La mort inégale: du recul de la mort à l'analyse sociohistorique de la mortalité différentielle by Cintract Aurélien (review)

Aurélien Cintract's book, based on the doctoral thesis he defended at the University of Besançon in 2013, offers a sociohistorical perspective on change in human longevity over the very long term, analysing social inequalities as they relate to mortality. Though Cintract concentrates on Europe, particularly France, he also cites historical and contemporary sources on other geographical zones throughout the book.

The first section retraces change in life expectancy over time, distinguishing three major periods. In the first, mortality was high, and death could strike anyone regardless of their position in the community. Most deaths were due to natural disasters and territorial conflict. In the second period, which saw the development of farming and animal domestication, epidemics of dysentery, plague, smallpox, tuberculosis, and other diseases arrived. Then, beginning in the eighteenth century, major advances of many sorts (industrial, scientific, and medical) enabled life expectancy to rise rapidly thanks to sharp reductions in mortality, initially early in life and ultimately at the oldest ages.

In the second section of the book, Cintract draws on an abundant bibliography and a full statistical apparatus to formulate a composite explanation of what contributed to the fall in mortality. Here he is critical of approaches that attribute the fall entirely to medical causes. While he recognizes the importance of medical advances–improvements in hygiene, the discovery of penicillin followed by the development of antibiotics, vaccination programmes, and treatments for cardiovascular disease–he is against all partial approaches based entirely on medical progress. Rather, he sees improved life expectancy as the result of a "complex human and demographic dynamic" that encompasses medicine, of course, but also sociocultural concerns such as "increasing respect for individual human lives", rising income and wealth, education, the "civilizing" of mores, etc.–all developments that the World Health Organization finally began to take into account in the late twentieth century, adopting a broader approach that considers nutrition, education, and sanitation to be necessary components of all health policies.

Cintract notes that the fall in human mortality is still quite unequally distributed, particularly when we take into account the social stratification inherent in every society. "Inequality in the face of death" is the subject of the third part of the book. From the outset, the author stresses the limits of a strictly medical approach to that inequality. He is particularly critical of the contention that prior to the Enlightenment, it would have been hard to imagine the existence of differential mortality by social position. As he sees it, death was already coming unequally by occupation and social position within ancient societies, though that inequality was not as sharp as it later became. In former times, the main causes of death were related to natural disasters and epidemics, and their effects differed little by social status. For example, the Black Plague that ravaged Europe from the fourteenth to the eighteenth centuries, killing from one-third to half of the population, caused higher mortality among "common folk" than among elites. Inhabitants in lands struck by plague or other epidemics were told to flee as soon as possible to unaffected areas: cito, longe, tarde (flee early, far away, and stay away for a long time) was the message that sovereigns and scientists worked to hammer home each time a disease appeared. But to organize flight, one needed to belong to a social group that would be informed quickly that an epidemic had arrived. Moreover, one needed a place to go, a place one could settle in for the duration, until the epidemic was over. Only privileged groups had the resources needed to take such measures.

Following this clarification, Cintract specifies that in the eighteenth century, gaps between commoners and elites began to grow. Industrialization in Europe accentuated inequalities, and here the main victims were workers and their...