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243 Eleven The Apparent End of Epidemics By the middle of the twentieth century some social and medical observers (including historians) believed that the end of epidemic diseases was in sight. The American magazine U.S. News and World Report, reflecting in 1955 on the development of a poliomyelitis vaccine, maintained, “There are diseases that offer threats, but, over all, in the field of infectious ones, most of the killing ones are under control.” The same magazine confidently predicted that “[m]an one day may be armed with vaccine shields against every infectious ill that besets him.” Richard Harrison Shryock, a distinguished historian of medicine, allowed that Condorcet’s remarkable Enlightenment prediction that science would free humanity of old age and death “may yet prove correct.”1 Scientific biomedicine had combined with sanitary engineering, sophisticated political machinery, and widespread public enthusiasm for the dictates of health to bring to apparent fruition the promises of science first made in the seventeenth century. One by one the perils of various infectious epidemic diseases seemed to fade away under the combined assault of enlightened public health and sanitation, the extension of the preventive principle of vaccination, and the curative powers of laboratory products, among which antibiotics created the greatest sensation and held out the most exciting prospects. In many ways twentieth-century scientific medicine changed the relations between humans and disease both decisively and for the better. Although scientific medicine owed most of its earlier success to nonmedical factors, a review of recent Western population history will show its demographic significance in the years after World War I. Two other phenomena have, however, intruded on that progressive picture: scientific medicine succeeded only by fits and starts, and never completely; and some of its consequences were both unforeseen and unpleasant. Disease, considered as an objective and biological reality, continues its symbiotic relations with its human hosts despite biomedicine’s best efforts; considered as a human mental construct, twentieth-century disease wears many faces, some of them molded by the purported end of epidemics, but others with a different, sometimes long (and not often happy) history. Disease, Medicine, and Demography The balance of power between people and certain infectious diseases shifted decisively (although perhaps temporarily) in the first sixty years of the twentieth century. Mortality from tuberculosis, syphilis, bacterial pneumonia, diphtheria, whooping cough, measles, and poliomyelitis (among others) plunged dramatically, in each case as a direct result of the application of preventive or curative biomedicine. But the demographic significance of those successes is harder to assess, for they followed on the heels of other demographic change mediated by human (not necessarily medical) agency. Were human responses to disease demographically effective even before the twentieth century? That question has been among the most widely discussed issues in modern historiography, and its resolution remains elusive, both because of the very large number of variables determining mortality (many of them interrelated if not actually interdependent) and because basic data for the period before the middle of the nineteenth century are fragmentary at best. Some review of the variables, and of the present tentative conclusions of scholarship, may place the impact of triumphant biomedicine in a clearer context.2 Modern demographic historians now widely agree that the transition to today’s low mortality in the West occurred in two or perhaps three stages. The first stage, roughly the eighteenth century (or perhaps the period from about 1730 to about 1820), saw a decline in mortality rates. Although that decline was halted in the early and mid-nineteenth century, it was not succeeded by notable upward surges in mortality rates of the kind that had marked the cyclical movements of earlier Western population history. Instead, after a mid-nineteenthcentury pause, the decline in mortality resumed with perhaps greater force in the last thirty years of the century, and that decline, though staggered by the appalling experience of early twentieth-century wars and an influenza pandemic, became steeper by the mid-twentieth century, a period that may constitute a third and separate stage. Of these periods the first is at once the simplest and the most difficult: simple because the number of variables may be fewer, especially those of human agency; difficult because the data are both sparse and controversial. This book has already noticed some of its likely elements, one of the most important of which was the decline in “crisis mortality” that followed the disappearance of plague from...

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