer took their place as well as external causes like murder, suicide and accidents (Omran 1971 and 1983).

By the end of the eighteenth century, death was still in the first phase of this transition and thus at a high level, between 30 and 40 deaths per year per 1000 of the population. Population levels nevertheless remained approximately even due to high fertility rates. During epidemics of the plague, smallpox, typhoid, dysentery, malaria and tuberculosis, aggravated by subsistence crises, mortality exceeded fertility. Infants and the elderly were particularly vulnerable and during these epidemics the population in parts of Europe could be decimated. In the Netherlands, though, the effects of the epidemics were not as disastrous as they could be elsewhere in Europe. Dutch agriculture had long been highly commercialized and the various parts of the country were as well connected with each other as with other countries, resulting in a steady supply of food.

It has proven impossible to point out a single reason for the decline of mortality that marked the second phase of the epidemiological transition. The mortality decline started at the time of industrialization, which entailed unhealthy working conditions and unsanitary, crowded living conditions in the cities, which could hardly have improved the health of the population. On the other hand we know that the agrarian revolution that preceded industrialization, as well as the economic growth that resulted from it, improved the standard of living considerably.