- The State and the Epidemiological Transition: An Introduction
Between 2011 and 2013 the Center for Historical Research at Ohio State University (OSU), in collaboration with scholars from throughout the university, hosted a two-year program of seminars, lectures, and fellowships on the problem of “Health, Disease, and Environment in World History.”1 The articles here by Nükhet Varlık, Katherine Arner, and Tamara Mann are a small sample of the excellent work presented by six fellows and twenty visiting and OSU scholars. These articles in particular bring together the important new work that scholars are doing on the role of the state in shaping the health of populations.
Four decades ago three scholars established grand frameworks for the history of disease in world history. Alfred Crosby’s Columbian Exchange described the devastating impact of Eurasian diseases on the peoples of the Americas and Oceania. William McNeill, in Plagues and Peoples, framed an interpretation of the arc of disease and health history from the Paleolithic to the modern period. Finally, Abdel Omran, in a short and seemingly modest article, charted a model of the “epidemiological transition.” The three articles in this forum build upon the great [End Page 737] legacy of the grand frameworks built by Crosby and McNeill. But they track more specifically both the substance and the spirit of the model proposed by Omran: advances in medical knowledge brought to bear by state intervention on the public health of large populations have been a profound force in the emergence of modernity.2
Omran’s proposal was a challenge to the more prominent work of Thomas McKeown, whose 1976 The Modern Rise of Populations argued that improving nutrition shaped by a general pattern of economic development—not medical advance or state intervention—was the fundamental determinant of the mortality decline that has been the essential demographic substrate of the modern condition.3 New work certainly suggests that improving nutrition played a critical role in the health of populations over the past century.4 But over the longer term, as these articles make clear, the administrative authority of the state has had a critical role in shaping the public health conditions that underlie our life circumstances.
The model of the epidemiological transition has evolved somewhat since Omran’s first proposition.5 It now encompasses four stages: an initial reduction of catastrophic epidemics, most prominently the bubonic plague, beginning in the late fourteenth century; a second stage—beginning in the mid eighteenth century—that saw the reduction of various communicable diseases such as smallpox, diphtheria, and scarlet fever; a third mid to late nineteenth-century stage that reduced the impact of respiratory diseases such as tuberculosis and influenza; and finally a fourth twentieth-century stage that for more than a half century has been reducing the toll of degenerative disease. This four-stage model works best for temperate “northern” populations; the effort to control the impact of equatorial “southern” insect-vector diseases can be viewed as a dimension of stages 2 and 3. [End Page 738]
Each of the three articles published in this forum investigates a central dimension of this sequence, and each focuses on how the institutional structures of the state played a foundational role in shaping public health. Nükhet Varlık’s paper describes how the mythic imagery of the plague shifted from apocalyptic to naturalistic in sixteenth-century Ottoman society, reflecting and enabling the emerging power of the early modern Ottoman state in containing devastating epidemics. Her paper makes a major contribution to our understanding of evolving attitudes toward the plague in the Islamic world. Katherine Arner tracks the role of late eighteenth-century American diplomatic consuls in providing a grid of medical and public health information in efforts to control the spread of yellow fever in the Mediterranean. Building on late medieval plague quarantine regulations and infrastructure, these far-flung agents of the state were part of international networks to contain equatorial disease. Finally, Tamara Mann examines how philanthropic and then state agencies debated the policy implications of the third and fourth stages of the transition—the rising numbers of people surviving the potential ravages...